Bridgeview Post Acute

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

History and Physical Examination (H&P) by Medical Doctor (MD) X, dated [DATE REDACTED], the H&P indicated that Resident 4 was taken via ambulance to Hospital A's emergency room immediately following the fall. The H&P indicated Resident 4 was assessed and received advanced Computer Tomography (CT) (a special type of camera that takes detailed images of inside the brain and body) to look for injuries. The CT of the brain results indicated CT Brain without Contrast [DATE REDACTED] Impression: 1. Small acute left frontotemporal (the area of brain between the ears and forehead) subdural hematoma causing 3 mm of left-to-right midline or subfalcine shift (a small bleed inside the brain, that pushes the brain against the skull). The H&P also shows Fall leading to subdural hematoma. This H&P indicated the patient condition as having a poor outlook.During a review of records titled Progress Note: Interdisciplinary Team (IDT-a group of professionals from different disciplines who collaborate to provide care for the resident ) Note, dated [DATE REDACTED], indicated that Resident 4 was brought back to facility on [DATE REDACTED], after treatment at local hospital, and was placed on Hospice Care (treatment and care that focuses on comfort near the end of life). During a review of records titled Progress Note: Alert Note, dated [DATE REDACTED], indicated that Resident 4 had died at facility at approximately 9:21 pm that evening. During an interview with Facility Administrator (Admin) on [DATE REDACTED] at 12:30 pm, Admin stated that the facility did not report Resident 4's fall because they did not consider the injury significant. Admin stated, It wasn't an unusual occurrence. During an interview with the Director of Nursing (DON) on [DATE REDACTED] at 2:27 pm, DON stated No, we didn't report [the injury]. We didn't think it was an unusual occurrence.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bridgeview Post Acute

521 Lorel Way Yuba City, CA 95991

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679

Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review the facility failed to honor an activity preference that was developed in the activity care plan for one of three residents (Resident 1).This failure had the potential for Resident 1's mental and psychosocial needs not to be met.Findings:A review of a facility policy titled Activity Programs revised June of 2018, indicated activity programs are designed to meet the Interests of and support the physical, mental and psychosocial well-being of each resident. The Activities Program is provided to support the well-being of residents and to encourage both Independence and community interaction. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. The Activities Program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health. Individualized and group activities are provided that reflect the schedules, choices and rights of the residents, are offered at hours convenient to the residents, including evenings, holidays and weekends; and reflect the cultural and religious Interests, hobbies, life experiences and personal preferences of the residents.A review of Resident 4's record indicated he was admitted on [DATE REDACTED], with diagnoses of dementia and left sided weakness.

Resident 4 was unable to make his own health care decisions.A review of a quarterly activity participation

review dated 7/30/25, indicated Resident 4 enjoyed being outdoors. A review of an activity care plan dated 8/23/22, indicated staff will take Resident 4 out to sit in sun when the weather was nice.A review of Resident 4's activity participation notes dated from 1/3/25 to 9/11/25, indicated no activity for going outside

on the patio was documented in the record.During an interview on 10/15/25 at 1:50 pm, Activity Assistant (AA) stated Resident 4 had one on one activities. AA confirmed that they did not have an activity for residents as a group to go outside in either of the two outside patios at the facility. AA stated she had not taken Resident 4 out on the patios and was not aware that it was in his care plan. During a concurrent

observation and interview on 10/15/25 at 2 pm, Activity Director (AD) stated she was not aware that Resident 4 had a care plan which indicated he liked to go sit outside. AD confirmed there was not a group activity for residents to sit outside on the two patios at the facility. AD confirmed the activity department had not provided an outside activity for Resident 4 due staff not getting him up in his wheelchair. AD confirmed that the care plan did not give clear direction to staff if Resident 4 required supervision and how often while out on either patio. AD stated Resident 4 could be out there alone if they door was open to allow staff to hear him if he called out for assistance. AD confirmed all areas of the patio were not visible depending on where a resident was placed.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bridgeview Post Acute

521 Lorel Way Yuba City, CA 95991

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

that Activities Department had never done that. AD stated that Resident 4's Plan of Care did not include directions to staff on how to supervise Resident 4 outside on patios. AD confirmed that residents sitting outside on patio could not be visualized with direct line of sight at all times from AD's office, and stated that patio doors would have to be open to hear residents calling for help. During an interview with CNA Q on [DATE REDACTED] at 1:25 pm, CNA Q stated that you can't leave [Resident 4], or someone like him. [Resident 4] who was disoriented. If [residents] are not alert, you should stay with them. If they have dementia, you don't leave them. CNA Q confirmed that staff cannot fully visualize or supervise residents from the nursing desk next to the patio. There's a portion of the patio you can't see. During an interview with CNA P on [DATE REDACTED] at 2:30 pm, CNA P stated, its common sense that residents with dementia should not be out on the patio alone, especially during the hot months. CNA P stated, [Resident 4] needed total supervision at all times.

CNA P confirmed while looking at the computer entering resident information, that there was not a clear line of site to the patio, and that the other station was even further from the door to the patio. CNA P confirmed you could not hear nor see residents out on the patio due to the level of noise at the nursing stations. CNA P confirmed that Resident 4 was totally dependent on staff for everything, wheelchair bound and could only use his right side. CNA P stated that Resident 4 enjoyed sitting on both patios in the facility.During a concurrent interview and record review with the Director of Nursing (DON) on [DATE REDACTED] at 2:45 pm, DON reviewed the facility records and MDS reports for Resident 4, and confirmed that Resident 4 had been classified as a Moderate Fall Risk prior to his fall incident on [DATE REDACTED]. DON also verbally confirmed that Resident 4 had been dependent on staff for all care and mobility. DON stated that residents with dementia, dependent residents, or resident with mobility issues only need to be supervised every 30 minutes while outside on patio. DON verbally confirmed that there was no method for residents on patio to call for help, such as a call light. DON confirmed the plan of care did not include how Resident 4 could safely be supervised when he requested to go outdoor patio. During an interview with Family Representative (FP) on [DATE REDACTED], FP stated they found Resident 4 to have moderate to severe changes in condition following the fall on [DATE REDACTED]. FP stated [Resident 4] doesn't talk as much, he's not aware anymore.

When asked about the fall incident, FP stated It's my understanding that some nurse took [Resident 4] outside, left him there, and then he fell out and cracked his head. FP stated that while informing FP about

the fall, the facility told FP We had eyes on the patio doors. FP stated, the facility shouldn't leave anyone unsupervised.During a review of records titled Progress Note: Alert Note, dated [DATE REDACTED], indicated that Resident 4 had died at facility at approximately 9:21 pm that evening.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bridgeview Post Acute

521 Lorel Way Yuba City, CA 95991

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

further from the door to the patio. CNA P confirmed you could not hear nor see residents out on the patio due to the level of noise at the nursing stations. CNA P confirmed that Resident 4 was totally dependent on staff for everything, wheelchair bound and could only use his right side. CNA P stated that Resident 4 enjoyed sitting on both patios in the facility.During a concurrent interview and record review with the Director of Nursing (DON) on 10/15/25 at 2:45 pm, DON reviewed the facility records and MDS reports for Resident 4, and confirmed that Resident 4 had been classified as a Moderate Fall Risk prior to his fall incident on 9/1/25. DON also verbally confirmed that Resident 4 had been dependent on staff for all care and mobility. DON stated that residents with dementia, dependent residents, or resident with mobility issues only need to be supervised every 30 minutes while outside on patio. DON verbally confirmed that there was no method for residents on patio to call for help, such as a call light. During a review of records titled Communication/Inservice 1:1, dated 9/5/2025, indicated the Director of Staff Development (DSD) had provided specialized training to RNA H following Resident 4's fall incident on 9/1/25. The Communication Inservice indicated the main topic of Supervision and Safety, and indicated if a resident is fall risk or disoriented, then supervision will be provided throughout the entirety of their time outside.

Event ID:

Facility ID:

If continuation sheet