Deficiencies (last 4 years)
Deficiencies (over 4 years)
40.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
913% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 15, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to report a major injury and provide adequate supervision to a resident who fell and sustained a subdural hematoma.
Complaint Details
The complaint investigation was substantiated. Resident 4 was left alone on a patio for approximately 30 minutes by Restorative Nursing Assistant H, resulting in a fall and a subdural hematoma. The injury was not reported timely, and the facility failed to provide adequate supervision and activities. Resident 4 was hospitalized, placed on hospice care, and died 13 days after the fall.
Findings
The facility failed to timely report a major injury of Resident 4 who fell on a patio and sustained a subdural hematoma. The facility also failed to provide adequate supervision and activities for Resident 4, resulting in a major injury, hospitalization, decline in condition, and eventual death. Staff competency and communication failures were identified.
Deficiencies (4)
F0609: The facility failed to timely report suspected abuse, neglect, or theft related to Resident 4's major injury from a fall on the patio resulting in a subdural hematoma.
F0679: The facility failed to provide activities that met Resident 4's preferences, including outdoor patio time, and did not provide clear supervision instructions for outdoor activities.
F0689: The facility failed to ensure adequate supervision and a safe environment for Resident 4, who was left alone on a patio, resulting in a fall causing a major head injury and subsequent death.
F0726: The facility failed to ensure that nursing staff and aides had the appropriate competencies to care for Resident 4, as evidenced by the failure to supervise and communicate about Resident 4's location and needs.
Report Facts
Duration resident left alone: 30
Midline shift: 3
Days until death: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Restorative Nursing Assistant H | Restorative Nursing Assistant | Named in findings for leaving Resident 4 alone on patio leading to fall and injury. |
| Director of Nursing | Director of Nursing | Interviewed regarding failure to report injury and supervision policies. |
| Registered Nurse C | Registered Nurse | Assigned nurse for Resident 4 on day of fall; stated Resident 4 should have had more supervision. |
| Licensed Vocational Nurse E | Licensed Vocational Nurse | Provided statements about inadequate supervision and communication failures. |
| Certified Nursing Assistant J | Certified Nursing Assistant | Found Resident 4 on ground after fall; reported lack of communication about Resident 4's location. |
| Medical Doctor Z | Medical Doctor | Performed medical assessment confirming major injury and poor prognosis. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 15, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report a major injury sustained by Resident 4 after being left alone on a patio, resulting in a fall and subdural hematoma.
Complaint Details
The complaint investigation found that Resident 4 was left alone on a patio for 30 minutes by Restorative Nursing Assistant H, resulting in a fall and subdural hematoma. The injury was not reported timely by the facility. Interviews with staff including the Facility Administrator and Director of Nursing confirmed the failure to report and inadequate supervision. Resident 4 was hospitalized, placed on hospice care, and died 13 days after the fall.
Findings
The facility failed to report a major injury for Resident 4, who was left unsupervised on a patio for 30 minutes, fell, and sustained a subdural hematoma. This failure delayed investigation and resulted in Resident 4's decline and eventual death. Additionally, the facility failed to provide adequate supervision and activities consistent with Resident 4's care plan, and staff lacked appropriate competencies to care for Resident 4.
Deficiencies (4)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failure to honor an activity preference developed in the activity care plan for Resident 1, potentially impacting mental and psychosocial needs.
Failure to ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, resulting in Resident 4's major head injury.
Failure to ensure nurses and nurse aides have appropriate competencies to care for every resident, resulting in Resident 4 being left alone and sustaining a major head injury.
Report Facts
Duration Resident Left Alone: 30
Subdural Hematoma Size: 3
Resident 4 Death: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Restorative Nursing Assistant H | Restorative Nursing Assistant | Left Resident 4 alone on patio leading to fall and injury. |
| Facility Administrator | Admitted facility did not report Resident 4's fall because it was not considered significant. | |
| Director of Nursing | Director of Nursing | Confirmed failure to report injury and inadequate supervision. |
| Registered Nurse C | Registered Nurse | Assigned nurse for Resident 4 on day of fall; was not informed Resident 4 was on patio. |
| Licensed Vocational Nurse E | Licensed Vocational Nurse | Stated Resident 4 did not have adequate supervision on patio. |
| Certified Nursing Assistant J | Certified Nursing Assistant | Found Resident 4 on ground after fall; was not informed Resident 4 was on patio. |
| Medical Doctor Z | Medical Doctor | Performed medical assessment confirming major injury. |
| Director of Staff Development | Provided specialized training to RNA H after fall incident. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 27, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely report suspected abuse involving a resident being slapped by another resident.
Complaint Details
The complaint investigation found that the facility did not report an abuse incident involving Resident 4 being slapped by Resident 5 on 6/20/25. The facility staff misunderstood reporting requirements related to perpetrators with dementia. The complaint is substantiated.
Findings
The facility failed to report an abuse allegation involving Resident 4 being slapped by Resident 5 on 6/20/25. The incident was not reported to the state licensing/certification agency due to a misunderstanding that abuse involving a perpetrator with dementia did not require reporting.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to proper authorities. Resident 4 was slapped by Resident 5 on 6/20/25, but the incident was not reported to the state agency.
Report Facts
Date of abuse incident: Jun 20, 2025
Date of survey completion: Aug 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator (ADN) | Confirmed the abuse incident occurred and was not reported | |
| Director of Nursing (DON) | Confirmed the abuse incident and misunderstanding of reporting requirements |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 27, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report suspected abuse involving Resident 4 who was slapped by another resident on 6/20/25.
Complaint Details
The complaint investigation found that the facility did not report an abuse incident involving Resident 4 being slapped by Resident 5 on 6/20/25. The facility staff misunderstood reporting requirements related to perpetrators with dementia. The abuse was not reported to the state licensing/certification agency.
Findings
The facility failed to report an abuse allegation involving Resident 4 being slapped by Resident 5 on 6/20/25. The incident was confirmed by the Administrator and Director of Nursing, who stated the facility believed reporting was not required if the perpetrator had a dementia diagnosis.
Deficiencies (1)
Failure to timely report suspected abuse of Resident 4 who was slapped by another resident.
Report Facts
Date of abuse incident: Jun 20, 2025
MDS BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator (ADN) | Confirmed abuse incident and misunderstanding of reporting requirements |
| Director of Nursing | Director of Nursing (DON) | Confirmed abuse incident and reporting misunderstanding |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 16, 2025
Visit Reason
The inspection was conducted to investigate complaints related to repeated resident falls and inadequate fall prevention interventions at Bridgeview Post Acute nursing home.
Complaint Details
The investigation was complaint-driven, focusing on repeated falls of Resident 1 and Resident 2. The complaint was substantiated with findings that the facility did not adequately evaluate or prevent falls, and care plans were insufficiently developed or communicated.
Findings
The facility failed to ensure residents were free from accident hazards by not properly evaluating post-fall causes, not reassessing care plan interventions for effectiveness, and not developing new interventions to prevent further falls. Staff lacked knowledge on identifying high fall risk residents and their fall care plans, resulting in multiple repeated falls and potential risk for all residents.
Deficiencies (1)
F 0689: The facility failed to ensure two of three sampled residents were free from accidents and hazards. Post-fall evaluations did not determine fall causes, care plan interventions were not reevaluated, new interventions were not developed, and staff did not know how to identify high fall risk residents or locate their fall plans.
Report Facts
Number of falls for Resident 1: 11
Date of Minimum Data Set for Resident 1: Feb 6, 2025
Date of Minimum Data Set for Resident 2: Feb 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding fall prevention program deficiencies and care plan issues. | |
| CNA A | Interviewed about fall risk identification and use of Point of Care system. | |
| CNA B | Interviewed about resident falls and use of Point of Care system. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 16, 2025
Visit Reason
The inspection was conducted to investigate complaints related to repeated resident falls and inadequate fall prevention measures at Bridgeview Post Acute nursing home.
Complaint Details
The investigation focused on two residents (Resident 1 and Resident 2) with multiple falls. Resident 1 had eleven falls since admission with inadequate evaluation of interventions and supervision. Resident 2 had moderate fall risk with cognitive impairment and ineffective interventions such as reminders to use call light. The Director of Nursing confirmed ongoing issues with fall prevention, lack of CNA involvement in care planning, and insufficient evaluation of intervention effectiveness.
Findings
The facility failed to ensure residents were free from accidents and hazards by not adequately evaluating post-fall causes, not reassessing care plan interventions for effectiveness, and not developing new interventions to prevent further falls. Staff lacked knowledge on identifying high fall risk residents and their fall care plans, resulting in multiple repeated falls and potential risk to all residents.
Deficiencies (4)
Post fall evaluations did not determine the reason for the falls.
Residents care plan interventions were not reevaluated for effectiveness.
New interventions were not developed to prevent further falls and injuries.
Direct care staff did not know how to identify high risk fall residents and find their fall plan of care.
Report Facts
Number of falls for Resident 1: 11
Date of Minimum Data Set for Resident 1: Feb 6, 2025
Date of Minimum Data Set for Resident 2: Feb 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed issues with fall prevention program, lack of CNA involvement in care planning, and ongoing efforts to improve fall program. |
| CNA B | Certified Nursing Assistant | Reported Resident 2 was falling frequently and did not use Point of Care system for fall risk interventions. |
| CNA A | Certified Nursing Assistant | Observed Resident 2's care plan and noted lack of fall risk identification and incomplete care plans. |
Inspection Report
Deficiencies: 1
Date: Jan 15, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding the safe, clean, and homelike environment for residents, specifically addressing concerns about improper storage of construction materials in resident rooms.
Findings
The facility failed to maintain a safe and homelike environment by improperly storing construction materials, including laminate flooring and paint/adhesive cans, in a resident room. This created potential hazards and discomfort for residents, violating facility policies and OSHA standards.
Deficiencies (1)
F 0584: The facility failed to honor residents' rights to a safe, clean, and homelike environment by storing construction materials in the room of three residents, creating tripping hazards and making the environment uncomfortable and dusty.
Report Facts
Residents affected: 3
Buckets of material: 10
Cartons of laminate flooring: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility Administrator A | Facility Administrator | Discussed the storage situation and acknowledged OSHA inquiry. |
| Licensed Vocational Nurse B | Licensed Vocational Nurse | Reported family concerns about flooring materials stored in resident room. |
| Maintenance Director C | Maintenance Director | Confirmed storage of flooring and glue cans in resident room and acknowledged policy violation. |
Inspection Report
Deficiencies: 1
Date: Jan 15, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding the safe, clean, and homelike environment for residents, specifically addressing concerns about improper storage of construction materials in resident rooms.
Findings
The facility failed to maintain a safe and homelike environment when construction materials, including laminate flooring and paint/adhesive cans, were improperly stored in a resident room, creating potential hazards and discomfort for residents. The facility acknowledged the issue and planned to move the materials to a proper storage area.
Deficiencies (1)
Improper storage of construction materials in the room of three residents, creating potential hazards and an environment not considered homelike.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility Administrator A | Facility Administrator | Named in relation to the storage of construction materials and OSHA inquiry. |
| Licensed Vocational Nurse B | Licensed Vocational Nurse | Mentioned regarding family concerns about flooring materials stored in resident room. |
| Maintenance Director C | Maintenance Director | Discussed the storage of flooring and glue cans and the facility's plan of correction. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 8, 2024
Visit Reason
The inspection was conducted due to complaints alleging failure to provide privacy and dignity, staff speaking non-English languages in front of residents, loud night shifts, and abuse allegations involving residents.
Complaint Details
The complaint investigation substantiated multiple issues including failure to provide privacy and dignity, staff speaking non-English in resident areas, loud noise at night, abuse by staff including physical restraint and neglect, and failure to report and investigate abuse allegations properly.
Findings
The facility failed to ensure residents were treated with dignity and respect, including failure to provide privacy during personal care, staff speaking non-English in resident areas, and loud noise during night shifts. The facility also failed to prevent abuse and neglect, including a CNA holding down a resident, a housekeeper making a resident clean her own toilet, and failure to report and investigate abuse allegations properly.
Deficiencies (4)
F 0550: The facility failed to honor residents' rights to dignity, respect, and privacy, including staff speaking non-English in front of residents, loud night shifts, and lack of privacy during personal care for Resident 101.
F 0600: The facility failed to protect residents from abuse when CNA E grabbed and held Resident 35's arm and Housekeeper A made Resident 40 clean her own toilet. Both staff continued assignments despite incidents.
F 0609: The facility failed to timely report suspected abuse and neglect involving Residents 22, 35, and 40, including failure to report CNA holding down Resident 35 and housekeeper abuse allegations.
F 0610: The facility failed to respond appropriately to alleged violations by not investigating abuse allegations involving Residents 22, 35, and 40 and not protecting residents during investigations.
Report Facts
Residents sampled: 22
Residents affected: 6
Residents affected: 2
Residents affected: 3
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nursing Assistant | Named in physical abuse allegation involving Resident 35 |
| HSK A | Housekeeper | Named in neglect allegation involving Resident 40 |
| CNA J | Certified Nursing Assistant | Named in failure to report abuse allegation involving Resident 40 |
| DSD | Director of Staff Development | Provided education and confirmed knowledge of abuse incidents |
| Admin | Administrator | Confirmed ongoing issues and lack of proper investigations |
| SC | Staffing Coordinator | Confirmed improper assignment of CNA E after abuse incident |
| IP | Infection Preventionist | Informed about CNA E incident but did not follow up |
| HSK M | Housekeeping Manager | Managed investigation and reassignment of Housekeeper A |
| CNA M | Certified Nursing Assistant | Failed to report suspected abuse involving Resident 22 |
Inspection Report
Routine
Deficiencies: 14
Date: Oct 8, 2024
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory requirements including resident rights, abuse prevention, medication management, food service, social services, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy, failure to prevent and report abuse, inadequate documentation and follow-up of resident transfers, unsafe medication and feeding tube management, incomplete physician progress notes, inadequate staff competencies, failure to honor resident food preferences, poor food quality and temperature control, unsanitary kitchen and food storage conditions, and failure to maintain proper social services and discharge planning.
Deficiencies (14)
F 0550: Facility failed to ensure dignity and privacy for residents, including failure to provide privacy during personal care and staff speaking non-English languages in resident areas.
F 0600: Facility failed to protect residents from abuse, including staff holding down a resident and instructing a resident to clean their own toilet.
F 0609: Facility failed to timely report suspected abuse and investigate allegations for multiple residents.
F 0610: Facility failed to ensure physician progress notes were complete, signed, and dated at each visit for two residents.
F 0622: Facility failed to document resident transfer to hospital including date, time, destination, transportation mode, and disposition of personal effects.
F 0689: Facility failed to ensure one resident wore non-skid footwear to prevent falls as per care plan.
F 0693: Facility failed to provide appropriate care for residents with gastrostomy tubes including inaccurate feeding documentation and excessive fluid administration.
F 0726: Facility failed to ensure nursing staff demonstrated appropriate competencies including failure to reassess and follow up on resident conditions and failure to report abuse.
F 0745: Facility failed to provide medically related social services meeting resident needs including failure to update care plans, assist with discharge planning, and timely dental services.
F 0758: Facility failed to limit PRN psychotropic medication orders to 14 days and failed to monitor for adverse effects.
F 0761: Facility failed to ensure medications and supplies were stored and labeled properly, with expired items and loose pills found.
F 0790: Facility failed to provide routine and emergency dental care timely for a resident resulting in delayed denture provision.
F 0804: Facility failed to ensure food was palatable, served at proper temperature, and met resident preferences, with multiple complaints of cold, burnt, or disliked food.
F 0812: Facility failed to maintain food safety and sanitation including improper food storage, unsanitary kitchen equipment and environment, and unclean resident refrigerators.
Report Facts
Residents sampled: 22
Residents affected by dignity/privacy deficiency: 6
Residents affected by abuse deficiency: 3
PRN Ativan order duration: 120
Expired Foley drainage bags: 4
Expired protein drink: 1
Food service sanitizer ppm: 150
Food service sanitizer ppm: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in dignity/privacy deficiency for failing to provide privacy during personal care |
| HSK A | Housekeeper | Named in abuse deficiency for instructing resident to clean own toilet and emotional distress |
| CNA E | Certified Nursing Assistant | Named in abuse deficiency for holding down resident and failure to report abuse |
| Resident 35's Daughter | Mentioned in dental services deficiency for requesting follow-up on dentures | |
| Director of Staff Development | Interviewed regarding privacy and abuse findings | |
| Dietary Manager | Interviewed regarding food complaints and kitchen sanitation | |
| Registered Dietitian | Interviewed regarding food safety and g-tube feeding | |
| Social Service Director | Interviewed regarding social services and discharge planning deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Oct 8, 2024
Visit Reason
The inspection was conducted based on complaints and allegations regarding failure to provide privacy during personal care, staff speaking non-English languages in front of residents, loud night shifts, and abuse allegations involving physical and emotional mistreatment of residents.
Complaint Details
The complaint investigation was triggered by multiple allegations including failure to provide privacy during personal care, staff speaking non-English languages in front of residents, loud night shifts, and abuse allegations involving physical and emotional mistreatment of residents. The investigation found substantiated issues of dignity violations, abuse, neglect, and failure to report and investigate abuse allegations.
Findings
The facility failed to ensure residents were treated with dignity and respect, including failure to provide privacy during personal care, staff speaking non-English languages in front of residents, and loud noise during night shifts. The facility also failed to protect residents from abuse, including physical abuse by staff and neglect, and failed to timely report and investigate allegations of abuse. Emotional distress and potential harm to residents were noted.
Deficiencies (7)
Failure to provide privacy during personal care for Resident 101.
Facility staff spoke non-English languages in front of residents 46, 90, and 100.
Night shift staff were loud, disturbing residents.
Resident 40 was instructed to clean her own toilet with feces present by Housekeeper A.
Certified Nursing Assistant E grabbed and held Resident 35's arm during care and continued to be assigned to Resident 35's room after the incident.
Failure to timely report suspicions and allegations of abuse for Residents 22, 35, and 40.
Failure to investigate allegations of abuse and protect residents during investigations for Residents 22, 35, and 40.
Report Facts
Residents sampled: 22
Residents affected by dignity and respect issues: 6
Residents affected by abuse and neglect issues: 2
Residents affected by failure to report abuse: 3
BIMS scores: 15
BIMS score: 7
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Acknowledged failure to provide privacy during dressing Resident 101 |
| HSK A | Housekeeper | Made Resident 40 clean her own toilet and was suspended pending investigation |
| CNA E | Certified Nursing Assistant | Grabbed and held Resident 35's arm during care and continued to be assigned to Resident 35's room |
| CNA J | Certified Nursing Assistant | Did not report allegation of Resident 40 being made to clean her own toilet |
| CNA M | Certified Nursing Assistant | Did not report suspicions of abuse when Resident 22 showed fear during care |
| DSD | Director of Staff Development | Provided education on English-only policy and confirmed knowledge of abuse incidents |
| Admin | Administrator | Confirmed ongoing issues with staff speaking non-English, noise complaints, and failure to report abuse |
| HSK M | Housekeeping Manager | Reported switching HSK A's assignment and suspension pending investigation |
| IP | Infection Preventionist | Informed about CNA E incident but did not follow up |
| SC | Staffing Coordinator | Confirmed CNA E was assigned to Resident 35 after incident and should not have been |
Inspection Report
Routine
Deficiencies: 16
Date: Oct 8, 2024
Visit Reason
The inspection was a routine regulatory survey of Bridgeview Post Acute nursing home to assess compliance with resident rights, abuse prevention, medication management, food service, social services, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy, failure to prevent and report abuse, inadequate investigation of abuse allegations, incomplete transfer documentation, failure to ensure non-skid footwear for fall prevention, improper gastrostomy tube care, incomplete physician progress notes, inadequate nursing competencies, failure to limit psychotropic medication use, improper medication storage and labeling, failure to provide timely dental care, failure to honor food preferences, poor food quality and temperature, inadequate social services, and unsanitary kitchen conditions.
Deficiencies (16)
Failure to ensure resident privacy and dignity during personal care.
Failure to prevent and report abuse and neglect of residents.
Failure to investigate allegations of abuse and protect residents during investigations.
Incomplete documentation of resident transfer to hospital including date, time, location, and disposition of personal effects.
Failure to ensure resident wore non-skid footwear to prevent falls as per care plan.
Failure to follow physician orders for gastrostomy tube feeding and care; excessive fluid administration and undocumented care.
Incomplete and unsigned physician progress notes for residents.
Failure to ensure nursing staff demonstrated appropriate competencies including abuse reporting, gastrostomy tube care, and meal tray checks.
Failure to limit PRN psychotropic medication orders to 14 days and failure to discontinue unnecessary medications.
Medications and medical supplies were not stored or labeled properly; expired items and loose pills found.
Failure to provide timely dental care and follow-up for resident with extracted teeth and insurance issues.
Failure to ensure resident care plans were updated quarterly or as needed and discharge planning was incomplete.
Failure to honor resident food preferences resulting in residents receiving disliked foods.
Food served was overcooked, undercooked, cold, or burnt; food temperatures were not maintained properly.
Unsanitary kitchen conditions including dirty floors, food debris, unclean equipment, improper sanitizer levels, and contaminated utensils.
Resident food improperly stored in resident refrigerators with unlabeled, expired, or spoiled food items.
Report Facts
PRN Ativan order duration: 120
Resident 61 BIMS score: 8
Resident 101 BIMS score: 7
Resident 87 total water intake: 3600
Resident 214 total water intake: 3907
Sanitizer solution strength: 500
Sanitizer solution strength: 50
Resident 77 BIMS score: 15
Resident 84 BIMS score: 7
Resident 11 BIMS score: 15
Resident 35 BIMS score: 15
Resident 215 BIMS score: 15
Resident 90 BIMS score: 15
Resident 106 BIMS score: 3
Resident 98 BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Acknowledged failure to provide privacy during personal care for Resident 101. |
| CNA E | Certified Nursing Assistant | Involved in abuse allegation of holding down Resident 35 and failure to report. |
| Director of Staff Development | Provided education on English only policy and noise level; confirmed knowledge of abuse incident with Resident 35. | |
| Housekeeper A | Housekeeper | Alleged to have made Resident 40 clean own toilet and hit bed with mop; suspended pending investigation. |
| Housekeeping Manager | Housekeeping Manager | Switched Housekeeper A's assignment after complaint. |
| CNA J | Certified Nursing Assistant | Received complaint from Resident 40 about Housekeeper A; did not report incident. |
| Administrator | Administrator | Confirmed ongoing issues with staff speaking non-English, noise complaints, and abuse reporting failures. |
| Assistant Director of Nursing | Confirmed no investigation of CNA holding down Resident 35; confirmed assignment errors. | |
| Infection Preventionist | Confirmed CNA E reported aggression but no follow-up investigation. | |
| Scheduler | Responsible for arranging appointments and transportation; unaware of Resident 98's eye surgery appointments. | |
| Licensed Nurse O | Licensed Nurse | Reviewed gastrostomy tube orders and medication administration records; acknowledged documentation errors. |
| Registered Dietitian | Reviewed gastrostomy tube orders and food safety concerns. | |
| Dietary Manager | Acknowledged food complaints, kitchen cleanliness issues, and food preference errors. | |
| Certified Dietary Manager | Acknowledged food temperature and sanitation issues in kitchen. | |
| Social Service Director | Failed to update care plans timely and follow up on dental and eye care referrals. | |
| Social Service Assistant | Acknowledged Resident 61's behavioral changes and participated in medication reviews. | |
| CNA P | Certified Nursing Assistant | Reported Resident 61's verbal aggressive behaviors. |
| CNA N | Certified Nursing Assistant | Reported Resident 61's verbal aggressive behaviors. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Mar 7, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to ensure informed consent for psychotropic medication, failure to provide ordered respiratory care (BiPAP), and failure to create accurate assessments and care plans for a resident.
Complaint Details
The complaint investigation focused on Resident 1 who was administered psychotropic medication without informed consent or clinical indication, and whose physician-ordered BiPAP respiratory treatment was not implemented for 14 days, resulting in respiratory failure and hospitalization. The facility also failed to create accurate assessments and care plans, and nursing staff lacked training on BiPAP use.
Findings
The facility failed to ensure informed consent was obtained before administering psychotropic medication, failed to implement physician-ordered BiPAP respiratory treatment for 14 days resulting in emergent hospitalization, and failed to create accurate admission assessments and baseline care plans. The Medical Director did not adequately supervise care plans and medication use.
Deficiencies (7)
F0552: The facility failed to ensure informed consent was obtained before administering psychotropic medication to Resident 1, resulting in unnecessary medication and potential adverse effects.
F0641: The facility failed to create an accurate comprehensive admission assessment for Resident 1 by not identifying the physician-ordered BiPAP treatment.
F0655: The facility failed to create a baseline care plan including respiratory treatment for Resident 1, omitting the physician-ordered BiPAP.
F0695: The facility failed to provide safe and appropriate respiratory care by not implementing BiPAP for Resident 1 for 14 days, resulting in emergent hospitalization for severe respiratory failure.
F0726: The facility failed to ensure nursing staff had appropriate competencies and training to implement the respiratory plan of care involving BiPAP for Resident 1.
F0758: The facility failed to ensure Resident 1 was free of unnecessary psychotropic medication; Lexapro was prescribed without clinical indication or informed consent.
F0841: The Medical Director failed to supervise the implementation of care plans and medication management, including failure to ensure BiPAP orders were implemented and psychotropic medication was clinically justified.
Report Facts
Days BiPAP not implemented: 14
Hospitalization duration: 5
Psychotropic medication dose: 5
Number of residents sampled: 4
Number of admissions on 12/29/2023: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON | Assistant Director of Nursing | Interviewed regarding lack of informed consent for psychotropic medication and BiPAP implementation. |
| MDir | Medical Director | Interviewed regarding oversight of psychotropic medication use and BiPAP order implementation. |
| LVN 1 | Licensed Vocational Nurse | Signed for BiPAP delivery and involved in admission assessment lacking BiPAP documentation. |
| MDS RN | Minimum Data Set Registered Nurse | Confirmed BiPAP was not included in admission care plan and was unaware of BiPAP order. |
| AS | Admission Supervisor | Interviewed about admission process and failure to communicate BiPAP order to nursing staff. |
| LVN 2 | Licensed Vocational Nurse | Signed for BiPAP machine delivery and placed it at Resident 1's bedside. |
| SSD | Social Services Director | Involved in care conference and communication with Resident 1's responsible party about BiPAP. |
| DSD | Director of Staff Development | Confirmed no staff training on BiPAP use was provided. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Mar 7, 2024
Visit Reason
The inspection was conducted based on complaints and concerns regarding the care of Resident 1, specifically related to the administration of psychotropic medication without informed consent and failure to implement physician-ordered respiratory treatment (BiPAP).
Complaint Details
The complaint investigation focused on Resident 1's care related to psychotropic medication administration without informed consent and failure to implement physician-ordered BiPAP treatment, resulting in respiratory decline and hospitalization.
Findings
The facility failed to ensure Resident 1 was informed and consented before administering psychotropic medication, resulting in unnecessary medication use. The facility also failed to create accurate admission assessments and baseline care plans including BiPAP treatment, leading to a 14-day delay in BiPAP implementation and subsequent respiratory decline requiring hospitalization. Additionally, the facility lacked adequate staff training and oversight by the Medical Director in these areas.
Deficiencies (7)
Failed to ensure informed consent before administering psychotropic medication to Resident 1.
Failed to create an accurate comprehensive admission assessment including BiPAP treatment for Resident 1.
Failed to create a baseline care plan including respiratory treatment for Resident 1.
Failed to provide safe and appropriate respiratory care by not implementing BiPAP for 14 days, resulting in emergent hospitalization.
Failed to ensure nursing staff had appropriate competencies and training to implement respiratory care plan including BiPAP use.
Failed to implement gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medication; psychotropic medication prescribed without clinical indication.
Failed to ensure Medical Director supervised implementation of resident care policies including BiPAP orders and psychotropic medication oversight.
Report Facts
Days BiPAP not implemented: 14
Hospitalization duration: 5
Psychotropic medication dose: 5
Oxygen saturation target: 90
Oxygen saturation target: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Documented ordering Lexapro and noted lack of informed consent; unable to recall clinical need for psychotropic medication. |
| Medical Director | MDir | Stated need for clinical justification and informed consent for psychotropic medications; acknowledged failure in BiPAP order implementation and oversight. |
| Licensed Vocational Nurse 1 | LVN 1 | Signed for BiPAP machine delivery; documented Resident 1 had no changes in mood or behavior. |
| Minimum Data Set Registered Nurse | MDS RN | Confirmed BiPAP was not included in admission assessment or baseline care plan. |
| Director of Nursing | DON | Confirmed lack of BiPAP documentation and training; stated nursing staff should verify physician orders and document respiratory assessments. |
| Social Services Director | SSD | Received family concerns about BiPAP; confirmed BiPAP machine was found after family inquiry. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jun 28, 2023
Visit Reason
The inspection was conducted due to complaints alleging staff to resident abuse and failure to report and investigate these allegations properly, as well as concerns about resident care and assessments.
Complaint Details
The complaint investigation focused on allegations of staff to resident abuse involving Residents 63, 74, and 86. The facility failed to report these allegations to mandated agencies and did not investigate them properly. Additional complaints involved inadequate care and failure to meet residents' needs.
Findings
The facility failed to timely report suspected abuse allegations to mandated agencies for three residents, failed to provide accurate assessments and baseline care plans, did not ensure residents received scheduled bathing and grooming, and did not obtain proper physician orders for treatments applied to a resident's skin condition.
Deficiencies (6)
F 0609: The facility failed to timely report suspected abuse allegations for three residents to mandated agencies, risking resident safety.
F 0641: The facility failed to provide an accurate and complete assessment for Resident 23, missing open skin areas on both legs.
F 0655: The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident 150.
F 0658: The nursing staff failed to identify and report a skin condition with open areas for Resident 23, resulting in refusal of care and risk of infection.
F 0677: The facility failed to provide routine grooming and scheduled showers for six residents, impacting their well-being and dignity.
F 0710: The facility failed to ensure Resident 23's medical care was supervised by a physician before applying lidocaine spray to open skin areas.
Report Facts
Resident complaints related to CNA care: 7
Bathing frequency for Resident 23: 2
Bathing frequency for Resident 29: 1
Bathing frequency for Resident 33: 0
Bathing frequency for Resident 302: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in findings related to failure to report abuse allegations and skin condition management for Resident 23. |
| Licensed Vocational Nurse Tx | Treatment Nurse | Named in findings related to wound care and application of lidocaine spray for Resident 23. |
| Nurse Practitioner | Nurse Practitioner (NP) | Named in findings related to lack of timely consultation and evaluation of Resident 23's skin condition. |
| Social Service Director | Social Service Director (SSD) | Named in findings related to failure to report abuse allegations and grievance follow-up. |
| Physical Therapy Assistant | Physical Therapy Assistant (PTA) | Named in findings related to resident complaints about CNA care and failure to report abuse allegations. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jun 28, 2023
Visit Reason
The inspection was conducted due to complaints alleging staff to resident abuse and failure to report such allegations to mandated agencies, as well as concerns about resident care, assessments, and treatment.
Complaint Details
The complaint investigation was triggered by allegations of staff to resident abuse involving three residents (Resident 63, 74, and 86). The facility failed to report these allegations to mandated agencies and failed to investigate them properly.
Findings
The facility failed to timely report suspected abuse allegations for three residents, failed to provide accurate assessments and baseline care plans, did not ensure professional standards of care for skin conditions, failed to provide scheduled bathing and grooming assistance, and did not have physician orders for certain treatments applied.
Deficiencies (6)
Failed to timely report suspected abuse allegations for three sampled residents to mandated agencies.
Failed to provide an accurate and complete assessment for one resident with known open skin areas.
Failed to develop and implement a baseline care plan within 48 hours of admission for one resident.
Failed to meet professional standards of care by not identifying and reporting a skin condition, resulting in resident refusal of care.
Failed to provide routine grooming and scheduled showers for six sampled residents.
Failed to ensure medical care was supervised by a physician; applied lidocaine spray without physician order.
Report Facts
Resident complaints related to nursing and CNA care: 7
Bathing frequency for Resident 23: 2
Bathing frequency for Resident 29: 1
Bathing frequency for Resident 33: 0
Bathing frequency for Resident 302: 1
Baseline care plan completion delay: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in findings related to failure to report abuse allegations and skin condition management. |
| Social Service Director | Social Service Director (SSD) | Named in findings related to failure to report abuse allegations and grievance follow-up. |
| Physical Therapy Assistant | Physical Therapy Assistant (PTA) | Reported resident complaints related to CNA care that were not reported as abuse. |
| Licensed Vocational Nurse | Licensed Vocational Nurse (LVN) | Treatment nurse who applied lidocaine spray without physician order. |
| Nurse Practitioner | Nurse Practitioner (NP) | Unaware of resident's skin condition until late in investigation; no wound consult in 2 years. |
| Director of Staff Development | Director of Staff Development (DSD) | Confirmed need for staff education on bathing and grooming. |
Inspection Report
Routine
Deficiencies: 22
Date: Jun 28, 2023
Visit Reason
Routine inspection of Bridgeview Post Acute nursing home to assess compliance with regulatory standards including resident rights, care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, communication barriers, unresolved resident complaints, failure to notify physicians of significant weight loss, privacy concerns, environmental maintenance issues, abuse reporting and investigation failures, incomplete care plans, inadequate assistance with activities of daily living, hearing aid management, pressure ulcer care, nutritional monitoring, pain management, staffing shortages, CNA competency, food service and safety, and quality assurance program implementation.
Deficiencies (22)
Failure to provide resident dignity and respect related to clothing and personal belongings.
Failure to ensure communication needs met for a Spanish-speaking resident without use of interpreter services.
Failure to timely address and resolve resident complaints and grievances.
Failure to notify physician of significant weight loss and complete change of condition assessment.
Failure to ensure privacy during resident showers due to lack of communication system indicating shower use.
Environmental maintenance issues including disrepair of walls, window screens, blinds, and cluttered rooms.
Failure to timely report and investigate allegations of staff to resident abuse.
Failure to protect residents during abuse investigations and ensure mandated reporting.
Failure to develop comprehensive care plan addressing depression for a resident with documented PHQ-9 score.
Failure to provide assistance with activities of daily living including grooming and scheduled showers.
Failure to provide hearing aids or appropriate hearing amplification in a timely manner.
Failure to prevent development and progression of pressure ulcers and provide timely wound care.
Failure to maintain adequate nutritional status and timely intervene for severe weight loss.
Failure to provide timely pain management for residents with new onset pain.
Insufficient nursing staff to meet resident care needs including answering call lights, providing showers, and meal assistance.
Failure to conduct annual performance reviews for Certified Nursing Assistants.
Failure to follow proper food preparation procedures including pureeing, portion control, and gravy addition.
Failure to accommodate resident food preferences and provide appealing food options.
Failure to maintain food safety and sanitation including ice machine cleanliness, food cooling logs, food storage, equipment cleanliness, and proper plumbing air gaps.
Failure to implement policy for safe handling and storage of foods brought by family or visitors.
Failure to maintain trash bin lids in good condition to prevent pest infestation.
Failure to implement an effective Quality Assessment and Performance Improvement (QAPI) plan addressing key resident care concerns.
Report Facts
Weight loss: 12.8
Weight loss: 15
Weight loss: 17.2
CNA staffing: 4
CNA staffing: 3
CNA staffing: 3
CNA staffing: 2
CNA staffing: 4
CNA staffing: 4
Portion size: 4
Portion size: 3
Portion size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nursing Assistant | Named in resident abuse complaint for rough care and withholding call light device |
| Social Services Director | Interviewed regarding clothing policies and abuse complaint handling | |
| Laundry Manager | Interviewed regarding clothing replacement process | |
| Administrator | Interviewed regarding clothing replacement and abuse complaint handling | |
| Director of Nursing | Interviewed regarding weight loss notification and abuse complaint handling | |
| Certified Nursing Assistant L | Interviewed regarding resident nail care | |
| Certified Nursing Assistant M | Interviewed regarding shower privacy and hearing impaired resident | |
| Certified Nursing Assistant H | Interviewed regarding hearing impaired resident and pain management | |
| Treatment Nurse LVN | Licensed Vocational Nurse | Interviewed regarding wound care and pressure ulcer |
| Director of Staff Development | Interviewed regarding CNA competencies and abuse training | |
| Certified Dietary Manager | Interviewed regarding food preparation and portion control | |
| Maintenance Assistant | Interviewed regarding ice machine cleaning | |
| Director of Maintenance | Interviewed regarding ice machine cleaning and kitchen equipment air gaps | |
| Director of Rehabilitation | Interviewed regarding abuse complaint reporting | |
| Licensed Vocational Nurse 2 | Interviewed regarding resident food preferences |
Inspection Report
Routine
Deficiencies: 22
Date: Jun 28, 2023
Visit Reason
Routine state inspection survey of Bridgeview Post Acute nursing home to assess compliance with regulatory requirements and resident care standards.
Findings
The facility had multiple deficiencies including failure to provide dignified care, communication barriers, unresolved resident complaints, failure to notify physicians of significant weight loss, privacy issues, environmental maintenance problems, failure to timely report and investigate abuse allegations, incomplete care plans, inadequate assistance with activities of daily living, hearing aid maintenance issues, pressure ulcer care deficiencies, nutritional monitoring failures, pain management delays, insufficient staffing, inadequate staff competency evaluations, food service and safety violations, and ineffective quality assurance processes.
Deficiencies (22)
F0550: Facility failed to provide one resident with dignity and respect by not providing clean clothing, causing frustration and loss of dignity.
F0552: Facility failed to ensure one resident received communication in a language she could understand, lacking interpreter services.
F0565: Facility failed to timely address resident complaints and implement corrective actions, resulting in ongoing unresolved issues.
F0580: Facility failed to notify physician of significant weight loss for one resident, delaying care and treatment.
F0583: Facility failed to ensure privacy for residents using showers due to lack of communication system indicating shower use.
F0584: Facility failed to maintain a clean, safe, and homelike environment; multiple rooms had disrepair, broken blinds, damaged screens, and unclean conditions.
F0609: Facility failed to timely report allegations of staff to resident abuse to mandated agencies for three residents.
F0610: Facility failed to investigate allegations of staff to resident abuse and protect residents during investigations for three residents.
F0656: Facility failed to develop a comprehensive care plan addressing depression for one resident despite documented mild depression.
F0677: Facility failed to provide adequate assistance with activities of daily living including grooming and scheduled showers for six residents.
F0685: Facility failed to provide hearing aids or adequate hearing assistance in a timely manner for one resident with hearing impairment.
F0686: Facility failed to prevent development and provide appropriate care for a stage 3 pressure ulcer that progressed to stage 4 for one resident.
F0692: Facility failed to maintain acceptable nutritional status for one resident by not completing weight monitoring, notifying physician, or timely implementing interventions for severe weight loss.
F0697: Facility failed to provide timely pain management for two residents by not identifying and reporting new onset pain.
F0725: Facility failed to provide sufficient nursing staff to meet the needs of 14 sampled residents, resulting in delayed care, missed showers, and cold food.
F0726: Facility failed to ensure CNAs demonstrated competency in skills to follow residents' plans of care, resulting in unmet care needs.
F0803: Facility failed to follow menu procedures including proper pureeing of foods, correct portion sizes, and adding gravy as per menu for multiple residents.
F0806: Facility failed to accommodate food preferences and allergies for seven residents, resulting in lack of variety and potential weight loss.
F0812: Facility failed to ensure food safety and sanitation including unsanitary ice machine, improper cooling and storage of food, unclean equipment, and lack of air gap on food prep sink and steamer.
F0813: Facility failed to implement policy for safe handling and storage of foods brought by family and visitors, including lack of education and labeling.
F0814: Facility failed to ensure trash bin lids were tight fitting, with one lid having a hole, risking pest infestation and disease spread.
F0865: Facility failed to implement an effective Quality Assessment and Performance Improvement (QAPI) plan to address weight loss, pressure ulcers, staffing, competency, and abuse.
Report Facts
Weight loss: 12.8
Weight loss: 15
Weight loss: 17.2
Scheduled CNAs: 5
Signed CNAs: 3
Scheduled CNAs: 4
Signed CNAs: 3
Scheduled CNAs: 5
Signed CNAs: 4
Scheduled CNAs: 5
Signed CNAs: 4
Scheduled CNAs: 5
Signed CNAs: 2
Signed CNAs: 4
Signed CNAs: 4
Pureed meatloaf portion: 4
Pureed carrot portion: 12
Weight of meatloaf portion: 4
Weight loss: 13
Weight loss: 18.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nursing Assistant | Named in abuse allegation involving Resident 63 |
| Social Services Director | Interviewed regarding clothing and abuse reporting | |
| Laundry Manager | Interviewed regarding clothing process | |
| Administrator | Interviewed regarding clothing and abuse reporting | |
| Director of Nursing | Interviewed regarding weight loss and abuse reporting | |
| Certified Nursing Assistant L | Interviewed regarding nail care | |
| Certified Nursing Assistant M | Interviewed regarding hearing aids | |
| Certified Nursing Assistant H | Interviewed regarding hearing aids | |
| Treatment Nurse LVN | Licensed Vocational Nurse | Interviewed regarding pressure ulcer care |
| Director of Staff Development | Interviewed regarding staff training and competencies | |
| Certified Dietary Manager | Interviewed regarding food preparation and menu compliance | |
| Dietary Supervisor | Interviewed regarding food safety | |
| Maintenance Assistant | Interviewed regarding ice machine cleaning | |
| Director of Maintenance | Interviewed regarding ice machine and kitchen equipment | |
| Director of Rehabilitation | Interviewed regarding abuse reporting | |
| Medical Director | Interviewed regarding weight loss and IDT meetings | |
| Certified Nursing Assistant F | Interviewed regarding staffing issues | |
| Certified Nursing Assistant J | Interviewed regarding pain management and communication | |
| Director of Nursing | Interviewed regarding staffing and abuse reporting | |
| Certified Nursing Assistant G | Interviewed regarding pressure ulcer care | |
| Certified Nursing Assistant CNA A | Named in abuse allegation and competency issues | |
| Certified Nursing Assistant CNA C | Named in abuse allegation and competency issues | |
| Certified Nursing Assistant CNA D | Named in competency issues | |
| Certified Nursing Assistant CNA B | Named in competency issues | |
| Licensed Vocational Nurse 2 | Interviewed regarding food preferences | |
| Director of Staff Development (DSD) | Interviewed regarding staff training and competencies | |
| Admission Coordinator | Interviewed regarding food brought by visitors policy |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure the responsible party was informed of changes in Resident 1's plan of care and concerns about unnecessary psychotropic medication use and lack of behavioral health evaluations.
Complaint Details
The complaint investigation found substantiated issues related to failure to obtain informed consent, lack of behavioral health evaluations, and unnecessary psychotropic medication administration for Resident 1.
Findings
The facility failed to obtain informed consent before administering psychotropic medication to Resident 1, did not provide necessary behavioral health evaluations or psychiatric services, and administered unnecessary psychotropic medication without clinical justification, putting the resident at risk for adverse effects and falls.
Deficiencies (3)
F 0552: The facility failed to ensure the responsible party was informed of a change in Resident 1's plan of care before administering psychotropic medication, violating informed consent policy.
F 0740: The facility failed to provide necessary behavioral health care and services to Resident 1, resulting in no psychiatric or telehealth evaluations despite multiple diagnoses and psychotropic medications.
F 0758: The facility failed to ensure Resident 1 was free from unnecessary psychotropic medication without clinical justification or consent, leading to risk of adverse side effects and falls.
Report Facts
Days lorazepam administered: 11
Psychotropic medications prescribed: 5
Date of survey completion: Jun 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed failure to obtain informed consent and lack of psychiatric services during interviews on 6/7/23. |
| Pharmacy Consultant | Pharmacy Consultant (Pharm D) | Confirmed psychotropic medication monitoring and justification issues during interview on 6/6/23. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 14, 2023
Visit Reason
The inspection was conducted based on a complaint regarding the facility's failure to ensure the responsible party was informed of changes in Resident 1's plan of care related to psychotropic medication and concerns about behavioral health evaluations and unnecessary psychotropic medication use.
Complaint Details
The complaint investigation found that the facility did not obtain informed consent before administering lorazepam, failed to conduct behavioral health evaluations or psychiatric referrals for Resident 1, and administered unnecessary psychotropic medication without clinical justification, resulting in potential harm and risk of falls.
Findings
The facility failed to obtain informed consent before administering lorazepam to Resident 1, did not provide necessary behavioral health evaluations or psychiatric services, and administered an unnecessary psychotropic medication without clinical justification, putting Resident 1 at risk for adverse effects and falls.
Deficiencies (3)
Failed to ensure the responsible party was informed of a change in Resident 1's plan of care before administering psychotropic medication.
Failed to provide necessary behavioral health evaluation and services to meet Resident 1's psychiatric behavioral needs.
Failed to ensure Resident 1 was free from unnecessary psychotropic medication without clinical justification or consent.
Report Facts
Days lorazepam administered: 11
Psychotropic medications prescribed: 5
Anxious behaviors documented: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed informed consent was not obtained before administering lorazepam and facility policy was not followed; confirmed lack of psychiatric telehealth contract and no IDT psychotherapeutic reviews. |
| Pharmacy Consultant | Pharmacy Consultant (Pharm D) | Stated IDT should monitor psychotropic medications and confirmed lorazepam order lacked specific behavior justification. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 13, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory inspection of a nursing home facility.
Findings
The facility failed to maintain a safe, clean, and homelike environment due to disrepair of tile and presence of dirty, standing water in two shower rooms. These conditions had the potential to promote disease spread and cause resident anxiety.
Deficiencies (1)
F 0584: The facility failed to provide a safe, clean, and homelike environment when tile in two shower rooms was in disrepair and dirty standing water was present on the floor of one shower room. This condition could promote disease-causing germs and cause resident anxiety.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) A | Confirmed condition of second shower room with standing water and worn tile. | |
| Administrator | Confirmed appearance of first shower room with tile disrepair. |
Inspection Report
Deficiencies: 1
Date: May 24, 2023
Visit Reason
The inspection visit was conducted to assess the facility's compliance with regulations regarding maintaining a safe, clean, comfortable, and homelike environment for residents.
Findings
The facility failed to maintain two shower rooms in a safe and clean condition, with tile in disrepair and dirty standing water present, which could promote the growth and spread of disease-causing germs and cause resident anxiety.
Deficiencies (1)
Tile in two shower rooms was in disrepair with worn white coating, large tan stains, blackened grout, and dirty standing water on the floor.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed the appearance of one of the shower rooms during observation and interview | |
| Certified Nursing Assistant (CNA) A | Confirmed the condition of a second shower room during observation and interview |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 8, 2023
Visit Reason
The inspection was conducted following complaints regarding safety hazards related to a resident possessing a firearm in the facility and concerns about food quality, temperature, and timeliness of meal delivery.
Complaint Details
The investigation was complaint-driven based on reports of a resident possessing a firearm in the facility and multiple complaints about food quality and meal delivery timeliness. The firearm incident was substantiated with policy violations noted. Food complaints were substantiated by resident interviews and observations.
Findings
The facility failed to follow its firearms policy when a resident brought a gun into the facility, creating a potential safety hazard. Additionally, multiple residents reported that meals were often late, unpalatable, and served at unsafe temperatures, resulting in dissatisfaction and potential health risks.
Deficiencies (2)
F 0689: The facility did not follow its firearms policy when a resident brought a firearm into the facility, and staff intervened contrary to policy. The facility lacked required signage and had policy discrepancies regarding firearm possession and resident discharge.
F 0804: Eight of 22 sampled residents reported food was too tough, cold, or unpalatable, and eight residents stated meals were frequently delivered late, risking weight loss, illness, and choking.
Report Facts
Residents sampled for food quality: 22
Residents reporting food issues: 8
Residents reporting late meals: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON A | Director of Nursing | Provided interviews regarding firearm incident and meal delivery issues |
| LVN B | Licensed Vocational Nurse | Provided interview about firearm incident |
| DM C | Dietary Manager | Provided interview about meal preparation and delays |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 8, 2023
Visit Reason
The inspection was conducted following a complaint regarding a resident bringing a firearm into the facility and concerns about food quality and meal delivery times.
Complaint Details
The visit was complaint-related due to a resident bringing a firearm into the facility and multiple complaints about food quality and meal delivery times. The firearm incident was substantiated with policy violations noted. Food complaints were supported by resident interviews and observations.
Findings
The facility failed to follow its firearms policy when a resident brought a gun into the facility, creating a potentially dangerous environment. Additionally, multiple residents reported that meals were often late, unpalatable, and difficult to eat, with observations confirming poor food quality and late delivery.
Deficiencies (2)
Failure to ensure the facility was free from accident hazards related to a resident bringing a firearm into the facility and not following the stated firearms policy.
Failure to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature, with multiple residents reporting tough, cold, or unpalatable food and frequent late meal delivery.
Report Facts
Residents sampled: 22
Residents affected: 8
Residents affected: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON A | Director of Nursing | Provided interviews regarding the firearm incident and food service issues |
| LVN B | Licensed Vocational Nurse | Provided interview about the firearm incident |
| DM C | Dietary Manager | Provided interview about meal service delays and food quality issues |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 9, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to properly review, revise, and implement care plans for a resident with a significant change in condition, which resulted in hospitalization.
Complaint Details
The complaint investigation focused on Resident 1, who experienced a significant decline in condition that was not properly communicated or documented by nursing staff. The failure to notify the physician and update the care plan was substantiated, resulting in Resident 1's emergency hospital transfer and ICU admission.
Findings
The facility failed to ensure that Resident 1's care plan was updated by the interdisciplinary team after a significant change in condition involving oxygen needs, elevated blood sugars, and low blood pressure. This failure led to inadequate monitoring, lack of physician notification, and delayed interventions, resulting in Resident 1's hospitalization in critical condition with sepsis and pneumonia.
Deficiencies (2)
F 0657: The facility failed to develop and revise Resident 1's care plan within 7 days of a significant change in condition, resulting in missed person-centered interventions and hospital admission for sepsis and pneumonia.
F 0684: The facility failed to recognize, monitor, and report Resident 1's significant change in condition, including shortness of breath requiring oxygen, elevated blood sugars, and low blood pressure, leading to deterioration and ICU admission.
Report Facts
Blood sugar readings: 400
Oxygen saturation: 83
Blood pressure readings: 99
Medication hold dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN C | Licensed Nurse | Documented oxygen saturation and administered oxygen on 2/19/23; failed to perform SBAR and fully notify physician of all condition changes. |
| Director of Nursing | Director of Nursing | Confirmed lack of care plan updates and SBAR documentation for Resident 1's condition change. |
| LN B | Licensed Nurse | Notified Nurse Practitioner on 2/22/23 and 2/23/23 about Resident 1's deteriorating condition. |
| Nurse Practitioner | Nurse Practitioner | Ordered labs, chest x-ray, and antibiotics on 2/22/23; confirmed lack of full information from nursing staff. |
| Resident 1's physician | Physician (MD) | Notified about oxygen on 2/19/23 but not about low blood pressure or high blood sugars; stated he would have sent Resident 1 to hospital if fully informed. |
| LN D | Licensed Nurse | Cared for Resident 1 on 2/20/23; assessed lungs but did not notify physician, only reported to DON. |
| Administrator | Administrator | Described IDT meetings relying on SBAR documentation to identify condition changes. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 9, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to properly review, revise, and implement a care plan for Resident 1 after a significant change in condition, which included oxygen requirement, increased insulin usage, and holding heart medications due to low blood pressure.
Complaint Details
The complaint investigation focused on Resident 1, who experienced a significant change in condition including shortness of breath requiring oxygen, elevated blood sugars, and low blood pressure leading to holding of heart medications. The facility failed to update the care plan, notify the physician fully, and monitor the resident adequately. This resulted in Resident 1's condition worsening and requiring ICU admission for severe sepsis and pneumonia.
Findings
The facility failed to ensure that Resident 1's care plan was updated by the interdisciplinary team following a significant change in condition. This failure led to inadequate monitoring, lack of communication with the physician, and delayed interventions, resulting in Resident 1's condition deteriorating and requiring emergency hospital admission to the ICU with diagnoses including sepsis and pneumonia.
Deficiencies (2)
Failure to develop and revise the complete care plan within 7 days of the comprehensive assessment by the interdisciplinary team after a significant change in Resident 1's condition.
Failure to recognize, monitor, and report a significant change in condition to the physician, resulting in delayed treatment and emergency transfer to acute care hospital.
Report Facts
Oxygen saturation: 83
Blood sugar readings: 400
Blood pressure: 99
Medication hold dates: 4
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN C | Licensed Nurse | Documented oxygen saturation and administered oxygen on 2/19/23; failed to perform SBAR and fully notify physician |
| Director of Nursing | Director of Nursing (DON) | Confirmed lack of care plan updates and SBAR documentation; confirmed failure to notify physician |
| LN B | Licensed Nurse | Notified Nurse Practitioner on 2/22/23; documented resident's deteriorating condition |
| Nurse Practitioner | Nurse Practitioner (NP) | Saw Resident 1 on 2/22/23; confirmed lack of full information from nursing staff |
| LN D | Licensed Nurse | Cared for Resident 1 on 2/20/23; did not notify physician despite abnormal findings |
| Resident 1's physician | Medical Doctor (MD) | Confirmed he was not fully informed of Resident 1's condition on 2/19/23 and would have sent resident to ER if fully informed |
| Administrator | Administrator | Described IDT process and reliance on SBAR documentation for identifying changes in condition |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Oct 16, 2019
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to obtain accurate code status and advance directives for residents, specifically Residents 212 and 106, potentially placing residents at risk for not having their healthcare decisions honored.
Complaint Details
The complaint investigation focused on the facility's failure to obtain accurate code status and advance directives for residents, specifically Residents 212 and 106, which posed a risk of not honoring residents' healthcare decisions.
Findings
The facility failed to obtain accurate Physician Orders for Life-Sustaining Treatment (POLST) and advance directives reflecting residents' wishes for two residents, R212 and R106. Additional deficiencies included failure to assess significant changes in condition, inaccurate Minimum Data Set (MDS) assessments, incomplete PASARR screenings, lack of care planning for edentulous residents, failure to provide adequate incontinence care, inadequate hand hygiene during wound care, and unsafe environmental conditions such as hazardous decorations and broken faucet knobs.
Deficiencies (9)
Failure to obtain accurate code status and advance directives for Residents 212 and 106.
Failure to assess significant change in condition for Resident 79.
Failure to ensure accurate Minimum Data Set (MDS) assessments for Residents 32 and 56.
Failure to ensure accurate PASARR screening for Residents 108, 40, and 65.
Failure to develop a care plan for edentulous Resident 70.
Failure to provide screening and/or services to regain lost function for Resident 79.
Failure to provide thorough incontinence care for dependent Resident 73.
Failure to perform effective hand hygiene during wound care for Resident 107.
Failure to maintain a safe environment including fire hazards in Resident 12's room and jagged faucet knobs in room shared by Residents 19 and 49.
Report Facts
Residents reviewed for advance directives: 39
Residents sampled: 23
Deficiencies cited: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 90 | Licensed Vocational Nurse | Entered DNR status for Resident 212 without contacting resident's representative. |
| RN 176 | Registered Nurse | Verified POLST form signature dates and lack of training on POLST completion. |
| Medical Records Director (MRD) 115 | Medical Records Director | Confirmed POLST, Advance Directive form, and admission forms were not completed timely. |
| Admission Coordinator 84 | Admission Coordinator | Verified Advance Directives and POLST were not completed upon admission and conflicting legal representative information. |
| Social Service Director | Social Service Director | Spoke with resident's family but did not confirm code status. |
| LVN 92 | Licensed Vocational Nurse | Confirmed POLST form was signed by physician but not resident's representative; checked code status for residents. |
| RN 130 | Registered Nurse | Signed POLST as person assisting with the form for Resident 106. |
| Director of Nursing (DON) | Director of Nursing | Expected nurses to determine resident capacity and complete POLST; stated hand hygiene expectations. |
| MDS Coordinator | MDS Coordinator | Verified coding errors in MDS assessments and PASARR screenings. |
| CNA 67 | Certified Nursing Assistant | Failed to provide thorough incontinence care for Resident 73. |
| LVN 91 | Licensed Vocational Nurse | Observed performing inadequate hand hygiene during wound care. |
| Maintenance Director | Maintenance Director | Identified fire hazard in Resident 12's room decorations. |
| Maintenance Supervisor | Maintenance Supervisor | Acknowledged failure to identify and repair jagged faucet knob posing risk to Residents 19 and 49. |
| Administrator | Administrator | Expected accurate PASARR completion and immediate repair of hazards. |
Inspection Report
Deficiencies: 9
Date: Oct 16, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, assessments, care planning, infection control, safety, and other aspects of care at Bridgeview Post Acute nursing home.
Findings
The facility was found deficient in multiple areas including failure to obtain accurate code status and advance directives for residents, incomplete significant change assessments, inaccurate Minimum Data Set (MDS) assessments, incomplete PASARR screenings, lack of care planning for dental needs, failure to provide therapy for decline in activities of daily living, inadequate incontinence care, insufficient hand hygiene during wound care, and environmental safety hazards such as fire hazards and broken faucet knobs.
Deficiencies (9)
F 0578: The facility failed to obtain accurate code status and advance directives for two residents, risking that their health care decisions would not be honored.
F 0637: The facility failed to assess a resident for significant change in condition after a decline in activities of daily living.
F 0641: The facility failed to ensure accurate Minimum Data Set assessments for two residents, affecting the ability to provide appropriate services.
F 0645: The facility failed to complete accurate Level I PASARR screenings for three residents, risking lack of specialized services for mental disorders or intellectual disabilities.
F 0656: The facility failed to develop a care plan for a resident assessed as edentulous, potentially affecting dental care planning.
F 0676: The facility failed to provide screening or services to regain lost function for a resident with decline in activities of daily living.
F 0677: The facility failed to provide thorough incontinence care for a dependent resident, risking hygiene and skin integrity.
F 0880: The facility failed to ensure effective hand hygiene during wound care for a resident, risking spread of infection.
F 0921: The facility failed to maintain a safe environment by allowing fire hazards and not repairing a jagged faucet knob that could cause injury.
Report Facts
Residents reviewed: 23
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Hand wash scrub times: 7
Hand wash scrub times: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Verified expectations for PASARR accuracy and safety hazard corrections | |
| Director of Nursing (DON) | Notified of Immediate Jeopardy, stated expectations for hand hygiene and safety hazard corrections | |
| Medical Records Director (MRD) | Confirmed incomplete POLST and Advance Directive documentation | |
| Licensed Vocational Nurse (LVN) 90 | Entered incorrect code status without contacting resident representative | |
| Registered Nurse (RN) 176 | Verified POLST form signing and lack of training | |
| MDS Coordinator | Verified assessment and coding deficiencies | |
| Admissions Coordinator | Verified incomplete PASARR screenings and advance directive processing | |
| Certified Nursing Assistant (CNA) 67 | Failed to provide thorough perineal care | |
| Licensed Vocational Nurse (LVN) 91 | Observed performing inadequate hand hygiene during wound care | |
| Maintenance Director | Identified fire hazard in resident room | |
| Maintenance Supervisor | Acknowledged failure to identify and repair jagged faucet knob |
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