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Bridgewood Post Acute: Wheelchair Collision - CA
The November 14 incident involved two residents enrolled in the facility's behavioral program....
Latest reports, citations, and penalties from CMS data
The November 14 incident involved two residents enrolled in the facility's behavioral program....
Resident 1 at Meadowbrook Post Acute was supposed to be checked every 30 minutes after her May 13, 2025 fall that sent her to the hospital with a head injury....
Columbia Crest Center denied readmission to a cognitively intact resident who used an electric wheelchair and required assistance with personal care....
Registered Nurse #30 entered Resident #26's room at 8:06 A.M....
The incident occurred December 4th at Lodi Creek Post Acute, where Resident 1's meloxicam was scheduled for 8:00 AM but not administered until 9:46 AM....
The assault was discovered through the facility's security camera system....
Federal inspectors found no care plan existed for any of the three residents during a December 30 complaint investigation....
The director told inspectors on December 30 that she relied on nurses to inform her of concerns from the reports rather than reviewing them herself....
Resident 1 had been placed in isolation due to suspected scabies and received a doctor's order for permethrin cream....
Resident 1 approached department heads complaining that items were missing related to use of their bank card....
Resident 3 was classified as high risk for falls and required frequent visual checks....
Resident 1, admitted in late 2025 with a urinary tract infection and weakness, had an uncovered urinal stored in the bottom drawer of their closet....
The assessment painted a picture of serious respiratory distress....
She had come in with Type 1 diabetes, muscle wasting, and dehydration....
The fall happened on December 22, 2025....
When an inspector arrived at his room on December 30, 2025, just before noon, Resident 2 was visibly upset....
Federal inspectors found that Citrus Grove Post Acute failed to ensure a safe discharge for the resident on December 17, 2025....
That is what inspectors found at Imperial Healthcare Center following a complaint investigation completed December 31, 2025....
"[Resident 2] is not calm," Certified Nurse's Aide 1 told inspectors....
LVN B, interviewed by inspectors that afternoon, laid out how the system was supposed to work....