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🔎 Bridgewood Post Acute

Inspection Results


Inspection Overview

Bridgewood Post Acute has been cited for a total of 160 deficiencies since we began saving each survey.

In California, the average facility has **64.18 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Survey Date: 2025-06-05
Correction Date: 2025-06-20
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2025-06-05
Correction Date: 2025-06-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2025-06-05
Correction Date: 2025-06-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2025-06-05
Correction Date: 2025-06-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2025-06-05
Correction Date: 2025-06-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Survey Date: 2025-06-05
Correction Date: 2025-06-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2025-06-05
Correction Date: 2025-06-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2025-06-05
Correction Date: 2025-06-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2025-06-05
Correction Date: 2025-06-20
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2025-04-30
Correction Date: 2025-05-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2025-04-30
Correction Date: 2025-05-20
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: G

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2025-01-23
Correction Date: 2025-01-28
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2024-10-08
Correction Date: 2024-10-09
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2024-09-03
Correction Date: 2024-09-04
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2024-07-11
Correction Date: 2024-07-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2024-07-11
Correction Date: 2024-07-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2024-07-11
Correction Date: 2024-07-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2024-07-11
Correction Date: 2024-07-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2024-07-11
Correction Date: 2024-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2024-07-11
Correction Date: 2024-07-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2024-07-11
Correction Date: 2024-07-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2024-07-11
Correction Date: 2024-07-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2024-07-11
Correction Date: 2024-07-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2024-07-11
Correction Date: 2024-07-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Survey Date: 2024-07-11
Correction Date: 2024-07-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Survey Date: 2024-07-11
Correction Date: 2024-07-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-07-11
Correction Date: 2024-07-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2024-07-11
Correction Date: 2024-07-11
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Keep all essential equipment working safely.

Survey Date: 2024-07-11
Correction Date: 2024-07-11
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2024-06-12
Correction Date: 2024-06-12
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2024-04-11
Correction Date: 2024-04-27
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Implement a program that monitors antibiotic use.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Have a Compliance and Ethics Program.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Make sure that a working call system is available in each resident's bathroom and bathing area.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2023-06-29
Correction Date: 2023-07-20
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: G

Plan the resident's discharge to meet the resident's goals and needs.

Survey Date: 2022-12-27
Correction Date: 2023-01-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-11-15
Correction Date: 2022-12-06
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Survey Date: 2022-09-15
Correction Date: 2022-09-15
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-09-15
Correction Date: 2022-09-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2022-08-29
Correction Date: 2022-09-30
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2022-07-28
Correction Date: 2022-08-10
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2022-03-28
Correction Date: 2022-04-23
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2022-03-28
Correction Date: 2022-04-23
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2022-03-28
Correction Date: 2022-04-23
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2022-01-04
Correction Date: 2022-01-28
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-09-27
Correction Date: 2021-10-14
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: B

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2021-05-18
Correction Date: 2021-07-04
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2021-05-18
Correction Date: 2021-07-04
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2021-05-18
Correction Date: 2021-07-04
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-04-15
Correction Date: 2021-07-30
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2021-04-12
Correction Date: 2021-04-29
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Make sure that a working call system is available in each resident's bathroom and bathing area.

Survey Date: 2021-04-07
Correction Date: 2021-04-15
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2021-04-05
Correction Date: 2021-05-05
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2021-03-24
Correction Date: 2021-04-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2021-03-24
Correction Date: 2021-07-16
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-01-25
Correction Date: 2021-03-08
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2021-01-25
Correction Date: 2021-03-08
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Survey Date: 2021-01-25
Correction Date: 2021-03-08
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Survey Date: 2021-01-25
Correction Date: 2021-03-08
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Survey Date: 2021-01-07
Correction Date: 2021-02-28
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Survey Date: 2021-01-07
Correction Date: 2021-02-28
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2020-12-15
Correction Date: 2021-07-27
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2020-09-10
Correction Date: 2021-07-30
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Assess the resident when there is a significant change in condition

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Assure that each resident’s assessment is updated at least once every 3 months.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2019-10-28
Correction Date: 2020-01-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2019-10-28
Correction Date: 2020-01-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2019-10-28
Correction Date: 2020-01-21
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: C

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: C

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that residents are free from significant medication errors.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Dispose of garbage and refuse properly.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Survey Date: 2019-10-28
Correction Date: 2019-12-11
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: B

Honor the resident's right to manage his or her financial affairs.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: B

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Assure the security of all personal funds of residents deposited with the facility.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Respond appropriately to all alleged violations.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Assure that each resident’s assessment is updated at least once every 3 months.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure the activities program is directed by a qualified professional.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: C

Post nurse staffing information every day.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Implement a program that monitors antibiotic use.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Survey Date: 2018-11-13
Correction Date: 2019-01-22
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure a qualified health professional conducts resident assessments.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Honor each resident's preferences, choices, values and beliefs.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Have a plan that describes the process for conducting QAPI and QAA activities.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2017-12-18
Correction Date: 2018-02-01
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**