Bridgewood Post Acute
Bridgewood Post Acute in Sacramento, CA — inspection on December 30, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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 .
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