Inspection·March 7, 2024

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12/20/2023, Resident 1 had no diagnoses for mental disorders such as Depressive Disorder, Anxiety Disorder and had not been prescribed any psychotropic medications. A review of Skilled Charting dated: 12/29/2023, 12/30/2023, 12/31/2023, 1/1/2024, 1/2/2024, 1/04/2024, 1/05/2024, 1/06/2024 (at 12:03 am), 1/06/2024 (at 12:42 pm), 1/08/2024, 1/09/2024, 1/10/2024, 1/11/2024, 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, indicated Resident 1 had no changes to mood and behavior. A review of document titled Weekly Progress Notes dated 12/31/2023, Licensed Vocational Nurse (LVN 1) documented Resident 1 had no changes in behavior or mood, was alert and oriented, able to make her needs known, had no complaints, no signs of distress and was adjusting well to the new environment. A review of Progress Notes dated 12/31/2023, 12/30/2023, 12/29/2023, indicated Resident 1 was adjusting well, no signs of distress, no changes in behavior and able to verbalize her needs. A review of document titled Minimum Data Set (MDS-a resident assessment and care screening tool) dated 1/05/2024, by MDS Registered Nurse (MDS RN) documented that Resident 1 was not considered to have a serious mental illness, there was no evidence of an acute change in mental status. A review of document titled Progress Notes dated 1/03/2024 at 1:04 am, RN 3 documented Resident 1 was awake and alert, able to tell her needs, no complaints reported. A review of document titles Progress Notes dated 1/06/2024 at 12:52 pm, RN 1 documented Resident 1 had no signs of distress and no complaints reported. A review of document titled Weekly Progress Note dated 1/07/2024, RN 1 documented Resident 1 was awake and alert, had no changes in behavior or mood, was not on psychoactive medication and had no signs of distress. A review of document titled Progress Notes dated 1/11/2024 at 8:40 pm, Activities Assistant documented that Resident 1 enjoyed watching true crime stories and was happy. A review of document titled Progress Note, alert note, on 1/11/2024 at 1:30 pm, by Assistant Director of Nursing (ADON) documented Nurse Practitioner (NP) in to see Resident 1, Lexapro (antidepressant) for depression ordered 5 milligrams (mg) daily. A review of Resident 1's record indicated no nursing progress note by ADON nor any physician or NP notes found in the record to indicate the clinical justification for the Lexapro. A review of document titled Weekly Progress Note dated 1/14/2024, RN 2 documented Resident 1 had no changes in behavior or mood, verbalizes needs and continued Lexapro. During a phone interview on 2/14/2024 at 10:39 am, ADON stated he remembered Resident 1. ADON stated he could not recall the medical reason Resident 1 was started on a psychotropic. ADON stated that nothing in [his] mind makes [him] recall that she needed Lexapro. ADON stated that if he puts in an order for psychotropic medication, he does the informed consent right then. When told that no consent for the psychotropic medication could be found in the medical record, he stated he fills out the consent and the doctor review it, then it goes to medical records. ADON was unable to find or provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 2 of 19 Printed: 05/15/2026 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 056346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 0552 informed consent or nursing progress notes that it was given to Resident 1. Level of Harm - Minimal harm or potential for actual harm During a phone interview on 2/14/2024 at 10:02 am, Medical Director (MDir) stated the Interdisciplinary Team (IDT, a group of multidisciplinary team members who discuss resident plan of care) meet to discuss residents who are on psychotropic medications. MD stated there needs to be a clinical reason documented and discussed before starting a psychotropic, including informed consent (discuss risks and benefits) of a medication. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 3 of 19 Printed: 05/15/2026 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 056346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to create an accurate comprehensive admission assessment for one four sampled residents (Resident 1) when a physician ordered treatment for a Bilevel Positive Airway Pressure (BiPAP-a device to help breathing) was not identified. Residents Affected - Few This resulted in a decline in Resident 1 ' s respiratory and metabolic status (a condition where the decline of the lung function negatively affects the functioning of the rest of the body) requiring a transfer to a hospital for emergent treatment. Findings: A review of a facility policy titled Resident Assessments F636; F637; F638 undated, indicated a comprehensive assessment of each resident is completed at intervals. Comprehensive admission Minimum Data Set (MDS, resident assessment) include Care Area Assessment (CAA) process for resident care planning. Information for the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. A review of Resident 1 ' s hospital Discharge summary dated [DATE] at 1:08 pm, indicated she had been hospitalized for 9 days for treatment of acute respiratory failure with hypercapnia (respiratory system fails and carbon dioxide [a gas by product that is removed from the body by exhalation] builds up in the body), chronic obstructive pulmonary disease (COPD-a condition of the respiratory system causing shortness of breath, cough, fatigue and frequent lung infections), toxic metabolic encephalopathy (a condition of acute brain dysfunction resulting in seizures, behavior changes , memory loss, confusion and altered consciousness) and congestive heart failure. During her hospitalization she was started on BiPAP. Resident 1 was transferred to a long-term care facility on 12/29/2023. During a review of hospital document titled Discharge Planning Needs sent to facility from hospital dated 12/29/2023 at 3:16 pm, by Case Manager Social Worker (CM/SW, coordinates care between hospital and care facility) indicated Resident 1 ' s discharge plan to facility was discussed with Resident 1 ' s family member how important it was for Resident 1 for the facility was to supply BiPAP for patient. A review of hospital document titled Discharge Summary, and Order Sheet indicated that the primary discharge packet was sent via fax by the hospital and received by the long-term care facility at 3:01 pm and 3:05 pm on 12/28/2023. A review of hospital order sheet faxed to the long-term care facility dated 12/29/2023 at 11:25 am, indicated a hospital medical doctor ordered BiPAP on at bedtime and off for 6 hours during the day to keep her oxygen level above 90-92% (normal is 95-100%). A review of an admission assessment dated [DATE] at 5:42 pm, by Licensed Vocational Nurse (LVN) 1, no documentation of Resident 1 ' s need for BiPAP was noted. A review of document titled Baseline Care Plan -WH-, which took place on 12/30/2023, Minimum Data Set Registered Nurse (MDS RN) indicated Resident 1 could communicate her needs with the staff and was oriented. MDS RN checked the box 1a under special treatments, procedures and program that Resident 1 would need oxygen therapy - while a resident. MDS RN did not check the box 1e in the assessment to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 4 of 19 Printed: 05/15/2026 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 056346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 0641 indicate that Resident 1 would need BiPAP/CPAP. Level of Harm - Minimal harm or potential for actual harm A review of the admission MDS dated [DATE], indicated under Section O G1, BiPAP was not selected and C3 indicated oxygen therapy was intermittent. Residents Affected - Few A review of a respiratory care plan dated 1/1/24, and updated 1/22/24, indicated no interventions related to the management of the BiPAP for Resident 1. During a concurrent interview and record review on 2/14/2024 at 11:30 am, MDS RN confirmed Resident 1 ' s BiPAP was not included in the admission MDS. MDS RN stated Resident 1 ' s hospital discharge summary should have been scanned into the electronic medical record and given to admissions nurse. MDS RN stated she was unaware Resident 1 ' s BiPAP was ordered/delivered to her room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 5 of 19 Printed: 05/15/2026 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 056346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to create a baseline care plan that included a respiratory treatment for one four sampled residents (Resident 1) when she did not receive her physician ordered Bilevel Positive Airway Pressure (BiPAP-a device that helps breathing). This resulted in a decline in Resident 1 ' s respiratory and metabolic status (a condition where the decline of the lung function negatively affects the functioning of the rest of the body) requiring a transfer to a hospital for emergent treatment. Findings: A review of a policy and procedure titled Care Plans - Baseline - F655, revised March 2022, indicated that the baseline care plan includes instructions needed to provide effective, person-centered care of the resident .must include the minimum healthcare information necessary to properly care for the resident including .physician orders. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop a comprehensive care plan to meet the needs of the resident. A baseline care plan includes but not limited to any services and treatments to be administered by the facility personnel. A review of Resident 1 ' s hospital Discharge summary dated [DATE] at 1:08 pm, indicated she had been hospitalized for 9 days for treatment of acute respiratory failure with hypercapnia (respiratory system fails and carbon dioxide [a gas by product that is removed from the body by exhalation] builds up in the body), chronic obstructive pulmonary disease (COPD-a condition of the respiratory system causing shortness of breath, cough, fatigue and frequent lung infections), toxic metabolic encephalopathy (a condition of acute brain dysfunction resulting in seizures, behavior changes, memory loss, confusion and altered consciousness) and congestive heart failure. During her hospitalization she was started on BiPAP. Resident 1 was transferred to a long-term care facility on 12/29/2023. A review of hospital document titled Discharge Planning Needs sent to facility from hospital dated 12/29/2023 at 3:16 pm, by Case Manager Social Worker (CM/SW, coordinates care between hospital and care facility) indicated Resident 1 ' s discharge plan to facility was discussed with Resident 1 ' s family member how important it was for Resident 1 for the facility was to supply BiPAP for patient. A review of hospital document titled Discharge Summary, and Order Sheet indicated that the primary discharge packet was sent via fax by the hospital and received by the long-term care facility at 3:01 pm and 3:05 pm on 12/28/2023. A review of hospital order sheet faxed to the long-term care facility dated 12/29/2023 at 11:25 am, indicated a hospital medical doctor ordered BiPAP on at bedtime and off for 6 hours during the day to keep her oxygen level above 90-92% (normal is 95-100%). A review of an admission assessment dated [DATE] at 5:42 pm, by Licensed Vocational Nurse (LVN) 1, no documentation of Resident 1 ' s need for BiPAP was noted. During a concurrent interview and record review of a Baseline Care Plan -WH dated, 12/30/2023, the Minimum Data Set Registered Nurse (MDS RN) confirmed Resident 1 ' s BiPAP was not included in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 6 of 19 Printed: 05/15/2026 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 056346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete baseline care plan. MDS RN confirmed she checked the box 1a under special treatments, procedures, and program that Resident 1 would need oxygen therapy - while a resident. MDS RN did not check the box 1e in the assessment to indicate that Resident 1 would need BiPAP/CPAP. MDS RN stated she did not create the baseline care plan assessment at the bedside because Resident 1 was admitted on a 12/29/23, and the care plan needed to be completed within 48 hours of admission. MDS RN stated she was unaware of the fax order dated 12/29/23. Event ID: Facility ID: 056346 If continuation sheet Page 7 of 19 Printed: 05/15/2026 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 056346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) received respiratory care when a physician ordered Bilevel Positive Airway Pressure (BiPAP-a device that helps breathing) was not implemented for 14 days. This resulted in an emergent transfer to hospital for treatment for severe respiratory failure (not enough oxygen) for five days. Residents Affected - Few Findings: A review of Resident 1 ' s hospital Discharge summary dated [DATE] at 1:08 pm, indicated she had been hospitalized for 9 days for treatment of acute respiratory failure with hypercapnia (respiratory system fails and carbon dioxide [a gas by product that is removed from the body by exhalation] builds up in the body), chronic obstructive pulmonary disease (COPD-a condition of the respiratory system causing shortness of breath, cough, fatigue and frequent lung infections), toxic metabolic encephalopathy (a condition of acute brain dysfunction resulting in seizures, behavior changes , memory loss, confusion and altered consciousness) and Congestive Heart Failure (CHF, weak heart causes fluid buildup). During her hospitalization she was started on BiPAP-a breathing machine. Resident 1 was transferred to a long-term care facility on 12/29/2023. During a review of hospital document titled Discharge Planning Needs sent to facility from hospital dated 12/29/2023 at 3:16 pm, by Case Manager Social Worker (CM/SW, coordinates care between hospital and care facility) indicated Resident 1 ' s discharge plan to facility was discussed with Resident 1 ' s family member how important it was for Resident 1 for the facility was to supply BiPAP for patient. A review of facility policy titled CPAP/BiPAP Support and Cleaning, dated March 2015, indicated only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP/BiPAP mask. A resident ' s medical record should be reviewed to determine his/her baseline oxygen saturation (amount of oxygen that's circulating in your blood), respiratory, circulatory status. The physician ' s order should be reviewed to determine the oxygen concentration and flow and pressure settings for the machine. A review of hospital document titled Discharge Summary, and Order Sheet indicated that the primary discharge packet was sent via fax by the hospital and received by the long-term care facility at 3:01 pm and 3:05 pm on 12/28/2023. A review of hospital order sheet faxed to the long-term care facility dated 12/29/2023 at 11:25 am, indicated a hospital medical doctor ordered BiPAP on at bedtime and off for 6 hours during the day to keep her oxygen level above 90-92% (normal is 95-100%). A record review of an admission assessment dated [DATE] at 5:42 pm, by Licensed Vocational Nurse (LVN) 1, no documentation of Resident 1 ' s need for BiPAP was noted. A review of Resident 1 ' s record dated from 12/29/23 to 1/16/24, indicated there was no documentation found that nursing staff called the physician to verify if Resident 1 was to continue the BiPAP machine. A review of a document titled Order Summary, indicated that there was an oxygen order dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 8 of 19 Printed: 05/15/2026 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 056346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 0695 12/29/2023, for Resident 1 to receive 3 liters via nasal cannula (a flexible tube worn under the nose delivering oxygen) or shortness of breath, as needed. Level of Harm - Actual harm Residents Affected - Few A review of document titled Weights and Vitals Summary for January 2024, Resident 1 had been receiving supplemental oxygen via nasal cannula from 1/6/2024 to 1/11/2024 during the day, and room air only from 1/11/2024 to 1/13/2024 at night. Resident 1 received BiPAP at bedtime only from 1/12/24 to 1/16/2024. A review of document titled Minimum Data Set (MDS is a tool for implementing standardized assessment and facilitating care management in nursing homes) dated 1/5/2024, by MDS Registered Nurse (MDS RN) no documentation for BiPAP was found in the record. A review of a Care Conference note dated 1/12/2024, a meeting was held between Responsible Party (RP, decision maker), Social Services Director (SSD), Director of Nursing (DON), and Administrator (Admin). RP expressed a concern that Resident 1 was not receiving BiPAP. After the care conference concluded, RP called SSD and repeated her concerns. SSD and Admin approached LVN 1 and questioned where the BiPAP machine was located. LVN 1 and Admin went to Resident 1 ' s room and could not locate the machine. LVN 1 located BiPAP in Resident 1 ' s closet in a pink bag. A review of a physician order dated 1/12/24, 14 days after admission, the BiPAP was ordered with settings for Resident 1, the oxygen saturation level should be at 90- 92%, at bedtime for sleep apnea (breathing starts and stops during sleep). During a review of a Progress Notes dated 1/15/2024, at 1:19 pm, Social Services Assistant (SSA) documented Resident 1 declined a room visit and stated she was not feeling well. There was no indication in the documentation that nursing staff performed an assessment of her overall status. During a review of document titled Change in Condition (SBAR) assessment dated [DATE] at 10:18 am, indicated the reason for the SBAR was Resident 1 was experiencing shortness of breath (SOB) and her oxygen saturation level was 76 % (oxygen saturation levels below 90% can lead to a serious deterioration in health status) when receiving oxygen via nasal cannula. The Medical Director (MDir) was notified. During a review a progress note on 1/16/2023 at 1:26 pm, RN 1 documented that an order was received to transfer Resident 1 to the hospital due to SOB. On 1/16/2024 at 2:50 pm, Assistant Director of Nurses (ADON) documented Resident 1 ' s oxygen saturation decreased. Nurse Practitioner (NP) notified; orders received to transfer Resident 1 to hospital. No further documentation was found in Resident 1 ' s record for ongoing assessment of oxygen saturation from 10:23 am until five hours later at 3:02 pm, done at the hospital. During an interview on 1/25/2024 at 10:40 am, the admission Supervisor (AS) stated the process for admissions was the case manager at the hospital would send her the resident ' s referrals and orders. AS stated, after receiving the information she sends it to Director of Nursing (DON), Assistant Director of Nursing (ADON), nursing staff and therapy departments via email and uploads the orders into the Electronic Medical Record (EMR). AS stated, that on 12/28/2023, Resident 1 ' s orders came by fax on several pieces of paper. AS explained orders would be emailed to the admission nursing staff. AS stated, a separate fax was received from the hospital with orders containing the settings for a BiPAP machine. AS stated, she did not think she needed to give this to the nursing staff and faxed the order to Interactive Medical Services (IMS-medical device supply company). AS reported, she did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 9 of 19 Printed: 05/15/2026 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 056346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 0695 not email, print, or upload the faxed BiPAP order and settings into the electronic medical record that admissions, nursing staff, and medical director have access to. Level of Harm - Actual harm Residents Affected - Few During a phone interview on 1/25/2024 at 11 am, the Interactive Medical Services representative (IMS-R, a BiPAP equipment rental agency) stated Resident 1 ' s BiPAP machine was delivered to the facility with preset settings on 12/29/2023 at 3:04 pm and was signed for by Licensed Vocational Nurse (LVN) 2. During an interview on 1/25/2024 at 2:40 pm, LVN 2 stated she had six admissions on 12/29/2023, it was very hectic. LVN 2 stated that she felt so overwhelmed with six admissions that she told ADON she would quit if they accepted a seventh admission. LVN 2 stated she remembered signing for Resident 1 ' s BiPAP machine and putting it at Resident 1 ' s bedside. LVN 2 stated that DON and Admin left at 2 pm that day. During a concurrent interview and record review on 1/25/2024 at 12 pm, Assistant Director of Nursing (ADON) stated he entered BiPAP order and diagnosis on 1/12/2024. ADON confirmed Resident 1 ' s documented diagnosis for the BiPAP was COPD and hypercapnia which utilizes BiPAP to help rid the body of excess carbon dioxide. ADON confirmed Resident 1 ' s BiPAP machine was delivered on 12/29/2024, and that Resident 1 did not use the BiPAP as ordered until 1/12/2024. During an interview on 1/25/2024 at 12:17 am, DON stated her expectations was the nursing staff should have verified physician orders for the BiPAP during the admission process for Resident 1. DON further stated the licensed nursing staff should have followed up when the BiPAP machine delivered and set up in Resident 1's room. DON stated licensed nurses should complete and document all respiratory assessments in the record when there was a change in condition. During interview on 1/25/2024 at 1:55 pm, SSD stated Resident 1 ' s RP called her on 1/12/24, and inquired about the BiPAP machine that her mother should have had since admission. SSD stated she called the RP later stating the BiPAP was found and now at Resident 1's bedside. A review of a hospital Discharge summary dated [DATE] at 10:16 am, the physician indicated Resident 1 was brought in by ambulance on 1/16/24, with increasing fatigue and altered mental status (changes in mood/cognitive function). Physician documented Resident 1 was found to have significant hypercapnia and was admitted to a step down unit for acute respiratory failure, COPD exacerbation, large pleural effusion (build up of fluid around and in lung tissue), pulmonary edema (too much fluid in lungs, and CHF exacerbation (worsening). Resident 1 was discharged from the hospital on 1/31/24, after five days. During a concurrent interview and record review on 2/7/2024 at 9:19 am, DON confirmed that in Resident 1 ' s admission Assessment document dated 12/29/2023 there was no BiPAP noted. DON confirmed there was no BiPAP documentation on Resident 1 ' s Baseline Care Plan dated 12/29/2023. DON confirmed that Resident 1 ' s BiPAP was not ordered by MDir until 1/12/2024, 14 days after admission. DON confirmed Resident 1 ' s hospital Discharge Summary was not scanned into EMR. During a phone interview on 2/14/2024 at 9:47 am, Medical Records Director (MRD) stated on the day of Resident 1 ' s admission on [DATE], there were six admissions. MRD stated that three admissions were their average and there had only been two occasions in the last eight years where there were six admissions. MRD stated that the staff was panicked, left in a scramble, was not prepared for the influx of residents, and felt abandoned. MRD stated that the Admin, DON, the business representative, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 10 of 19 Printed: 05/15/2026 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 056346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 0695 and admissions staff left early that day. When asked if she saw Resident 1 ' s order for BiPAP, she confirmed that she was unaware of the BiPAP order. Level of Harm - Actual harm Residents Affected - Few During a concurrent interview and record review on 2/14/2024 at 11:30 am, MDS RN confirmed Resident 1 ' s BiPAP was not in initial care plan. MDS RN stated Resident 1 ' s hospital discharge summary should have been scanned into EMR and given to the admissions nurse. MDS RN confirmed it could not be found in EMR and stated she was unaware Resident 1 ' s BiPAP was ordered and delivered at bedside. During a phone interview on 2/14/2024 at 10:13 am, MDir stated he was not responsible for how many admissions a facility would receive, but that six admissions in one day would be unusual. MDir stated the admissions coordinator puts everything into the EMR (which he has access to) including discharge records from hospital, which he reads after admission is finalized. When told that AS had the order for the BiPAP prior to admission and that it did not come in until 14 days post admission, MDir stated AS should have relayed that to DON or ADON. MDir stated he did not know how any of that happened. Regarding Resident 1 not feeling well after not receiving ordered BiPAP for 14 days, MDir stated if she wasn ' t doing well, what could happen, did happen. Carbon dioxide goes up, then she would eventually become lethargic, and comatose. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 11 of 19 Printed: 05/15/2026 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 056346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure enough nursing staff had the appropriate competencies and skills to implement a respiratory plan of care for one of four sampled resident (Resident 1). This failure resulted in a decline in Resident 1 ' s respiratory and metabolic status (a condition where the decline of the lung function negatively affects the functioning of the rest of the body) resulting in emergent transfer to a hospital for treatment. Refer to F695. Findings: A review of facility policy titled CPAP/BiPAP Support and Cleaning dated March 2015, indicated only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP/BiPAP mask. A resident ' s medical record should be reviewed to determine his/her baseline oxygen saturation, respiratory, circulatory status. The physician ' s order should be reviewed to determine the oxygen concentration and flow and pressure settings for the machine. A review of Resident 1 ' s hospital Discharge summary dated [DATE] at 1:08 pm, indicated she had been hospitalized for 9 days for treatment of acute respiratory failure with hypercapnia (respiratory system fails and carbon dioxide [a gas by product that is removed from the body by exhalation] builds up in the body), chronic obstructive pulmonary disease (COPD-a condition of the respiratory system causing shortness of breath, cough, fatigue and frequent lung infections), toxic metabolic encephalopathy (a condition of acute brain dysfunction resulting in seizures, behavior changes , memory loss, confusion and altered consciousness) and congestive heart failure. During her hospitalization she was started on bilevel positive airway pressure (BiPAP-a breathing machine that delivers positive air pressure when you breathe in and out). Resident 1 was transferred to a long-term care facility on 12/29/2023. During a review of hospital order sheet faxed to the long-term care facility dated 12/29/2023 at 11:25 am, indicated a hospital medical doctor ordered BiPAP on at bedtime and off for 6 hours during the day to keep her oxygen level above 90-92% (normal is 95-100%). During a record review of an admission assessment dated [DATE] at 5:42 pm, by Licensed Vocational Nurse (LVN) 1, no documentation of Resident 1 ' s need for BiPAP was noted. During a review of a document titled Order Summary, indicated that there was an oxygen order dated 12/29/2023, for Resident 1 to receive 3 liters via nasal cannula (a flexible tube worn under the nose delivering oxygen) or shortness of breath, as needed. A review of a physician order dated 1/12/24, 14 days after admission, the BiPAP was ordered with settings 40, 92, AS 14/6, BUR 10, titrate oxygen saturation at 90- 92% at bedtime for sleep apnea (breathing starts and stops during sleep). During concurrent interview and record review on 1/24/2024 at 11:30 am with Director of Staff Development (DSD-person in charge of planning employee training and professional development classes), she confirmed she could not produce any documentation of in-services/instruction to staff for BiPAP use. DSD confirmed that physician order for BiPAP was in the Resident 1 ' s record on 12/29/2024 but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 12 of 19 Printed: 05/15/2026 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 056346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 did not show up in active orders (orders that instruct nurses how to care for residents) until 1/12/2024. Level of Harm - Minimal harm or potential for actual harm During interview on 1/24/2024 at 2:28 pm with Licensed Vocational Nurse Infection Preventionist (LVN-IP) stated she has not had any training on using BiPAP machines. Residents Affected - Some During an interview on 1/25/2024 at 10:30 am with LVN 7, LVN 5 at 10:40 and LVN 1 at 3:15 pm, all reported having no in-services for BiPAP. During an interview on 1/25/2024 at 12:17 am, DON stated her expectations was the nursing staff should have verified physician orders for the BiPAP during the admission process for Resident 1. DON further stated the licensed nursing staff should have followed up when the BiPAP machine delivered and set up in Resident 1's room. DON stated licensed nurses should complete and document all respiratory assessments in the record when there was a change in condition. DON confirmed there were no in-services/training on the use of BiPAP machines. During a concurrent interview and record review on 2/7/2024 at 9:19 am, DON confirmed that in Resident 1 ' s admission Assessment document dated 12/29/2023 there was no BiPAP noted. DON confirmed there was no BiPAP documentation on Resident 1 ' s Baseline Care Plan dated 12/29/2023. DON confirmed that Resident 1 ' s BiPAP was not ordered by MDir until 1/12/2024, 14 days after admission. DON confirmed Resident 1 ' s hospital Discharge Summary was not scanned into electronic medical record so all staff have access to it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 13 of 19 Printed: 05/15/2026 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 056346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that one of four residents (Resident 1) was free of an unnecessary psychotropic medication (drug prescribed to affect the mind, emotions, or behavior) when she was prescribed Lexapro (medication used to treat depression and anxiety) was administered without clinical indication. This failure resulted in Resident 1 to receive an unnecessary medication and put her at risk for adverse side effects such as sedation, dry mouth, weakness, headaches, dizziness, nausea and being unable to sleep. Refer to F552. Findings: A review of facility policy titled Psychotropic Medication Use, dated July 2022, indicated the use of any psychotropic medication is based on comprehensive review of the resident. Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. A review of facility policy titled Informed Consent Verification, undated, indicated the facility shall verify that informed consent (IC) has been obtained by the physician before a psychotherapeutic medication is administered. When a medication is going to be used in a psychotherapeutic manner the facility will need to verify from the physician or their office staff that IC has been obtained and will need to obtain the indication for use from the physician. The facility staff who are authorized to take such orders shall either document or include the printed or electronic version of the IC with the resident ' s medical record. Resident 1 was admitted to the facility on [DATE], with diagnoses which included heart failure, acute and chronic respiratory failure with hypercapnia ( a disease affecting the lungs ability to remove carbon dioxide or deliver oxygen to your blood) and chronic obstructive pulmonary disease (COPD) with acute exacerbation and bronchitis due to respiratory syncytial virus (COPD refers to a group of diseases that cause airflow blockage and breathing related problems complicated by a respiratory infection) and cognitive communication deficit (difficulty communicating, thinking, remembering and responding accurately). A review of a Discharge Summary from the local hospital dated 12/29/2024, Resident 1 was noted to be able to give a clear history and was not taking any psychotropic medications. A review of hospital document titled Preadmission Screening and Resident Review (PASRR-a pre-admission screening for mental illness performed by the hospital before discharge) dated 12/20/2023, Resident 1 had no diagnoses for mental disorders such as Depressive Disorder, Anxiety Disorder and had not been prescribed any psychotropic medications. A review of Progress Notes dated 12/31/2023, 12/30/2023, 12/29/2023 and 1/3/24, Resident 1 was documented as adjusting well, no signs of distress, no changes in behavior and able to verbalize her needs. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 14 of 19 Printed: 05/15/2026 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 056346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of facility ' s documents titled Skilled Charting dated: 12/29/2024, 12/30/2024, 12/31/2024, 1/1/2024, 1/2/2024, 1/04/2024, 1/05/2024, 1/06/2024 (at 0:03 am), 1/06/2024 (at 12:42 pm), 1/08/2024, 1/09/2024, 1/10/2024, 1/11/2024, 1/12/2024, 1/13/2024, 1/14/2023, 1/15/2023 all the documents indicated Resident 1 had no changes in her mood and behavior. A review of Weekly Progress Notes dated 12/31/2023, Licensed Vocational Nurse (LVN) 1 documented Resident 1 had no changes in behavior or mood, was alert and oriented, able to make her needs known, had no complaints, no signs of distress and was adjusting well to the new environment. A review of a Minimum Data Set (MDS-a resident assessment and care screening tool) dated 1/05/2024 by MDS RN documented that Resident 1 was not considered to have a serious mental illness, there was no evidence of an acute change in mental status. A review of Progress Notes dated 1/06/2024 at 12:52 pm, Registered Nurse (RN) 1 documented Resident 1 had no signs of distress and no complaints reported. A review of Weekly Progress Note dated 1/07/2024, RN 1 documented Resident 1 was awake and alert, had no changes in behavior or mood, was not on psychoactive medication and had no signs of distress. A review of an Order Details dated 1/11/2024 at 1:26 pm, by Nurse Practitioner (NP) indicated Escitalopram Oxalate (Lexapro) 5 mg once daily by mouth for depression. This order was documented as created and confirmed by Assistance Director of Nursing (ADON) on 1/11/2024 at 1:26 pm. A review of a Progress Note, alert note, on 1/11/2024 at 1:30 pm, by ADON documented Nurse Practitioner (NP) in to see Resident 1, probiotics ordered, Lexapro for depression ordered 5 mg daily. No documentation or clinical indications were found indicating Resident 1 was depressed. No Interdisciplinary Team (IDT-a meeting of health care team members to coordinate resident treatment/care) meeting notes indicating Resident 1 was depressed. No informed consent for psychotropic drugs were found in record. A review of a Weekly Progress Note dated 1/14/2024, RN 2 documented Resident 1 had no changes in behavior or mood, verbalizes needs and continues Lexapro. A review a Progress Notes dated 1/11/2024 at 8:40 pm, Activities Assistant documented that Resident 1 enjoyed watching true crime stories and was happy. During a phone interview on 2/14/2024 at 10:39 am, ADON stated he could not recall the clinical need for Resident 1 to be taking a psychotropic drug. ADON stated that if he puts in an order for psychotropic medication, he does the informed consent right then. When told that no consent for the psychotropic medication could be found in the medical record, he stated he fills out the consent and the doctor review it, then it goes to medical records. ADON was given the opportunity to send this office a copy of the informed consent. No consent has been received. During a phone interview on 2/14/2024 at 10:02 am with Medical Director (MDir) stated, usually the Interdisciplinary Team (IDT, a group of multidisciplinary team members who discuss resident plan of care) meet to discuss residents who are on psychotropic medications. MDir stated there needs to be a clinical reason documented and discussed before starting a psychotropic, including informed consent (discuss risks and benefits) of a medication. When told that there was no indication in her medical record that Resident 1 was depressed, MDir stated that may have just been bad judgement by the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 15 of 19 Printed: 05/15/2026 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 056346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 0758 Nurse Practitioner. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 16 of 19 Printed: 05/15/2026 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 056346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 0841 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the Medical Director (MD) supervised the development and implementation of a plan of care for one of four sampled residents (Resident 1) when: 1. Upon admission orders for BiPAP (device to help breathing) were not implemented. Refer to F 695 2.a. Informed consent was not obtained before administering a psychotropic (alters mood behavior) medication. Refer to F 552 b. An unnecessary psychotropic was prescribed without clinical justification. Refer to F 758 This failure resulted in respiratory failure that required emergent hospitalization and an unnecessary psychotropic medication to be administered without clinical justification. Findings: A review of a facility policy titled Medical Director revised July 2016, indicated physician services are under the general supervision of the Medical Director (MD). The MD was responsible for ensuring adequate and appropriate physician services. MD was to oversee and help develop and implement care related policies and practices. MD to participate in efforts to improve quality of care and services. MD to help assure residents receive services to meet their needs by assuring resident care plan reflects the medical regimen. 1. A review of Resident 1 ' s hospital Discharge summary dated [DATE] at 1:08 pm, indicated she had been hospitalized for 9 days for treatment of acute respiratory failure with hypercapnia (respiratory system fails and carbon dioxide [a gas by product that is removed from the body by exhalation] builds up in the body), chronic obstructive pulmonary disease (COPD-a condition of the respiratory system causing shortness of breath, cough, fatigue and frequent lung infections), toxic metabolic encephalopathy (a condition of acute brain dysfunction resulting in seizures, behavior changes , memory loss, confusion and altered consciousness) and congestive heart failure. During her hospitalization she was started on bilevel positive airway pressure (BiPAP-a breathing machine that delivers positive air pressure when you breathe in and out). Resident 1 was transferred to a long-term care facility on 12/29/2023. A review of hospital document titled Discharge Planning Needs sent to facility from hospital dated 12/29/2023 at 3:16 pm, by Case Manager Social Worker (CM/SW, coordinates care between hospital and care facility) indicated Resident 1 ' s discharge plan to facility was discussed with Resident 1 ' s family member how important it was for Resident 1 for the facility was to supply BiPAP for patient. A review of facility policy titled CPAP/BiPAP Support and Cleaning, dated March 2015, indicated only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP/BiPAP mask. A resident ' s medical record should be reviewed to determine his/her baseline oxygen saturation, respiratory, circulatory status. The physician ' s order should be reviewed to determine the oxygen concentration and flow and pressure settings for the machine. A review of hospital document titled Discharge Summary, and Order Sheet indicated that the primary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 17 of 19 Printed: 05/15/2026 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 056346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 0841 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few discharge packet was sent via fax by the hospital and received by the long-term care facility at 3:01 pm and 3:05 pm on 12/28/2023. A review of hospital order sheet faxed to the long-term care facility dated 12/29/2023 at 11:25 am, indicated a hospital medical doctor ordered BiPAP on at bedtime and off for 6 hours during the day to keep her oxygen level above 90-92% (amount of oxygen in blood, normal is 95-100%). A review of an admission assessment dated [DATE] at 5:42 pm, by Licensed Vocational Nurse (LVN) 1, no documentation of Resident 1 ' s need for BiPAP was noted. A review of Resident 1 ' s record, there was no documentation found that nursing staff called the physician to verify if Resident 1 was to continue the BiPAP machine as documented in Resident 1 ' s discharge summary. A review an Order Summary, indicated that there was an oxygen order dated 12/29/2023, for Resident 1 to receive 3 liters via nasal cannula (a flexible tube worn under the nose delivering oxygen) or shortness of breath, as needed. A reviewWeights and Vitals Summary for January 2024, Resident 1 had been receiving supplemental oxygen via nasal cannula from 1/6/2024 to 1/11/2024 during the day, and room air only from 1/11/2024 to 1/13/2024 at night. Resident 1 received BiPAP at bedtime only from 1/12/24 to 1/16/2024. A review of a physician order dated 1/12/24, 14 days after admission, the BiPAP was ordered with settings 40, 92, AS 14/6, BUR 10, titrate oxygen saturation at 90- 92% at bedtime for sleep apnea (breathing starts and stops during sleep). A review of a Change in Condition (SBAR) assessment dated [DATE] at 10:18 am, indicated the reason for the SBAR was Resident 1 was experiencing shortness of breath (SOB). Medical Director (MDir) was notified. A review a progress notes on 1/16/2023 at 1:26 pm, RN 1 documented that an order was received to transfer Resident 1 to the hospital due to SOB. On 1/16/2024 at 2:50 pm, Assistant Director of Nurses (ADON) documented Resident 1 ' s oxygen saturation decreased. Nurse Practitioner (NP) notified; orders received to transfer Resident 1 to hospital. No further documentation was found in Resident 1 ' s record for ongoing assessment of oxygen saturation from 10:23 am until five hours later at 3:02 pm, done at the hospital. A review of a hospital Discharge summary dated [DATE] at 10:16 am, the physician indicated Resident 1 was brought in by ambulance on 1/16/24, with increasing fatigue and altered mental status (changes in mood/cognitive function). Physician documented Resident 1 was found to have significant hypercapnia and was admitted to a step down unit for acute respiratory failure, COPD exacerbation, large pleural effusion (build up of fluid around and in lung tissue), pulmonary edema (too much fluid in lungs, and CHF exacerbation (worsening). Resident 1 was discharged from the hospital on 1/31/24, after five days. 2.A review of a hospital Discharge summary dated [DATE], indicated Resident 1 was able to give a clear history and was not taking any psychotropic medications. A review of a Preadmission Screening and Resident Review (PASRR-screening for mental illness) dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 18 of 19 Printed: 05/15/2026 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 056346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2024 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 0841 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 12/20/2023, Resident 1 had no diagnoses for mental disorders such as Depressive Disorder, Anxiety Disorder and had not been prescribed any psychotropic medications. A review Minimum Data Set (MDS-a resident assessment and care screening tool) dated 1/05/2024, by MDS Registered Nurse (MDS RN) documented that Resident 1 was not considered to have a serious mental illness, there was no evidence of an acute change in mental status. A review of Skilled Charting dated: 12/29/2023, 12/30/2023, 12/31/2023, 1/1/2024, 1/2/2024, 1/04/2024, 1/05/2024, 1/06/2024 (at 12:03 am), 1/06/2024 (at 12:42 pm), 1/08/2024, 1/09/2024, 1/10/2024, 1/11/2024, 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, indicated Resident 1 had no changes to mood and behavior. A review of document titled Progress Note, alert note, on 1/11/2024 at 1:30 pm, by Assistant Director of Nursing (ADON) documented Nurse Practitioner (NP) in to see Resident 1, Lexapro (antidepressant) for depression ordered 5 milligrams (mg) daily. A review of Resident 1's record indicated no nursing progress note by ADON nor any physician or NP notes found in the record to indicate the clinical justification for the Lexapro. During a phone interview on 2/14/2024 at 10:13 am, Medical Director (MDir) stated he was not responsible for how many admissions a facility would receive, but that six admissions in one day would be unusual. MDir stated the admissions coordinator puts everything into the Electronic Medical Record (EMR, which he has access to) including discharge records from hospital, which he reads after admission was accepted. When told that AS had the order for the BiPAP prior to admission and that it did not come in until 14 days post admission, MDir stated AS should have relayed that to DON or ADON. MDir stated he did not know how any of that happened. Regarding Resident 1 not feeling well after not receiving ordered BiPAP for 14 days, MDir stated if she wasn ' t doing well, what could happen, did happen. Carbon dioxide goes up, then she would eventually become lethargic, and comatose. MDir stated, usually the Interdisciplinary Team (IDT, a group of multidisciplinary team members who discuss resident plan of care) meet to discuss residents who are on psychotropic medications. MDir stated there needs to be a clinical reason documented and discussed before starting a psychotropic, including informed consent (discuss risks and benefits) of a medication. When told that there was no indication in her medical record that Resident 1 was depressed, MDir stated that may have just been bad judgement by the Nurse Practitioner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 19 of 19