Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0742
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental
disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress
disorder.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure that the physician's orders for psychiatric evaluation
and treatment were implemented and incorporated into the care plan for two of the three residents
(Residents 1 and 2). This failure resulted in Resident 1 and 2 not receiving mental health evaluation and
had the potential for both residents not to reach their highest practicable level of mental and psychosocial
well-being.Findings:
A record review of the facilities policy and procedures titled, Behavioral Assessment, Intervention and
Monitoring dated 2/2025, indicated:
- Behavioral symptoms are identified using facility approved behavioral screening tools and a
comprehensive assessment.
- Behavior is the response of an individual to a wide variety of factors. These factors may include medical,
physical, functional, psychosocial, emotional, psychiatric, or environmental causes.
- Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or
express thoughts that cannot be articulated.
- The nursing staff identify, document, and inform the physician about changes in an individual's mental
status, behavior, and cognition including onset, duration, intensity, and frequency of behavioral symptoms.
- The Interdisciplinary Team (IDT- a coordinated group of healthcare professionals who collaborate to
manage a resident's comprehensive care) thoroughly evaluates new or changing behavioral symptoms to
identify underlying causes and address any modifiable factors that may have contributed to the resident's
change in condition, including, emotional, psychiatric, or psychological stressors such as depression and
loneliness; functional, social, or environmental factors such as alteration in routine, sleep disturbances,
decline in ability to perform self-care or tasks that they could previously complete without help.
1. A record review of Resident 1's admission record, indicated Resident 1 was admitted to the facility on
[DATE] with diagnoses which included major depressive disorder (mood disorder that causes a persistent
feeling of sadness and loss of interest), cognitive communication deficit, and history of alcohol abuse.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
056346
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
02/10/2026
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 0742
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
A record review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 7/27/25,
indicated, Resident 1's had no cognitive impairment and had depression. Resident 1's MDS Mood
assessment indicated Resident 1 was feeling tired, had a poor appetite, and felt their life was a failure. MDS
indicated Resident 1 expressed they had little interest or pleasure in doing things.
A record review of Resident 1's hospital Discharge Summary dated 7/14/25 indicated Resident 1 was
discharged with a medication order for Paroxetine (anti-depressant) for depression.
A record review of Resident 1's physician order from 7/14/25 to 12/14/25, indicated, Resident 1 was not
prescribed Paroxetine or other anti-depressant medications.
A record review of Resident 1's physician order, dated 7/14/25, indicated Resident 1 had an order for
Psychiatric evaluation and treatment per psychiatrist for management of psychotropic meds and
Psychological services as needed.
A record review of Resident 1's Care Plans dated 7/19/25, indicated a care plan was initiated due to
Resident sometimes feels lonely or isolated from those around them.
A record review of Resident 1's Nurse Practitioner (NP) progress notes, dated 7/22/25, indicated that NP
ordered a psychiatric referral to assess for depression.
A record review of Resident 1's Physical Therapy (PT) progress notes, indicated, from 7/19/25 to 8/9/25,
Resident 1 refused PT 6 out of 15 times. PT progress notes indicated Resident 1 had low motivation and
required maximum encouragement to participate in therapy.
A record review of Resident 1's Occupational Therapy (OT) progress notes, dated, from 7/30/25 to 8/1/25,
and 8/6/25 to 8/8/25, Resident 1 refused to get out of bed. OT progress note, dated 8/7/25, indicated that
the nursing was made ware of Resident 1's Lack of participation.
A record review of Resident 1's care plans indicated a care plan was initiated on 9/4/25 for episodes of
refusing showers.
A record review of Resident 1's Social Services (SS) progress note, dated 11/6/25, indicated, Resident 1
immediately shut down and did not respond verbally when Family member (FM) notified him of the intent to
file for divorce.
During an interview on 1/29/26 at 11:51 am with CNA A, CNA A stated that Resident 1 was upset that FM
was divorcing them and sometimes asked, Why did FM leave me here?. CNA A stated Resident 1
minimally participated in personal hygiene care.
During a concurrent interview and record review with the Social Serves Director (SSD) on 1/29/26 at 12:26
pm, Resident 1's admission assessment was reviewed. When asked if Resident 1 had received any type of
counseling or psychological evaluation, SSD stated, No. SSD confirmed that Resident 1 was identified to
have depression during admission assessment. When asked about Resident 1's emotional state after
Resident 1 was informed about FM wanting a divorce, SSD stated Resident 1 shut down and wouldn't talk
to anyone. SSD confirmed that the facility did not initiate a new care plan or change in condition.
During an interview with Director of Nursing (DON) on 1/29/26 at 1:23 pm DON stated Resident 1's
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056346
If continuation sheet
Page 2 of 3
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
02/10/2026
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 0742
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
orders for Paroxetine were discontinued by the NP upon admission [DATE]). DON confirmed Resident 1
was not prescribed medications for treating depression from 7/15/25 to 12/14/25. DON confirmed Resident
1 had orders for a psychiatric evaluation dated 7/22/25. DON confirmed Resident 1 should have been
evaluated by psychiatry following their admission MDS assessment which identified depression.
During an interview with DON on 2/5/26 at 2:02pm DON stated, Resident 1's psychiatric referral Got away
from them and confirmed Resident 1 had no psychiatric services while at the facility.
During a concurrent interview and record review with NP on 2/5/26 at 3:15 pm NP stated, they avoid
prescribing Paroxetine for Residents due to the medicine's anticholinergic (dry mouth, constipation, urinary
retention, blurry vision, and confusion) effects. NP stated at the time of admission Resident 1 did not want
to continue Paroxetine however Resident 1's MDS Mood assessment indicated depression, and a new
psychiatric referral was ordered on 7/22/25. NP verbalized that they were unaware that Resident 1 had not
been evaluated by psychiatry and acknowledged Resident 1's psychiatric referral was not followed up on by
the nursing staff or the clinicians.
2. A record review of Resident 2's admission Summary Report, indicated that Resident 2 was admitted to
the facility on [DATE] to with diagnoses of major depressive disorder, cognitive decline, and cancer.
A record review of Resident 2's MDS Cognitive and Mood assessments, dated 11/15/25, indicated
Resident 2 had mild cognitive impairment and depression. Mood assessment indicated Resident 2 had
expressed that they felt bad about themselves, down and depressed, having little pleasure in doing things,
and difficulty staying asleep.
A record review of Resident 2's physician order, indicated that Resident 2 had a psychiatric referral,
evaluation, and treatment orders, dated 11/7/25 and 12/15/25. No psychiatric evaluations were found in
Resident 2's medical record.
A record review of Resident 2's NP progress notes dated 11/7/25 indicated, Resident 2 had orders for
monitoring for signs and symptoms of depression as evidenced by episodes of crying.
A record review of Resident 2's NP progress notes dated 12/15/25 indicated, Resident 2 had been
monitored for sign and symptoms of depression as evidenced by poor oral intake.
During a concurrent interview and record review with Registered Nurse (RN) B on 2/6/26 at 10:40 am,
Resident 2's medical record was reviewed. RN B was unable to locate any documentation regarding
Resident 2 having a psychiatric evaluation or treatment. RN B stated whoever received the order for
psychiatric referral is responsible for placing the order in the electronic health record (EHR) and to
communicate to the appropriate staff to coordinate care.
During an interview with Activities Assistant (AA) on 2/6/26 at 11:35 am, AA stated, on Monday (2/2/26)
Resident 2 was upset and crying. AA stated Resident 2 told them that they were upset because they were
dying.
During an interview with SSD on 2/6/26 at 11:40 am, SSD stated, [Resident 2] does get emotional and had
episodes of crying.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056346
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F742 - Based on the comprehensive assessment of a resident, the facility must
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
FAQ · About this visit
Common questions about this visit
What happened during the February 10, 2026 survey of BRIDGEVIEW POST ACUTE?
This was a inspection survey of BRIDGEVIEW POST ACUTE on February 10, 2026. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BRIDGEVIEW POST ACUTE on February 10, 2026?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psycho..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.