Bridgewood Post Acute

Inspectors wroteBased on interview and record review the facility failed to ensure necessary respiratory care was provided to one of one sampled resident (Resident 1) when: the facility did not have evidence they applied Bipap (Bilevel Positive Airway Pressure, a non-invasive form of ventilation that delivers pressurized air through a mask to help you breathe) oxygen therapy to Resident 1 as needed. This failure had the potential to worsen Resident 1's chronic respiratory illnesses. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to protect two of five sampled residents' (Resident 3 and Resident 4) right to be free from physical abuse by another resident when:Resident 1 punched Resident 4, andResident 2 punched Resident 3 in his right eye. These failures had the potential to cause physical/mental harm to Resident 3 and Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision for two of three sampled residents (Resident 1, Resident 2) when Resident 2 pushed Resident 1's wheelchair from behind causing Resident 1 to react impulsively and strike Resident 2 on the hand. This failure had potential to cause harm and psychosocial distress. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to prevent two of three sampled residents (Resident 1 and Resident 2) from having a physical altercation when Resident 2 bumped Resident 1 with his wheelchair and Resident 1 struck Resident 2. This failure resulted in Resident 1 experiencing frustration and Resident 2 experiencing physical injury to his face. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in June 2025 with multiple diagnoses including malignant neoplasm of the tonsil (tonsil cancer), dysphagia (difficulty swallowing foods or liquids), and severe protein calorie malnutrition (inadequate intake of calories and protein to maintain nutritional status). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for three of six sampled residents from Medication Administration (Resident 25, 37, and 447), when; 1. For Resident 25, a licensed nurse did not administer resident's prescribed haloperidol (medication used to treat nervous, emotional, and mental conditions) as it was prescribed by the doctor. 2. For Resident 37, a licensed nurse did not follow the instructions on the medication label for resident's divalproex sodium (medication used to treat certain types of seizures). 3(a). For Resident 447, a licensed nurse did not follow the instructions on the medication label for resident's mycophenolate (medication used to prevent organ transplant rejection), and (b). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored properly, when unlabeled loose pills and labeled pharmaceutical products were found behind the drawers and in the back of medication cart A. These failures had the potential for medication error, misuse and drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four dietary staff had the appropriate skill set to safely perform the daily operations of the food and nutrition services department when: 1. Two Dietary Aides were not able to verbalize the process of manual dishwashing with 3-compartment sink (cross refer to F812, #8), and 2. Two Cooks did not perform handwashing before touching the clean dishes at the clean side of the dishwashing machine (cross refer to F812, #9) These failures had the potential to place 45 out of 47 highly susceptible residents who consumed food from the facility kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed for the therapeutic diet during lunch meal on 6/3/25 when: 1. One resident (Resident 26) with a diet of mechanical soft (MS) texture diets (a diet consisting of soft, moist foods for people who have chewing and/or swallowing difficulties) and small portions received the wrong portion for the meat. 2. One resident (Resident 13) with diet of MS, CCHO (diet where number of sugars and starches are controlled), and Renal (special diet to avoid foods that can be harmful to kidneys) received brown rice instead of wheat pasta. 3. One resident (Resident 22) with MS diet received parsley sprig for garnish instead of parsley flakes 4. Six residents (Resident 12, 34, 35, 37, 38, and 43) did not receive parsley sprig garnishes with their lunch meals. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service in a safe manner when: 1. The ice machine was not clean. 2. Found pans stacked wet and had food debris stored at the clean and ready-to-use storage area. 3. Found opened packaged food products with improper labeling and dating procedure in the reach-in refrigerator and reach-in freezer. 4. Found food products that stated, keep frozen, stored in the dry storage area. 5. Found produces were not fresh stored in dry storge area. 6. Found personal belonging stored in dry storage area. 7. One Dietary Aide used a mask to replace the beard net and not covered the facial hair completely. 8. Two Dietary Aides were not able to verbalize the process of manual dishwashing with 3-compartment sink correctly. 9. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, functional, and comfortable environment for a census of 47 when: 1. rooms [ROOM NUMBER] had broken/missing wardrobe drawers. 2. room [ROOM NUMBER] had a cracked toilet seat and a broken call light in the bathroom. 3. room [ROOM NUMBER] and 115 had missing call lights in the bathrooms. 4. room [ROOM NUMBER] had a broken windowsill lying on the floor with nails sticking up. These failures resulted in non-functional rooms and an unsafe environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 19 sampled residents (Resident 30) was free of unnecessary psychotropic medications (drug prescribed to affect the mind, emotions or behavior) when he was prescribed an antianxiety medication without adequate indication. This failure placed the resident at risk for unnecessary psychotropic medication use and excessive sedation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for one of 16 sampled residents, Resident 33, when the Director of Nursing (DON) removed, and did not measure the length of Resident 33's Peripherally Inserted Central Catheter (PICC, thin, and long plastic tube that goes into a vein in your arm and ends in a large vein close to your heart) before throwing it in the trash can. This deficient practice had the potential risk of not removing the full length of the catheter and causing infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for one of 46 residents (Resident 25) when: Resident 25's haloperidol (medication used to treat nervous, emotional, and mental conditions) was not available to administer in the dose prescribed by the doctor. This failure had the potential for medication error and disruption of the resident's treatment plan.

Inspectors wroteBased on interview and record review, the facility failed to ensure the availability and timely administration of medications for four of 15 sampled residents (Residents 2, 3, 7, and 9) when: 1. Resident 2 did not receive a dose of Venlafaxine (A drug used to treat depression and certain anxiety disorders) and two doses of Clonazepam (a medication used to treat anxiety), 2. Resident 3 did not receive four doses of Clozapine (a medication that treats mental health conditions like schizophrenia - a mental illness that is characterized by disturbances in thought), 3. Resident 7 did not receive four doses of Haloperidol Decanoate injection (Haldol, medication used to treat schizophrenia), and 4. Resident 9 did not receive nine doses of Clozapine and three doses of Austedo (a medication used to treat movement disorders). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan to prevent falls was implemented for one resident (Resident 1) for a census of 47. This failure increased Resident 1's risk of falling, which could result in injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one of four sampled residents (Resident 2) when Resident 1 threw a plate on Resident 2's face. This failure resulted in Resident 2 sustaining a laceration on the right eyebrow.

Inspectors wroteBased on interview and record review, the facility failed to develop a specific care plan for weight loss and pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for one resident (Resident 1) out three sampled residents, that included measurable objectives and timeframes. This failure had the potential to compromise the nutritional and health status for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures (P&P) for the prohibition and prevention of abuse for a census of 48 residents when two out of five sampled facility staff (Certified Nurse Assistant [CNA] 1 and CNA 2) were actively working in the facility without an initial background check (a formal process that verifies an upcoming employee's personal and professional information such as identity, work history, criminal record, and any other relevant information) done. This failure placed all the residents in the facility at risk for possible serious physical and/or psychosocial harm and decreased the facility' ability to protect residents from exposure to an employee with a criminal history of abuse, neglect, and/or exploitation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a safe, clean, comfortable and homelike environment was provided for seven of 18 sampled residents (Resident 9, Resident 18, Resident 153, Resident 253, Resident 254, Resident 255, and Resident 256), when a cabinet and closet drawers were in disrepair, with chipped paint, and the walls were empty and bare inside the residents' rooms. This failure had the potential to result in the residents not attaining their highest practicable level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive, documented care plans for four of 18 sampled residents (Resident 18, Resident 15, Resident 204, and Resident 19), when: 1. Resident 18 had no documented care plan for the isolation precautions; 2. Resident 15 had no documented care plan for skin integrity; 3. Resident 204 had no documented care plan for the use of dentures; and 4. Resident 19 had no documented care plan for medication combined with other medications. These failures had the potential to put the residents at risk for unmet needs and as well as the potential to negatively impact their highest practicable level of well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their policy and procedure (P&P) for the accurate accountability of controlled medications (medications with a high potential for abuse and addiction) when controlled drug count records (a record used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were not routinely signed by the outgoing and incoming nursing shifts, and ensure controlled substance medications were accurately accounted for on the medication administration record (MAR) and Controlled Drug Record (CDR) for two of three randomly selected residents (Residents 6 and 45). These failures resulted in the facility not having accurate accountability of controlled medications, and the potential for abuse or misuse of these medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure multi-dose medications were dated with an open and discard date to ensure they were not used beyond the discard date, prescription medications were appropriately labeled with a pharmacy label or name to correctly identify which resident they were for, medications with different routes of administration were stored in accordance with facility policy and procedures (P&P), and expired medications were not available for resident use. The deficient practices had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date, incorrect medications from inadequate labeling, medications given incorrectly through the wrong route of administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide alternatives to the meal entree that were of similar nutritive value. This had the potential of leading to protein/calorie malnutrition for the 44 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that dietary staff provided the correct portions when plating the consistent carbohydrate diet. This had the potential of leading to poor blood sugar control for the 11 residents (Residents 9, 13, 18, 28, 30, 33, 41, 153, 253, 255, and 453) eating the controlled carbohydrate diet (CCHO).

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards of food safety in order to prevent the outbreak of foodborne illness when: 1) Opened food items were not protected and sealed after opening; 2) Food labeling process was not followed when drinks on a tray in the refrigerator were not labeled and dated, and almond extract did not have a readable use-by date; 3) Unclean food service items, including a food processor bowl, were found with brown build-up, along with a cutting board which was noted to have food residue on the cutting surface; 4) Paint on the kitchen walls, sink backsplash, and ceilings were found to be chipped, stained, and covered with glue-like build-up; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control guidelines and practices for a census of 44 when: 1. Transmission based precautions were not followed for contact/droplet infection for Resident 18; 2. Bandage scissors were not cleaned during wound care treatment for Resident 13; 3. There were no Enhanced Barrier Precautions (EBP, involves use of gown and gloves during high contact resident care designed to reduce transmission of Multi Drug Resistant Organisms [MDRO, bacteria resistant to antibiotics]) in place for Resident 2's wound care and indwelling catheter; 4. There was no EBP in place for Resident 19; 5. Resident 453's isolation trashcan was not covered; and 6. A toothbrush, balled up paper towels were found on the floor, and a commode with white spots over the seat were found in an adjoining resident bathroom. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise the comprehensive care plan for one of 18 sampled residents (Resident 153), when the fall risk care plan was not updated after a fall incident. This failure had the potential to result in further falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with acceptable professional standards of quality for one of eight sampled residents (Resident 45) when nursing staff failed to verify the contents of a probiotic (a supplement to support and promote gut health) administered to Resident 45. This failure resulted in Resident 45 receiving the incorrect probiotic and the potential for worsening of their clinical condition or complications related to gut health such as diarrhea, nausea and vomiting.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the facility provided care and services consistent with professional standards for one of 18 sampled residents (Resident 15) when a pressure ulcer/injury (PU/PI, localized damage to the skin and/or underlying tissue from prolonged pressure on the skin) was found on his right heel. This failure resulted in Resident 15 developing an unstageable pressure ulcer (full thickness skin and tissue loss) to his right heel.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status when two of 5 sampled residents (Residents 16 and Resident 33) lost 20 pounds or more over 6 months, without an identified cause and food preferences were not obtained. These failures had the potential to negatively affect Resident 16's and Resident 33's overall health by leading to malnutrition and muscle wasting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (Resident 10) was free of a significant medication error when he received Advair Diskus (generic name fluticasone/salmeterol, a medication to treat asthma) 42 times (doses) past the expiration date. This deficient practice had the potential for ineffective use of the Advair Diskus, resulting in breathing complications and worsening of Resident 10's clinical condition.

Inspectors wroteBased on observation and record review, the facility failed to puree zucchini by methods that conserved nutritive value and flavor. This had the potential of leading to poor intake and malnutrition for the four residents (Resident 5, Resident 33, Resident 49, and Resident 153) eating pureed meals.

Inspectors wroteBased on observation and interview the facility failed to maintain one of the reach-in freezers. This had the potential of leading to food-borne illness for the 44 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper infection prevention and control practices for two of three sampled residents (Resident 1, and Resident 2) when: 1. Oxygen tubing was not labeled, 2. Urinal ½ full of a yellow amber colored fluid was found sitting on top of the bedside table. 3. The floor has multiple white shiny pieces of food laying on the floor next to the bed. 4. Urinal was mislabeled. During an initial tour on 6/12/24 at 12:35 p.m., an observation of room [ROOM NUMBER] with three residents, Resident 2's bedside table had a urinal with yellow amber colored fluid in it, multiple white shiny pieces of food on the floor next to the bed. Resident 1 has a mislabeled urinal on his bedside table and his oxygen tubing was not labeled. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from abuse when Resident 2 struck him in the face and head. This failure had the potential to result in serious physical injury for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection prevention and control program guidelines and practices were maintained for a census of 44, when: 1. Licensed Nurse 6 (LN 6) did not sanitize hands and changed gloves during wound dressing change for Resident 3; 2. Unlabeled and undated opened humidifiers found at the bedside of Resident 153; 3. Outdated humidifier was used for Resident 155; 4. Used coffee mugs and office equipment were found on top of a folding table in the dining room; 5. Nursing staff did not perform hand hygiene during direct resident care in an isolation room; and 6. Infection Preventionist (IP) verbalized no knowledge of infection control and prevention. These failures had the potential to result in transmission and spread of infection for a vulnerable population.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a comfortable and dignified atmosphere for dining for a facility census of 44 residents, when residents waited for their meals while the other residents were eating. This failure resulted in the residents' frustration and anger when residents were not all served meals at the same time.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' needs were accommodated for four of 22 sampled residents (Resident 27, Resident 32, and Resident 154), when: 1. Call light was broken and no call bell was provided to Resident 27, Resident 32 and Resident 154. These failures had the potential to result in the residents not attaining their highest practicable physical and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe, clean, comfortable and a homelike environment was provided for three of 22 sampled residents (Resident 22 and Resident 153), when: 1. The immediate environment was empty and walls were bare in Resident 22's room; and 2. A dirty commode was found at Resident 153's bedside; These failures had the potential to result in the residents not attaining their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the instructions needed for effective person-centered care were provided for four of 22 sampled residents (Resident 151, Resident 152, Resident 153 and Resident 155), when the Baseline Care Plan (BCP) was not completed and no copy given to the resident nor the responsible party (RP). This failure had the potential to result in the lack of communication among staff, inadequate care for the resident, and leaving the resident and the RP with no information summarizing the goals, medications, treatments, diet, and discharge plans.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the communication needs were met for two of 22 sampled residents (Resident 151 and Resident 37), when there was no communication board or device accessible to the staff to communicate with the residents. This failure had the potential to result in not meeting the residents' highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment free from potential accident hazard for two of 22 sampled residents (Resident 11 and Resident 34), when water coming out from the bathroom sink faucets was too hot to touch. This failure had the potential to result in accidents and burns for Resident 11 and Resident 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of each resident in a census of 44, when: 1. There was an absence of accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction), when random controlled medication audits for three out of three residents (Resident 17, 30 and 37) did not reconcile; and 2. An efficient system was not in place to accurately document and secure emergency medications (e-Kit). These failures had the potential to allow for abuse or misuse of these medications and the potential for emergency medications to be unavailable when needed.

Inspectors wroteBased on observation, interview and record review, the facility's consultant pharmacist (CP) failed to identify drug-related issues on one of 22 sampled residents (Resident 31), and act upon the CP's monthly medication regimen reviews (MRR) for all residents from January 2023 to June 2023. These failures had the potential for unsafe medication use for all residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure labeling and storage of drugs and medications were followed for a census of 44, when: 1. Discontinued and expired medications were not removed from stock; 2. Medications were not labeled properly to ensure it was used for the correct resident and medications were not dated with an open date and discard date to ensure that they were not used beyond the discard date; and 3. The medication storage room and the medication refrigerator temperatures were not monitored appropriately. These failures had the potential to result in medications being administered not in accordance with physician's order and residents receiving medications with unsafe or reduced potency (measure of strength).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food storage and preparation, and maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 44 residents who ate facility prepared meals when: 1. The garbage can located next to the hand washing sink was soiled and the foot pedal to lift lid was broken; 2. One of two refrigerators and two of three freezers did not have thermometers inside the cold storage areas; 3. New margarine cube in refrigerator was partially unwrapped and exposed to the air; 4. Dented can of yams was in the dry storage area; 5. Fifty pound bag of oatmeal in the dry storage area was open; 6. Six loaves of bread had a delivery date of 6/15/23; 7. Bag of frozen turkey cubes had label that had worn off and was unreadable; 8. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure resident safety for a census of 44, when the facility did not develop an Antibiotic Stewardship Program that included antibiotic use protocols and a system to monitor antibiotic use. This failure had the potential to increase resident mortality, increase adverse drug events and drug interactions, and resident infection with antibiotic-resistant organisms.

Inspectors wroteBased on interview and record review, the facility failed to monitor residents or staff who had or had not received a Covid-19 vaccine series for a census of 44, when vaccination records were requested but not provided. This failure had the potential to endanger the health and well-being of residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement compliance and ethics policy for a census of 44, when a medication temperature monitoring log was falsified. This failure had the potential to negatively impact the quality of pharmaceutical products being stored in a the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an adequate call light system was provided for three out of 22 sampled residents (Resident 27, Resident 32 and Resident 154), when the call light was not working. This failure had the potential to negatively affect residents' safety by preventing the residents from communicating a request for assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards were followed for one of 22 sampled residents (Resident 29), when a lidocaine (an anesthetic used to treat pain) 5% (percent, a unit of measurement) patch was applied to Resident 29's shoulder blade without ensuring all edges of the patch were adhered and the date, time and initials of the nurse applying it were not documented. This failure had the potential for Resident 29 to not achieve adequate pain relief or be exposed to unwanted side effects of the medication due to incorrect timing of administration.

Inspectors wroteBased on interview and record review, the facility failed to identify one of 22 sampled residents (Resident 33) was at nutritional risk when the Dietary Supervisor (DS) and Registered Dietitian (RD) were not notified of Resident 33's meal refusals for five days. This failure had the potential to result in Resident 33 experiencing weight loss and nutritional deficiencies.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 22 sampled residents (Resident 31) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when Resident 31 received psychotropic medication without adequate indication for use and was not being appropriately monitored. This failure resulted in unnecessary medication for the resident, which had the potential for increased risks and exposure of side effects associated with psychotropic medications such as sedation, memory loss, falls and abnormal involuntary movements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functional and comfortable environment when one of 22 sampled residents (Resident 33) did not have a functioning over-the-bed light. This failure had the potential to cause Resident 33 to not have proper lighting to support his needs.