Bridgewood Post Acute
5901 Lemon Hill Avenue · Sacramento, CA · 95824 · 9163832741
49 certified beds For profit - Individual Chain: Spyglass Healthcare
Why this verdict
- Carries CMS’s abuse warning icon.
- No federal fines or payment denials in CMS’s 3-year window.
- Inspection results have improved across recent cycles.
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Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 3 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 4.12 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.50 | 0.55–0.75 |
| Weekend hours / resident-day | 3.73 | ≈ weekday level |
| Nursing turnover / year | 35% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (53 in the current record)
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Potential for harm · D January 28, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Past Non-Compliance · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 30, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 23, 2026 · Quality of Life and Care
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Potential for harm · D July 24, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected August 15, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 5, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected June 20, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 5, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected June 20, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 5, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected June 20, 2025 · Pharmacy Service
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Potential for harm · E June 5, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected June 20, 2025 · Pharmacy Service
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Potential for harm · E June 5, 2025
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.
Corrected June 20, 2025 · Pharmacy Service
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Potential for harm · E June 5, 2025
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected June 20, 2025 · Nutrition and Dietary
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Potential for harm · E June 5, 2025
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.
Corrected June 20, 2025 · Nutrition and Dietary
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Potential for harm · E June 5, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected June 20, 2025 · Nutrition and Dietary
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Potential for harm · E June 5, 2025
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected June 20, 2025 · Environmental
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Potential for harm · D April 30, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected May 20, 2025 · Resident Assessment and Care Planning
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Potential for harm · E April 30, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected May 20, 2025 · Pharmacy Service
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Actual harm · G January 23, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected January 28, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D October 8, 2024 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected October 9, 2024 · Resident Assessment and Care Planning
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Potential for harm · D September 3, 2024 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected September 4, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E July 11, 2024
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.
Corrected July 11, 2024 · Resident Rights
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Potential for harm · E July 11, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected July 11, 2024 · Resident Assessment and Care Planning
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Potential for harm · D July 11, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected July 11, 2024 · Resident Assessment and Care Planning
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Potential for harm · D July 11, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected July 11, 2024 · Resident Assessment and Care Planning
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Potential for harm · D July 11, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected July 11, 2024 · Quality of Life and Care
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Potential for harm · D July 11, 2024
Provide enough food/fluids to maintain a resident's health.
Corrected July 11, 2024 · Quality of Life and Care
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Potential for harm · E July 11, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected July 11, 2024 · Pharmacy Service
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Potential for harm · D July 11, 2024
Ensure that residents are free from significant medication errors.
Corrected July 11, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 055956 · certified since November 1, 1969. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.