Medicare flags this nursing home for abuse. Medicare adds this flag when a home was cited for abuse that harmed a resident, or for potential abuse more than once. Ask the home what changed.
Inspection citations
19’23
19’24
14’25
2’26
54 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jul 10, 2026 | E · potential | Provide safe and appropriate respiratory care for a resident when needed. | Complaint |
| Jan 28, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Dec 30, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jul 24, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jun 5, 2025 | D · potential | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Routine |
| Jun 5, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Jun 5, 2025 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Jun 5, 2025 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Jun 5, 2025 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Jun 5, 2025 | E · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Jun 5, 2025 | E · potential | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Routine |
| Jun 5, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jun 5, 2025 | E · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
| Apr 30, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Apr 30, 2025 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Jan 23, 2025 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Oct 8, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Sep 3, 2024 | D · potential | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Complaint |
| Jul 11, 2024 | E · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Jul 11, 2024 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Jul 11, 2024 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Jul 11, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Jul 11, 2024 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Routine |
| Jul 11, 2024 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Jul 11, 2024 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Jul 11, 2024 | D · potential | Ensure that residents are free from significant medication errors. | Routine |
| Jul 11, 2024 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Jul 11, 2024 | D · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Jul 11, 2024 | E · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Routine |
| Jul 11, 2024 | E · potential | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Routine |
| Jul 11, 2024 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jul 11, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Jul 11, 2024 | D · potential | Keep all essential equipment working safely. | Routine |
| Jun 12, 2024 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Apr 11, 2024 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jun 29, 2023 | E · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Jun 29, 2023 | E · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Jun 29, 2023 | E · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Jun 29, 2023 | E · potential | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Routine |
| Jun 29, 2023 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Jun 29, 2023 | E · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Jun 29, 2023 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Jun 29, 2023 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Jun 29, 2023 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Jun 29, 2023 | E · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| Jun 29, 2023 | D · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Routine |
| Jun 29, 2023 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Jun 29, 2023 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jun 29, 2023 | F · potential | Provide and implement an infection prevention and control program. | Routine |
| Jun 29, 2023 | E · potential | Implement a program that monitors antibiotic use. | Routine |
| Jun 29, 2023 | E · potential | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Routine |
| Jun 29, 2023 | E · potential | Have a Compliance and Ethics Program. | Routine |
| Jun 29, 2023 | E · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Jun 29, 2023 | D · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Bridgewood Post Acute
5901 Lemon Hill Avenue, Sacramento, CA 95824 · (916) 383-2741
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 055956
- Certified beds
- 49
- Legal owner
- Bridgewood Post Acute LLC
- Part of
- Spyglass Healthcare
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
Is this your business, or is something wrong? Request a correction. It's free, and we never charge to be listed.
Other nursing homes in Sacramento
- Cedarwood Post Acute4 of 5 stars overall
- Sherwood Healthcare Center5 of 5 stars overall
- Saylor Lane Healthcare Center4 of 5 stars overall
- Mid-Town Oaks Post-Acute3 of 5 stars overall
- Arden Park Post Acute2 of 5 stars overall
- Sacramento Post-Acute4 of 5 stars overall
Nursing homes near Sacramento
- Nursing homes in Sacramento
- Nursing homes in Carmichael 8
- Nursing homes in Citrus Heights 1
- Nursing homes in Elk Grove 1
- Nursing homes in Fair Oaks 1
- Nursing homes in Folsom 1
- Nursing homes in Galt 1
- Nursing homes in Rancho Cordova 1
- Search near Sacramento on a map
- All senior living and care in Sacramento