Bridgewood Post Acute
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
prior incidents with each other or any other residents. During an interview on 12/30/25 at 12:42 p.m. with
the Administrator (ADM), the ADM stated Resident 1 and Resident 2 were in wheelchairs in front of the nursing station when Resident 2 was trying to go around Resident 1 and moved her wheelchair. The ADM stated Resident 1 was startled and swung her arm and made contact with Resident 2's arm. The ADM stated he spoke with Resident 1 who stated she did not mean to hurt her but was startled. The ADM stated
a staff member witnessed the incident and separated the residents. The ADM stated there were no injuries to either resident. The ADM stated both residents are in the behavioral program and they are monitored for behavioral needs and have not had any previous incidents with each other or other residents. During a telephone interview on 12/30/25 at 12:58 p.m. with the Director of Rehab (DOR), the DOR stated she was a witness to the incident between Resident 1 and Resident 2 on 11/14/25. The DOR stated she saw both residents in their wheelchairs by the nursing station. The DOR stated Resident 2 wanted to get by and pushed Resident 1's wheelchair forward. The DOR stated Resident 1 reached back and swiped Resident 2's left hand. The DOR stated Resident 1 was upset because her wheelchair was moved and said, Don't push me. The DOR stated the residents were separated and then assessed by nursing. During a concurrent
observation and interview on 12/30/25 at 2:34 p.m. with Resident 2, observed Resident 2 with frequent mouth and jaw movements and folding blanket over and over. Resident 2 stated she was hit by a man in a wheelchair but did not recall any altercation with a woman. Resident 2 then indicated she did not want to talk any further.During an interview on 12/30/25 at 2:36 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was not aware of any incident between Resident 1 and Resident 2, but she had not seen any physically aggressive behaviors from Resident 1 or Resident 2. During an interview on 12/30/25 at 2:39 p.m. with Resident 1, Resident 1 stated a resident pushed her from the back and said, Get out of my way.
Resident 1 stated she did not try to hit her and stated, Please do not push me. Resident 1 stated she was startled when pushed. During an interview on 12/30/25 at 2:50 p.m. with Licensed Nurse (LN) 1, LN 1 stated Resident 1 has auditory hallucinations and is mostly quiet in her wheelchair but will yell and get upset. LN 1 stated Resident 2 has hallucinations and can be verbally aggressive but has not seen any physical aggression.A review of the facility's Policy and Procedure (P&P) titled Safety and Supervision of Residents, not dated, indicated . Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents and facility-wide priorities .Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment .The type and frequency of resident supervision may vary among residents and over time for
the same resident .
Event ID:
Facility ID:
If continuation sheet
BRIDGEWOOD POST ACUTE in SACRAMENTO, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SACRAMENTO, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BRIDGEWOOD POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.