Bridgeview Post Acute
BRIDGEVIEW POST ACUTE in YUBA CITY, CA — inspection on October 15, 2025.
Found 4 citations. 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 a review of records titled Progress Note: Alert Note, dated [DATE], indicated that Resident 4 had died at facility at approximately 9:21 pm that evening.
During an interview with Facility Administrator (Admin) on [DATE] 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] at 2:27 pm, DON stated No, we didn't report [the injury]. We didn't think it was an unusual occurrence.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bridgeview Post Acute
521 Lorel Way Yuba City, CA 95991
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bridgeview Post Acute
521 Lorel Way Yuba City, CA 95991
SUMMARY STATEMENT OF DEFICIENCIES
During an interview with CNA Q on [DATE] 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] 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] 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]. 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], FP stated they found Resident 4 to have moderate to severe changes in condition following the fall on [DATE]. 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], indicated that Resident 4 had died at facility at approximately 9:21 pm that evening.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bridgeview Post Acute
521 Lorel Way Yuba City, CA 95991
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID: