Inspection·October 15, 2025

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], 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] 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], indicated that Resident 4 was brought back to facility on [DATE], 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], 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. Event ID: Facility ID: 056346 If continuation sheet Page 2 of 10 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 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], 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: 056346 If continuation sheet Page 3 of 10 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 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a plan of care for safety and supervision for one of three sampled residents (Resident 4), when Restorative Nursing Assistant (RNA) H left Resident 4 alone outside on a patio for 30 minutes, where Resident 4 fell and sustained a subdural hematoma (bleeding between the brain and its lining). This deficient practice resulted in Resident 4 experiencing a major head injury, emergency care at hospital, and a significant decline in their quality of life. Resident 4 was transferred to the hospital on [DATE] after he fell. Resident 4 returned to the facility on [DATE], with Hospice services (specialized end of life care). Resident 4 passed away at the facility on [DATE], 13 days following the fall.Refer to F609, F679 and F726.FindingsDuring a review of facility policy titled Assessing Falls and their Causes, revised [DATE], indicated falls are a leading cause of morbidity and mortality among the elderly in nursing homes. Falling may be related to underlying clinical or medical conditions, overall functional decline, medication side effects, and/or environmental risk factors. Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly.During a review of Resident 4's Facility admission Record, indicated that Resident 4 was admitted on [DATE], with diagnoses that included Vascular Dementia (a condition where the brain doesn't get enough blood flow, causing problems with memory and thinking), hemiplegia and hemiparesis (weakness and difficulty moving one side of the body) following nontraumatic intracerebral hemorrhage (a stroke, where brain tissue is damaged by a leaking blood vessel), and muscle weakness.During a review of Resident 4's Minimum Data Set (MDS: a standardized resident assessment and care screening tool), dated [DATE], indicated that the Resident 4 had a Brief Interview for Mental Status score of 99 (a quick, verbal quiz that tests memory and shows how a person's brain is working) indicating the resident had been unable to fully participate in the assessment due to their mental state, and was likely confused. The MDS indicated that Resident 4's functional status required one-person assistance with bed mobility, and transfers. The MDS data indicated that Resident 4's ability to walk was unsteady. During a review of Resident 4's Care Plan on Fall, last revised on [DATE], indicated [Resident 4] had hx (history) of falls r/t (related to) weakness, poor balance, impaired in communication, impaired decision making ability, poor safety awareness, incontinence (unable to control urine flow or bowels), on cardiac meds (heart medications), on narcotics (strong pain medications) and diagnosis of CVA (a stroke, where brain tissue is damaged by a leaking blood vessel) with left sided weakness. This Care Plan on Fall indicated interventions for Resident 4 that included activities that minimize the potential for falls while providing diversion and distraction. [Resident 4] needs a safe environment with even floors free from spills and/or clutter.Educate [Resident 4]/family/caregivers about safety reminders and what to do if a fall occurs. This care plan also indicated [Resident 4] has an ADL (activities of daily living) self-care performance deficit r/t CVA with left hemiplegia, impaired cognition, impaired in communication, poor endurance, with interventions listed including Provide appropriate assistance in all ADLs. This Care Plan on Fall also indicated that staff should provide Resident 4 with prompt response to all requests for assistance. This Care Plan on Fall also indicated [Resident 4] needs a safe environment with even floors free from spills and/or clutter, adequate, glare-free light; a working and reachable call light, and the bed in low position.During a review of Resident 4's activity Care Plan Report, revised [DATE], indicated preferred activities are sitting in the sun. This Care Plan Report also indicated that Resident 4 needs activities that minimize the potential for falls while providing diversion and distraction. This Care Plan Report does not indicate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 4 of 10 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 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 how to provide those activities, or what kind of supervision was needed. During a review of Resident 4's Progress Note: Alert Note dated [DATE], indicated Resident was found on the ground outside the patio. Resident 4 was found to be unresponsive to verbal or tactile stimuli (trying to cause a patient to respond verbally or physically), he has a pulse and has shallow breathing. The Progress Note also indicated Resident 4 was unresponsive, had unstable vital signs, and was soon transported to local hospital for evaluation. This Progress Note also indicated according to investigation of fall, [RNA H] took [Resident 4] outside to the patio, and [Resident 4] was found on the ground afterward.During a review of local Hospital A records titled History and Physical Examination (H&P) by Medical Doctor (MD) X, dated [DATE], 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 (imaging that does not use special contrast dyes inside the body) [DATE] Impression: 1. Small acute left frontotemporal (the area of brain between the ears and forehead) subdural hematoma causing 3 millimeter 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 Resident 4's condition as poor prognosis.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], indicated that Resident 4 was brought back to facility on [DATE], 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 Communication/Inservice 1:1, dated [DATE], indicated the Director of Staff Development (DSD) had provided specialized training to RNA H following Resident 4's fall incident on [DATE]. 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. During a review of facility records titled Fall Incident Occurrence [DATE], a written statement by the facility's Infection Preventionist Licensed Vocational Nurse (IP LVN) describing Resident 4's fall on [DATE], the IP wrote As I was running down the hallway with a staff member, I asked her what happened, and she said they found him outside on the ground. I asked her who took him outside and why wasn't there someone with him. She said she doesn't know. This written statement also indicated I questioned [RNA H] why she took [Resident 4] outside, why did she take him outside if she was not going to stay with him, why didn't she stay with him, why didn't she ask for someone to stay with him if she couldn't stay with him, why didn't she let someone know that she left him outside, and why didn't she let his nurse know. This written statement also indicated [RNA H] was very distraught and crying. She said she was sorry; she confirmed with me that she didn't think to let anyone know. This written statement also indicated IP explained to RNA H that confused residents cannot be left alone outside without a staff supervision. During a review of Registered Nurse C's (RN C) untitled written statement, dated [DATE], indicated [RNA H] did not tell me when she took [Resident 4] outside to the patio. And I did not know [Resident 4] was outside until his CNA told me that he is on the ground. During an interview with Facility Administrator (Admin) on [DATE] at 12:30 pm, Admin stated [CNA H] admitted there was nobody at the nursing station [after placing Resident 4 on patio alone]. Admin also stated that depending on the level of visual supervision, if staff had been at the nursing station, [the patio] would have been safe. During an observation on [DATE], at 12:40 pm, the facility's patio courtyard was approximately 15 feet wide and 25 feet long, and located in the center of the building. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 5 of 10 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 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 patio was not covered, and open under the sky. The patio was found to have numerous potted plants, decorations, a metal table, umbrella, and metal chairs. The large double doors of the patio were clear glass, and located directly next to the central nursing desk. The doors were found to be moderately heavy, and did not open automatically. It was found that only approximately 50% of the patio could be visualized while sitting at any of the nursing station desks. The second nursing desk did not have clear line of vision onto the patio.During an interview with RNA H on [DATE] at 10:25 am, RNA H stated she had taken care of Resident 4 many times in the past. RNA H stated Yes, they had a high fall risk wristband on. RNA H stated that she took Resident 4 onto the facility patio in a wheelchair, and left him there alone. RNA H stated she did not see anyone at nursing station desks at that time. RNA H stated that Resident 4 was placed on patio at approximately 8:30 am on the morning of [DATE], and was found fallen on ground at approximately 9:00 am. RNA H stated she did make a mistake by leaving Resident 4 alone on patio.During an interview with Registered Nurse (RN) C on [DATE] at 10:07 am, RN C stated they had cared for Resident 4 many times in the past few years, and knew Resident 4's abilities and habits. RN C stated that Resident 4 was dependent on staff for all mobility, including in a wheelchair. RN C stated they were the assigned bedside nurse for Resident 4 on [DATE], the day of the fall incident. RN C stated that they had not been told that Resident 4 was sitting on the patio in his wheelchair. RN C stated that Resident 4 should have received more supervision on the patio, stating Yes, in my professional opinion, [Resident 4] should have had more supervision. During an interview with LVN E on [DATE] at 10:35 am, LVN E stated that Resident 4 did not have adequate supervision alone on the patio. LVN E stated that Resident 4's fall could have been prevented if we knew about it, or he was being supervised. LVN E also stated that verbal communication is the best way to provide safe and competent care to residents. During an interview with Certified Nursing Assistant J (CNA J) on [DATE] at 1:07 pm, CNA J stated they had worked at facility in the past, and had taken care of Resident 4 several times. CNA J stated that the morning of [DATE], they were assigned CNA for Resident 4. RNA H had been assisting Resident 4 at breakfast. CNA J was performing his other usual CNA duties, and an unknown staff member passed by and informed CNA J that Resident 4 was yelling on a patio. CNA J stated he did not know where the patio was located, and began looking for the patio in question. CNA J stated I started looking for [Resident 4] right away. CNA J stated that he found Resident 4 on the ground of central patio, next to his wheelchair, groaning. CNA J then called for help, and other staff came to assist. CNA J stated that prior to the fall, no staff member verbally informed him that Resident 4 was on the patio. CNA J stated that prior to the fall, he did not have verbal contact with RNA H, and said I didn't speak to [RNA H] until afterwards. During an interview with the IP LVN on [DATE] at 9:37 am, IP LVN stated she did interview RNA H immediately following the fall incident on [DATE]. IP LVN stated she asked RNA H Why didn't you let anyone know where he was? and that RNA H replied to IP LVN I didn't think to let anyone know. IP LVN stated that RNA H did not tell Resident 4's assigned staff of his location on the patio. IP LVN stated RNA H should have told more people, she should have known better. During an interview with Medical Doctor Z (MD Z) on [DATE] at 9:35 am , MD Z confirmed that they were one of the treating physicians for Resident 4, and performed the medical assessment on [DATE]. MD Z stated I identified a small bleed, a subdural hematoma. MD Z also stated Yes its absolutely a major injury, any bleed in the brain is a big deal. There was also midline shift (when bleeding and pressure inside skull becomes strong enough to push brain to one side), that was concerning. MD 1 stated that a major injury like this could negatively impact a person's quality of life. During an interview with Activities Director (AD) on [DATE] at 2:00 pm, AD stated that Resident 4's Care Plans had included going outside on facility patios, but (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 6 of 10 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 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] 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. Event ID: Facility ID: 056346 If continuation sheet Page 7 of 10 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 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 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 that direct care staff had competencies necessary to care for one out of three sampled residents (Resident 4) when Restorative Nursing Assistant H (RNA H) left Resident 4 alone on a patio for 30 minutes, where Resident 4 fell and sustained a major head injury. This deficient practice resulted in Resident 4 experiencing a major head injury, admission to an acute care hospital, a decline in condition, and eventually death. This failure also had the potential for incompetent staff to care for other residents. FindingsDuring a review of records titled Restorative Nursing Assistant (RNA) Job Description, indicated that RNA H signed the document on 8/26/25, indicating they understood the duties and responsibilities outlined. The RNA Job Description indicated that RNA H's Duties and Responsibilities included Follow established safety precautions in the performance of all duties.Help residents to perform tasks for him/herself as appropriate as assigned in resident's plan of care.Follow appropriate safety, hygiene and infection control measures.Review care plans daily and Keep the nurses' call system within easy reach of the resident.During a review of Resident 4's Facility admission Record, indicated that Resident 4 was admitted on [DATE] with diagnoses that included Vascular Dementia (a condition where the brain doesn't get enough blood flow, causing problems with memory and thinking), hemiplegia and hemiparesis (weakness and difficulty moving one side of the body) following nontraumatic intracerebral hemorrhage (a stroke, where brain tissue is damaged by a leaking blood vessel), and muscle weakness.During a review of Resident 4's Minimum Data Set (MDS: a standardized resident assessment and care screening tool), dated 7/29/25, the MDS indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 99 (BIMS: a quick, verbal quiz that tests memory and shows how a person's brain is working) indicating the resident had been unable to fully participate in the assessment due to their mental state, and was likely confused. The MDS indicated that Resident 4's functional status required one-person assistance with bed mobility, and transfers, and Resident 4's ability to walk was unsteady. During a review of Resident 4's Care Plan on Fall, last revised on 8/4/25, indicated [Resident 4] had hx (history) of falls r/t (related to) weakness, poor balance, impaired in communication, impaired decision making ability, poor safety awareness, incontinence (unable to control urine flow or bowels), on cardiac meds (heart medications), on narcotics (strong pain medications) and diagnosis of CVA (a stroke, where brain tissue is damaged by a leaking blood vessel) with left sided weakness. This Care Plan on Fall indicated interventions for Resident 4 that included activities that minimize the potential for falls while providing diversion and distraction. [Resident 4] needs a safe environment with even floors free from spills and/or clutter.Educate [Resident 4]/family/caregivers about safety reminders and what to do if a fall occurs. This care plan also indicated [Resident 4] has an ADL (activities of daily living) self-care performance deficit r/t CVA with left hemiplegia (one side of he body is weak or paralyzed), impaired cognition, impaired in communication, poor endurance, with interventions listed including Provide appropriate assistance in all ADLs. This Care Plan on Fall also indicated that staff should provide Resident 4 with prompt response to all requests for assistance. [Resident 4] needs a safe environment with even floors free from spills and/or clutter, adequate, glare-free light; a working and reachable call light, and the bed in low position.During a review of Resident 4's Progress Note: Alert Note dated 9/1/25, indicated Resident was found on the ground outside the patio. Resident was found to be unresponsive to verbal or tactile stimuli (trying to cause a patient to respond verbally or physically), he has a pulse and has shallow breathing. The Progress Note also indicated Resident 4 had unstable vital signs, and was soon (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 8 of 10 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 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 transported to local hospital for evaluation. This Progress Note also indicated, According to investigation of fall, [RNA H] took [Resident 4] outside to the patio, and [Resident 4] was found on the ground afterward.During a review of Registered Nurse (RN) C's untitled written statement, dated 9/1/25, the untitled statement indicated [RNA H] did not tell me when she took [Resident 4] outside to the patio [in his wheelchair]. And I did not know [Resident 4] was outside until his CNA told me that he is on the ground. During an interview with the Director of Nursing (DON) on 9/11/25 at 10:18 am, DON confirmed that RNA H did not tell appropriate staff the location of Resident 4 on the patio. Yes, [RNA H] should have told more people. DON also verbally confirmed that the nursing station was empty at the time of the incident. During an interview with RN C on 9/11/25 at 10:07 am, RN C stated they had cared for Resident 4 many times in the past few years, and knew Resident 4's abilities and habits. RN C stated that Resident 4 was dependent on staff for all mobility, including in a wheelchair. RN C stated they were the assigned bedside nurse for Resident 4 on 9/1/25, the day of the fall incident. RN C stated that they had not been told that Resident 4 was sitting on the patio in his wheelchair. RN C stated that Resident 4 should have received more supervision on the patio, stating Yes, in my professional opinion, [Resident 4] should have had more supervision. RN C stated [RNA H] should have told more people, [RNA H] could see that the nursing station was empty. During an interview with RNA H on 9/11/25 at 10:25 am, RNA H stated she had taken care of Resident 4 many times in the past. RNA H stated Yes, they had a high fall risk wristband on. RNA H stated she did take Resident 4 onto the facility patio in a wheelchair, and left him there alone. RNA H stated she didn't see anyone at nursing station desks at that time. RNA H stated that Resident 4 was placed on patio at approximately 8:30 am on the morning of 9/1/25, and was found fallen on ground at approximately 9:00 am. RNA H stated they felt that they did make a mistake by leaving Resident 4 alone on patio.During an interview with Licensed Vocational Nurse (LVN) E on 9/11/25 at 10:35 am, LVN E stated that Resident 4 did not have adequate supervision on the patio. LVN E stated that Resident 4's fall Could have been prevented if we knew about it, or he was being supervised. LVN E also stated that verbal communication between staff members is the best way to provide safe and competent care to residents.During an interview with Certified Nursing Assistant (CNA) Q on 10/15/25 at 1:25 pm, CNA Q stated, No, you can't leave [Resident 4], or someone like him. [Resident 4] 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 R on 10/15/25 at 1:40 pm, CNA R stated that residents with dementia, are confused, or already a high fall risk, are more at risk for accidents when outside on patios. CNA R stated that previous to fall incident of 9/1/25, CNA R had also taken Resident 4 outside onto a patio, but had stayed with him, provided one-on-one supervision, and brought him back inside after five minutes. CNA R stated she would not have left Resident 4 outside on patio alone, and stated Everyone knows not to do that. CNA R stated that Resident 4 needed more supervision, and that she would have checked on Resident 4 every five minutes. CNA R stated that staff at the nursing desk cannot fully visualize residents on the patio, and stated You can't see the full patio from the desk.During an interview with CNA P on 10/15/25 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 also verbally confirmed that [Resident 4] was totally dependent on staff for everything, wheelchair bound and could only use his right side. 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 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056346 If continuation sheet Page 9 of 10 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 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: 056346 If continuation sheet Page 10 of 10