Bridge Crest Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were provided to meet the immediate needs of 1 of 3 sampled residents (Resident 1) reviewed for pharmacy services when the resident's prescribed pain medication was unavailable following admission. The facility failed to utilize available medication access procedures or contact the provider for an alternative medication order. This failure placed the resident at risk for untreated pain and delayed medication administration. Resident 1 was admitted to the facility on [DATE] with diagnoses including intervertebral disc degeneration with back pain and lower extremity pain (degeneration of the discs between the bones of the spine that can cause back and leg pain). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure services provided met professional standards for 2 of 3 residents [Residents 1 and 2] when reviewed for quality of care. The facility failed to follow or document physician orders as indicated, and only sign for tasks completed. These failures placed residents at risk for unmet care needs, medical complications, inaccurate medical record, and a diminished quality of life. < Resident 1>Resident 1 was admitted to the facility 02/26/2026. The Minimum Data Set (MDS, an assessment tool), dated 03/05/2026, showed Resident 1 admitted with diagnoses that included Type 2 diabetes mellitus with neuropathy and left foot ulcer. The MDS documented Resident 1 was cognitively impaired and required assistance with activities of daily living. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's legal guardian of the discovery of a medication omission and failed to notify the resident's legal guardian of the resident's transfer to the emergency department on 6/20/2026 for 1 of 3 sampled residents (Resident 1) reviewed for resident representative notification requirements. This failure placed residents at risk of their legal representatives being unable to participate in decisions regarding the resident's care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided meal service according to the facility's posted meal service schedule for 4 out of 4 meals [Breakfast served on 05/30/2026 and breakfast, lunch, and dinner meals served on 06/13/2026] reviewed for meal service. These failures placed residents at risk for not receiving their meals as scheduled, medical complications, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure safe food preparation by not documenting food temperatures for 8 out of 18 meals reviewed for food safety. This failure placed residents at risk for food borne illness and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan for 4 of 16 sampled residents (Resident 1, 73, 3, & 6) reviewed for bed rails, pressure ulcer/injury, unnecessary medications, dental, and communication/sensory needs. This failure placed residents at risk for risk of injury, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure activities of daily living (ADLs) were provided for dependent residents for 3 of 4 sampled residents (Resident 8, 30 & 50) reviewed for ADL care. This failure placed residents at risk for poor hygiene, health complications and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to initiate bowel interventions for 1 of 7 residents (Resident 30) reviewed for bowel management and failed to obtain accurate weights for 3 of 9 residents (Resident 12, 41 & 50). This failure placed residents at risk for discomfort, experiencing health complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain written consent prior to administering psychotropic medications (medications that affect the mind, emotions, and behavior) for 2 of 5 residents (Residents 3 & 4) reviewed for unnecessary medications. This failure placed residents at risk of not being informed of psychotropic medication risks and benefits and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure adequate living space was available for 1 of 3 residents (Resident 41) reviewed for accommodation of needs/preferences. This failure placed residents at risk of restricted mobility and potential for a decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents' medical information was maintained in a manner to ensure privacy and confidentiality when staff failed to properly secure the Electronic Health Record (EHR) for 1 of 4 medication cart computers (Number Two medication cart) reviewed for privacy and confidentiality. This failure placed residents at risk for loss of confidential medical information and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) test (a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications [drugs used primarily to treat symptoms such as hallucinations and delusions]) for 2 of 5 sampled residents (Resident 3 & 4) reviewed for unnecessary medications. This failure placed residents at risk for adverse medication side-effects, medical complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to provide a written bed hold notice (a way for the resident to reserve their bed when away from the facility) at the time of transfer or within 24 hours for 1 of 1 sampled residents (Resident 77) reviewed for hospitalization. This failure placed the residents at risk for not being informed of their right to hold their bed while in the hospital, protection of resident rights during transfer, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately assess oral care status and communication needs for 1 of 20 residents (Resident 6) reviewed for accuracy of assessments. This failure placed residents at risk of having unmet needs, ineffective communication and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident care plans were reviewed, revised, and accurately reflected residents' care needs for 1 of 20 residents (Resident 30) whose care plans were reviewed. These failures placed residents at risk for unidentified/ unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide resident centered activities incorporating the resident's preferences for 3 of 3 sampled resident (Resident 7, 14 & 62) reviewed for activities. This failure placed residents at risk of unmet needs and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a Bed Rail/Bed Enabler and Device Consent and Evaluation for 1 of 4 sampled residents (Resident 1) reviewed for accidents. This failure placed residents at risk of injury, unmet needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure routine pain medication was acquired timely for 1 of 6 residents (Resident 53) reviewed for pain management. This failure placed residents at risk for increased pain and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as directed by the physician's orders for 2 of 5 residents (Resident 4 & 32) reviewed for unnecessary medications. This failure placed residents at risk for increased side effects and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to secure medications in 1 of 4 sampled medication carts (Number Two medication cart) reviewed for medication storage. This failure placed residents at risk of misappropriation of medication and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consistently assess, monitor, and provide wound care treatments as ordered to existing pressure ulcers for 1 of 3 residents [Resident 1] reviewed for pressure ulcers. Resident 1 experienced harm when the residents left heel wound became malodorous, excessive fluid discharge, developed a maggot (fly larvae) infestation that required hospitalization and antibiotic treatment and placed the resident at risk of decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy and procedure by not ensuring a background check was completed prior to the hire date for 1 out of 5 staff [Staff F] reviewed for background checks. In addition, the facility did not ensure reference checks were conducted prior to the hire date for 5 of 5 staff [Staff D, E, F, G, and H] reviewed for reference checks. This failure placed the residents at risk for abuse, neglect, exploitation, and misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing assistants were screened through the nurse aide registry [OBRA] prior to providing care to the residents for 2 of 2 staff [Staff E and H] reviewed for staff qualifications. This failure placed residents at risk for receiving care from unqualified staff.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of discharge for 1 of 4 residents (Resident 1) reviewed for transfer and discharge requirements. This failure placed residents at risk of uninformed discharge plans, psychological distress, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to acquire, administer, and accurately document a medication for 1 of 4 residents (Resident 1) reviewed for pharmacy services and drug regime. Failure to ensure the medication was received and administered placed Resident 1 at risk for delayed treatment, medical complications, and decreased quality of life

Inspectors wroteBased on interview and record review, the facility failed to address a new skin pressure injury, timely notify the provider, and timely implement wound treatment orders for 1 of 1 sampled residents (Resident 1) reviewed for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). Resident 1 experienced harm when they developed a facility acquired pressure ulcer which deteriorated prior to staff obtaining timely orders for wound treatment and pressure reduction modalities. This failure placed residents at risk for development and/or worsening of wounds, medical complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 1 sampled residents (Resident 1) reviewed for significant medication errors. Resident 1 experienced harm when they received two doses, of 10 times the ordered amount, of a blood thinner medication that resulted in hospitalization with three hematomas (bleeding within a muscle group) and transfusion of one unit of packed red blood cells. This failure placed residents at risk for a significant medication error, medication side effects and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely laboratory services were provided for 1 of 1 sampled residents (1) reviewed for laboratory services. Resident 1 experienced a critically elevated white blood cell (WBC) count and was sent to the emergency department with increased swelling and discomfort in both lower legs and left arm. This failure placed residents at risk for delay in treatment and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide at least eight hours of Registered Nurse (RN) supervision for 3 of 30 days. This failure placed residents at risk for not receiving needed care and supervision.

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed pharmacist completed a monthly Medication Regimen Review (MRR) for 4 of 5 sampled residents (28, 41, 12, & 26) reviewed for unnecessary medications. This failure placed residents at risk for delays in necessary medication changes, adverse side effects, and receiving medications without required pharmacist oversight.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering a psychotropic medication (medications capable of affecting the mind, emotions, and behaviors) for 2 of 5 sampled residents (41 & 3) reviewed for unnecessary medications. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide and/or have procedures in place to assist with completing advance directives (ADs), and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for 2 of 11 sampled residents (3 & 9) reviewed for ADs. This failure place residents at risk for losing their right to have healthcare preferences and decisions honored and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' medical information was maintained in a manner to ensure privacy and confidentiality when staff failed to properly secure medical records for 1 of 1 sampled resident (258) reviewed for privacy and confidentiality. These failures placed residents at risk for loss of confidential medical information and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from restraints for 1 of 3 sample residents (38) reviewed for physical restraints. This failure placed residents at risk for injury and a decrease quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written Bed Hold Notice was provided at the time of transfer to the hospital to the resident or resident representative for 1 of 2 sampled residents (7) reviewed for notice of bed hold. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed while at the hospital.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan addressing an urinary catheter (a tube inserted into the bladder that drains urine into a bag outside the body) for 1 of 2 sampled residents (28) reviewed for comprehensive care plan. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician's orders in the Electronic Health Record (EHR) were updated to accurately reflect the resident's wishes for Cardiopulmonary Resuscitation (CPR) status as directed by the Physician Orders for Life Sustaining Treatment (POLST) form for 1 of 1 sampled resident (13) reviewed for CPR. This failure placed residents at risk for not receiving care in accordance with the resident's and/or resident's representative decision-making if their heart stopped beating or breathing stopped.

Inspectors wroteBased on interview and record review, the facility failed to perform ongoing neurological assessments (assesses the nervous system and identifies any abnormalities that affect function and activities of daily living) for residents after an unwitnessed fall for 1 of 3 sampled residents (38), and failed to ensure bowel interventions were initiated for 4 of 6 sampled residents (10, 11, 28 & 41) reviewed for quality of care. These failures placed residents at risk of having unidentified injuries, a delay in treatment, at risk for worsening conditions, health complications and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain urinary catheter (a tube inserted into the bladder that drains urine into a bag outside of the body) physician orders for 1 of 2 sampled residents (28) reviewed for urinary catheter. This failure placed residents at risk for infection, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify and address weight loss for 1 of 7 sampled residents (3) reviewed for nutrition. This failure placed residents at risk for inadequate nutrition and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nursing hours were accurately posted daily for 4 of 30 days reviewed for nurse staff postings. This failure placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels and census.

Inspectors wroteBased on interview and record review, the facility failed to ensure targeted behaviors (desired responses to prescribed drugs) were monitored for 1 of 3 sampled residents (3) and failed to complete an AIMS (Abnormal Involuntary Movement Scale) Test (a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications) for 2 of 5 sampled residents (3 & 41) reviewed for unnecessary psychotropic medications. These failures placed residents at risk of receiving unnecessary medications, experience adverse side effects and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication refrigerators were monitored for appropriate temperatures on 2 of 2 sampled units (West Hall & TCU (Transitional Care Unit)) reviewed for medication storage. This failure placed the residents at risk of receiving unsafe or ineffective medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) when providing medical device care and wound care for 3 of 3 sampled residents (13, 28 & 107) and the facility failed to ensure staff properly donned (putting on) and doffed (removing) personal protective equipment (PPE) for 1 of 1 staff (S) reviewed for infection prevention and control. These failures placed residents, staff, and visitors at risk for contracting infectious diseases, developing infections and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were offered, educated and provided the risks and benefits of Pneumococcal, Influenza and COVID-19 vaccines for 1 of 5 sampled residents (15) reviewed for immunizations. This failure placed residents at risk for developing Pneumonia, Influenza and/or COVID-19, with potential negative outcomes.

Inspectors wroteBased on observation and interview, the facility failed to conduct routine inspections of beds and/or bed rails throughout the facility to identify loose bed rails or areas of possible entrapment due to gaps between the mattress and side rail for 1 of 3 sampled residents (106) reviewed resident beds. This failure placed residents at risk of entrapment and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure activities of daily living (ADLs) for residents dependent on staff assistance were provided related to bathing for 4 of 8 sampled residents (1, 2, 3 & 4) reviewed for ADLs for dependent residents. This failure placed residents at risk for poor hygiene and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was a comprehensive and safe system in place for residents dependent on emergency respiratory equipment in a power failure including the proper emergency equipment at the bedside, a written emergency plan for residents dependent on life sustaining equipment and staff who specialized in respiratory care equipment and were knowledgeable in respiratory care for 1 of 1 sampled resident (Resident 10) reviewed for respiratory services. This facility failure, to have a necessary respiratory care system placed residents at risk of death in an emergency situation and was determined to be a Immediate Jeopardy. This failure placed residents at risk for serious adverse outcomes in the event of an emergency and a diminished quality of life. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the required Type 1 essential electrical system (EES) and generator was in place and operational prior to accepting a ventilator assisted resident where an emergency electrical power system would be needed to maintain life support equipment in the event of a power outage for 1 of 1 sampled residents (10) reviewed for respiratory services. This was determined to be an Immediate Jeopardy to not have the necessary Type 1 EES system and placed residents at risk of death if an emergency occurred. This failure placed residents at risk in case of a power outage and needing respiratory support. An Immediate Jeopardy (IJ) was called on 11/07/2023 at 3:00 PM when the facility failed to have a Type 1 electrical system when the facility was providing care to a resident who was a ventilator assisted individual. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent significant weight loss when a resident was removed from weight monitoring, was not consistently assisted with meals, and was not provide the requested supplement for 1 of 1 sampled residents (36) reviewed for nutrition. This caused harm to Resident 36 when he experienced a significant weight loss of 30.18 percent (%) in five months and four days. This failure placed residents at risk for weight loss, a lack of nutrition and a diminished quality of care.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident rooms were maintained in good condition for 6 of 11 sampled rooms (108, 112, 113, 115, 117 & 119) reviewed for homelike environment. This failure placed residents at risk of not having rooms maintained with a comfortable interior and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations in the facility were comprehensively investigated for 4 of 4 sampled residents (42, 153, 12 & 44) reviewed for investigation of alleged abuse/neglect. This failure placed residents at risk of inadequate interventions, abuse, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to adhere to proper transmission-based precautions for 4 of 4 sampled residents (6, 24, 41 & 45) reviewed for infection control and prevention. This failure placed residents at risk of contracting a multi-drug resistant organism and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written notice of transfer was provided to the resident and/or resident's representative describing the reason for transfers for 1 of 1 sampled residents (32) reviewed for transfer notifications regarding hospitalization. This failure placed residents and/or their representatives at risk of not being informed of the resident's condition, unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a care plan addressing placing a bed against the wall was developed for 1 of 2 sampled residents (1) reviewed for comprehensive care plans including restraints. This failure placed residents at risk for abuse, entrapment, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure hospice services were being managed when not discontinuing the order and care plan when removed from hospice services and when not acting on a new recommendation to re-start hospice services for 1 of 1 sampled residents (1) reviewed for quality of care related to hospice services. This failure placed residents at risk of not getting the services needed and unmet care needs and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly evaluate the resident population in order to develop a facility assessment to meet each resident's care and service needs and accurately reflect the resources the facility determined were necessary for day-to-day and emergency operations including a ventilator assisted resident dependent on life sustaining equipment and trained respiratory service staff for 1 of 1 sampled residents (10) reviewed for facility assessment regarding respiratory services. This failure placed residents at risk for unmet care needs, possible death and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the development of pressure ulcers for 1 of 3 sampled residents (Resident1) reviewed for pressure ulcers. This caused harm to Resident 1 when a pressure ulcer developed under a neck brace that was not looked at for 26 days after being admitted to the facility. This failure placed residents at risk for worsening skin impairment, a change in health status and a diminished quality of life.