Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bridgeview Post Acute during CMS and state inspections, most recent first.
The facility failed to implement physician orders for psychiatric evaluation and treatment and to integrate these services into the care plans for two residents with diagnosed depression. One resident was admitted with major depressive disorder and a hospital discharge order for an antidepressant that was not continued, had an MDS showing depression, repeatedly refused therapy, showed low motivation and withdrawal after learning of a divorce, and had psychiatric referrals ordered but never completed. Another resident with major depressive disorder, cognitive decline, and cancer had documented depressive symptoms, including crying and poor intake, and had two separate psychiatric referral orders with no evidence of any psychiatric evaluation or treatment in the record. Staff interviews confirmed that psychiatric referrals were not followed through and that no counseling or psychological services were provided, resulting in both residents not receiving ordered mental health evaluations and services.
A resident with dementia, hemiplegia, and a high fall risk was left unsupervised on an outdoor patio by an RNA for about 30 minutes. The resident, dependent on staff for mobility and unable to call for help, was later found on the ground with a major head injury. The care plan did not specify supervision needs for outdoor activities, and staff were unaware of the resident's location. The resident suffered a subdural hematoma and died after emergency care.
A resident with significant cognitive and physical impairments was left unattended on a patio by a staff member, resulting in a fall that caused a subdural hematoma. The facility did not report the major injury to authorities, as required, because leadership did not consider it significant or unusual. This failure delayed investigation into the incident.
A resident with dementia and left-sided weakness, who enjoyed being outdoors, was not provided with outdoor activities as specified in their care plan. Activity staff were unaware of the care plan directive, and no documentation showed the resident was taken outside. The care plan also lacked clear instructions for supervision and frequency of outdoor activities, and staff did not facilitate the resident's participation due to not getting the resident up in a wheelchair.
A resident with vascular dementia, hemiplegia, and a history of falls was left unsupervised on a patio by an RNA for approximately 30 minutes, resulting in a major head injury and subsequent death. The resident was dependent on staff for all mobility and required close supervision, but staff failed to communicate the resident's location and did not provide adequate monitoring. The patio area could not be fully visualized from the nursing stations, and there was no call system available for the resident to request help.
A resident with multiple medical conditions and intact cognition reported being slapped by another resident, resulting in visible injuries. Although the incident was documented and known to facility leadership, it was not reported to the state agency as required by policy, due to staff misunderstanding about reporting requirements when the perpetrator has dementia.
Two residents with dementia and a history of falls experienced repeated incidents due to the facility's failure to determine the causes of falls, reevaluate care plan interventions, and develop new strategies to prevent further injuries. Direct care staff were not adequately informed about high fall risk residents or their care plans, and the electronic system used by CNAs did not provide sufficient information. The DON confirmed gaps in root cause analysis and communication regarding fall prevention interventions.
The facility failed to maintain a safe and homelike environment by storing construction materials in the rooms of three residents, creating potential hazards and cleanliness issues. Family members and residents raised concerns about tripping hazards and dustiness. The facility's policy required proper storage of supplies, which was not followed.
The facility failed to meet food safety and sanitation standards, with improper storage, labeling, and dating of food items in kitchen refrigerators. Expired and unlabeled food items were found, and kitchen equipment was unsanitary, with debris and grease on surfaces. Sanitizer levels were inconsistent, and dishwashing logs were incomplete. The kitchen environment was not clean, with food crumbs and spills on floors and walls. Resident food was not labeled or stored per policy, posing a risk of foodborne illness.
The facility failed to provide adequate social services and timely care for four residents, leading to unmet needs and potential delays in care. Care plans were not updated, financial assistance was not provided, and necessary referrals for outside services were delayed. Additionally, dental services were not promptly provided, resulting in significant delays for one resident.
The facility failed to properly store and label medications and supplies, with loose pills found in a medication cart, six medications opened but not dated, and expired Foley drainage bags and Pro-Stat liquid protein being used. The DON and ADON confirmed these actions were against facility policy.
Several residents in the facility reported issues with food being overcooked, undercooked, cold, or unappetizing. Despite complaints, the Dietary Manager failed to address these concerns effectively. Observations confirmed that food was not maintained at appropriate temperatures, with delays in meal service contributing to the problem. The facility's policies for food preparation and distribution were not followed, impacting the quality and safety of meals.
The facility failed to ensure resident dignity and privacy, as staff spoke in non-English languages in front of residents, night shift noise disturbed residents, and a CNA did not provide privacy during personal care. A resident was also inappropriately instructed to clean her own toilet, causing distress.
The facility failed to investigate and report alleged abuse involving three residents. A CNA did not report suspicions of abuse when a resident showed fear during care. Another resident was instructed by a housekeeper to clean her own toilet, and the incident was not reported. A third resident reported being held down by a CNA, but the incident was not investigated, and the CNA continued to care for the resident.
A facility failed to document essential details for a resident's transfer to a hospital, including the date, time, destination, and mode of transportation. The resident, who had undergone hip replacement surgery and experienced a change in condition, was transferred without proper documentation, as confirmed by the DON.
A resident with severe cognitive impairment and a history of falls was observed without non-skid footwear, contrary to his care plan. Despite requiring maximal assistance, he was left to dress himself, and his call light was out of reach. A CNA assisted him but did not provide footwear, as the resident was not assigned to him that day. The DSD confirmed the need for non-skid footwear to prevent falls.
Two residents with g-tubes in an LTC facility received inappropriate care due to staff not following Physician's orders. One resident received incorrect fluid amounts, risking fluid overload, while another was given excessive fluids, leading to aspiration pneumonia. Documentation and communication lapses contributed to these deficiencies.
The facility failed to ensure complete, signed, and dated physician progress notes for two residents. One resident, with chronic conditions, had no physician notes for several months and reported never seeing a doctor. Another resident, awaiting eye surgery, had only one incomplete note and reported missed surgeries and no doctor visits. The DON confirmed the documentation issues, and the MRA noted the previous doctor's incomplete and inaccurate notes.
The facility failed to ensure nursing staff competencies, leading to deficiencies in resident care. LNs did not reassess or notify physicians about a resident's potentially infected eye, and suspicions of abuse were not reported for multiple residents. Additionally, LNs did not adequately monitor gastrostomy tube feedings or check meal trays, resulting in discrepancies and unmet resident preferences.
A resident in a long-term care facility was prescribed both routine and PRN Ativan without an end date, contrary to CMS regulations. Despite recommendations from the consulting pharmacist to limit the PRN order to 14 days, the facility failed to address this in medication reviews. The resident, with a history of schizoaffective disorder and dementia, was at risk of adverse effects from excessive psychotropic medication use. Interviews revealed daily aggressive behaviors and unwitnessed falls, highlighting deficiencies in medication management.
A resident had teeth extracted and impressions taken for dentures, but due to an insurance change, the contracted dental service did not proceed with the dentures. The facility failed to follow up in a timely manner, leaving the resident unable to chew food properly.
The facility failed to honor food preferences for several residents, leading to dissatisfaction and potential negative impacts on their psychosocial health. Residents with specific dislikes, such as eggs, rice, tomatoes, and certain vegetables, were repeatedly served these items despite documented preferences. Staff admitted to oversight due to being rushed, and corporate menu controls limited options. These issues were noted in resident council meetings and satisfaction surveys, indicating ongoing problems with food service.
Two residents experienced abuse in a facility, leading to emotional distress. A CNA grabbed a resident's arm during personal care, despite the resident's distress and request for the CNA not to enter his room. The incident was not reported or investigated, and the CNA continued to be assigned to the resident's room. In another case, a housekeeper made a resident clean her own toilet after an episode of diarrhea, causing emotional distress. The housekeeper continued to be assigned to the resident's room until the issue was addressed. Both incidents highlight a failure in the facility's abuse prevention program.
The facility failed to report abuse allegations involving three residents. A CNA did not report suspicions of abuse when a resident showed fear during care. Another resident was instructed by a housekeeper to clean her own toilet, and the incident was not reported by a CNA. Additionally, a resident reported being physically restrained by a CNA, but the incident was not investigated. These failures to report and investigate abuse allegations were confirmed by facility staff.
Failure to Implement Psychiatric Evaluation Orders for Depressed Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders for psychiatric evaluation and treatment and to incorporate these services into the care plans for two residents with diagnosed depression. Facility policy on Behavioral Assessment, Intervention and Monitoring requires nursing staff to identify and report changes in mental status and for the IDT to evaluate behavioral symptoms and underlying causes. Despite this, Resident 1, admitted with major depressive disorder, cognitive communication deficit, and a history of alcohol abuse, had a hospital discharge order for Paroxetine that was not continued in the facility, and no other antidepressant was prescribed from admission through several months. Resident 1’s MDS identified depression and documented symptoms such as feeling tired, poor appetite, feeling life was a failure, and little interest or pleasure in activities, yet the psychiatric evaluation and treatment orders dated shortly after admission were not carried out. For Resident 1, multiple clinical notes documented ongoing depressive indicators and functional decline without corresponding psychiatric intervention or care plan updates. The NP ordered a psychiatric referral to assess for depression, and therapy notes showed repeated refusals of PT and OT, low motivation, and refusal to get out of bed. A care plan was initiated for feelings of loneliness and later for refusing showers, and social services documented that the resident “shut down” and became nonverbal after being informed of a pending divorce. CNA interview confirmed the resident was upset about the divorce and minimally participated in personal hygiene. The SSD acknowledged that no counseling or psychological evaluation was provided and that no new care plan or change-in-condition assessment was initiated after the emotional event. The DON confirmed that the psychiatric referral “got away from them” and that the resident received no psychiatric services while in the facility, and the NP acknowledged being unaware that the psychiatric evaluation had not occurred. Resident 2 was admitted with major depressive disorder, cognitive decline, and cancer, and the MDS documented mild cognitive impairment and depression, including feeling bad about self, being down and depressed, having little pleasure in activities, and difficulty staying asleep. Physician orders included psychiatric referral, evaluation, and treatment on two separate dates, but no psychiatric evaluations were found in the medical record. NP progress notes documented monitoring for signs and symptoms of depression, including episodes of crying and poor oral intake, yet there was no evidence that the psychiatric referrals were implemented. RN B confirmed the absence of psychiatric evaluation or treatment documentation and stated that the nurse receiving the psychiatric referral order is responsible for entering it into the EHR and coordinating care. Additional interviews with activities and social services staff described the resident as emotional, crying, and upset about dying, further indicating ongoing depressive symptoms without documented follow-through on ordered psychiatric services. This failure resulted in both residents not receiving mental health evaluation and had the potential for them not to reach their highest practicable level of mental and psychosocial well-being.
Resident Left Unsupervised on Patio Resulting in Fatal Fall
Penalty
Summary
A deficiency occurred when a restorative nursing assistant (RNA) left a resident, who was at moderate risk for falls and had significant cognitive and physical impairments, unsupervised on an outdoor patio for approximately 30 minutes. The resident had a history of vascular dementia, hemiplegia, muscle weakness, and was dependent on staff for all mobility and activities of daily living. The resident's care plan identified a need for a safe environment, assistance with all ADLs, and interventions to minimize fall risk, but did not specify supervision requirements for outdoor activities. On the day of the incident, the RNA took the resident outside in a wheelchair and left him alone on the patio, without informing other staff or ensuring supervision. The patio was not fully visible from the nursing stations, and there was no method for the resident to call for help. Staff interviews confirmed that the resident was not alert, was dependent on staff, and should not have been left unsupervised. The resident was later found on the ground, unresponsive, next to his wheelchair, having sustained a major head injury. Medical evaluation revealed a subdural hematoma with midline shift, and the resident was transported to the hospital for emergency care. The incident resulted in a significant decline in the resident's condition and ultimately led to death. Staff statements and record reviews confirmed that the lack of supervision and failure to communicate the resident's location contributed directly to the fall and subsequent injury.
Failure to Report Major Injury After Resident Fall
Penalty
Summary
The facility failed to report a major injury involving a resident who was left unattended on a patio by a Restorative Nursing Assistant for 30 minutes. During this time, the resident, who had vascular dementia, hemiplegia, hemiparesis, and muscle weakness, fell and was found unresponsive with shallow breathing and unstable vital signs. The resident was transported to a hospital, where a CT scan revealed a small acute subdural hematoma with a midline shift. The resident was later returned to the facility on hospice care and subsequently died that evening. Despite the severity of the injury, which met the CMS definition of a major injury, the facility did not report the incident to the appropriate authorities. Both the Administrator and the Director of Nursing stated in interviews that they did not consider the injury significant or an unusual occurrence, and therefore did not report it. This failure delayed the investigation into the major injury and was not in accordance with facility policy or professional standards of practice.
Failure to Provide Outdoor Activity per Resident's Care Plan
Penalty
Summary
The facility failed to honor an activity preference that was documented in the activity care plan for a resident with dementia and left-sided weakness, who was unable to make his own health care decisions. The resident's care plan specified that staff should take him outside to sit in the sun when the weather was nice, and a quarterly activity review indicated he enjoyed being outdoors. However, a review of activity participation notes over several months showed no documentation of the resident being taken outside to the patio. Interviews with the Activity Assistant and Activity Director revealed that neither was aware of the care plan directive for outdoor activities for this resident. The Activity Assistant confirmed that she had not taken the resident outside and that there was no group activity for residents to go outdoors. The Activity Director also confirmed the lack of outdoor activities and stated that the care plan did not provide clear instructions regarding supervision or frequency for outdoor time. Additionally, the Activity Director noted that staff had not facilitated the resident's participation in outdoor activities due to not getting him up in his wheelchair, and that not all areas of the patio were visible from inside, raising concerns about supervision.
Resident Left Unsupervised on Patio Resulting in Fatal Fall
Penalty
Summary
A deficiency occurred when a Restorative Nursing Assistant (RNA) left a resident with vascular dementia, hemiplegia, and a history of falls alone on a facility patio for approximately 30 minutes. The resident was known to be dependent on staff for all mobility, had impaired cognition, and was classified as a moderate fall risk. The resident's care plan required staff to provide a safe environment, prompt response to requests for assistance, and appropriate supervision, especially during activities that could increase the risk of falls. On the day of the incident, the RNA took the resident outside in a wheelchair and left them unsupervised on the patio. The RNA did not inform other staff members of the resident's location, and the nursing station was unstaffed at the time. The resident was later found unresponsive on the ground outside, having sustained a major head injury. The resident was transported to an acute care hospital, experienced a decline in condition, and subsequently died. Multiple staff interviews confirmed that the resident required total supervision due to their cognitive and physical impairments, and that the patio area could not be fully visualized or monitored from the nursing stations. Staff members, including CNAs and nurses, stated that it was common knowledge that residents with dementia or high fall risk should not be left unsupervised, particularly in areas where they could not be easily seen or heard. The RNA acknowledged the mistake of leaving the resident alone, and other staff confirmed that proper communication and supervision protocols were not followed. The facility's Director of Nursing also confirmed that there was no method for residents on the patio to call for help, such as a call light, further contributing to the lack of supervision and safety for the resident.
Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving one of five sampled residents. A resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including Parkinson's Disease, COPD, hypertension, and muscle weakness, informed staff that another resident had slapped them on the face and chest, resulting in discoloration and scratches. The incident was documented in the resident's progress notes and a report of suspected dependent adult/elder abuse was completed, confirming the physical altercation between the two residents. Despite the facility's policy requiring all reports and findings of resident abuse to be reported to local, state, and federal agencies, the incident was not reported to the state licensing/certification agency. Both the Administrator and the DON confirmed the incident occurred but stated their belief, based on an All Facilities Letter, that abuse involving a perpetrator with a dementia diagnosis did not require reporting. As a result, the abuse allegation was not reported as required by facility policy.
Failure to Prevent Repeated Falls Due to Inadequate Evaluation and Communication of Fall Interventions
Penalty
Summary
The facility failed to ensure that two of three sampled residents were free from accident hazards and received adequate supervision to prevent accidents. Post-fall evaluations did not determine the reasons for repeated falls, and the care plan interventions for these residents were not reevaluated for effectiveness. New interventions were not consistently developed to prevent further falls and injuries, and direct care staff were not adequately informed on how to identify high-risk fall residents or locate their fall plans of care. One resident, with diagnoses including dementia, difficulty walking, anxiety disorder, and a history of repeated falls, experienced multiple falls during their stay. Despite being identified as a high fall risk, the resident's care plan interventions, such as one-to-one supervision and toileting programs, were inconsistently applied and not evaluated for effectiveness. Several falls occurred during shifts not covered by the interventions, and repeated interventions were implemented without assessing their impact. Documentation showed that the interdisciplinary team did not address falls occurring during the day shift, and there was no clear rationale for changes in supervision levels. Another resident, also with dementia and a history of falls, was assessed as a moderate fall risk and had significant cognitive impairment. The care plan included interventions such as frequent checks and reminders to use the call light, despite the resident's inability to use the call light due to cognitive limitations. Staff interviews revealed a lack of awareness of the resident's fall risk status and care plan details, and the electronic care plan system used by CNAs did not provide comprehensive information. The Director of Nursing confirmed gaps in root cause analysis, care planning, and communication of fall risk interventions to direct care staff.
Improper Storage of Construction Materials in Resident Rooms
Penalty
Summary
The facility failed to honor residents' rights to a safe, clean, comfortable, and homelike environment by improperly storing construction materials in the room of three residents. The materials included piles of flooring and adhesive or paint, which were stored in a manner that created potential hazards and made the environment less homelike. Family members and residents expressed concerns about the tripping hazards and the difficulty in maintaining cleanliness due to the presence of these materials. The facility administrator acknowledged the situation, stating that the room had been vacant and was used for storage, but later needed for residents. Interviews with staff and residents confirmed the presence of the materials, with some residents noting the stuffiness and dustiness caused by the storage. The facility's maintenance director admitted that storing the materials in the residents' room was against the facility's policy and recognized it as a poor decision. The facility's policy on the receipt and storage of supplies and equipment clearly indicated that supplies should be stored in designated areas and that hazardous materials must be properly stored and labeled, which was not adhered to in this case.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food safety and sanitation requirements were met, as evidenced by improper storage, labeling, and dating of food items in the kitchen refrigerator/freezers. Observations revealed expired food items, such as an open jar of applesauce and a foil-covered container of puree bread without a use-by date. Additionally, there were unlabeled and undated food items, including boiled eggs and sliced bread, which were not stored according to the facility's policy and procedure. The Registered Dietitian and Dietary Manager acknowledged these issues, noting that compromised packaging and improper labeling could allow bacteria or pests to enter, posing an infection control risk. The kitchen and food service equipment were found to be in unsanitary conditions, with thick, black debris under stovetop burners, greasy substances on the stove backsplash, and food crumbs on various surfaces. The sanitizer solution in the dishwashing sink was tested and found to be outside the acceptable range, indicating improper sanitization. The Dietary Manager acknowledged the cleanliness issues and the potential infection risks posed by the unclean equipment and utensils. Additionally, the dishwashing log entries were incomplete, and the sanitizer levels were not consistently monitored, further contributing to the unsanitary conditions. The kitchen environment was not maintained in a sanitary condition, with food crumbs, spills, and stains observed on the floors and walls. The dry storage room floor was visibly dirty, and the fan over the food preparation area was dusty. The facility's policy required the kitchen to be kept clean and sanitary, but observations revealed that these standards were not met. The Dietary Manager and Maintenance Supervisor acknowledged the cleanliness issues, and the Dietary Manager indicated that disciplinary actions would be taken due to the general lack of cleanliness in the kitchen. Additionally, resident food in the refrigerator was not labeled or stored according to policy, with expired and unlabeled items present, posing a risk of foodborne illness to residents.
Failure to Provide Adequate Social Services and Timely Care
Penalty
Summary
The facility failed to provide adequate medically-related social services for four residents, leading to unmet needs and potential delays in care. For two residents, the social service care plans were not updated quarterly or as needed, failing to reflect their discharge plans. One resident's care plan inaccurately indicated long-term care instead of short-term care, and another resident's discharge plan was uncertain, with no updates made to reflect their needs. Additionally, the facility did not assist one resident with financial documents when requested, hindering their ability to obtain necessary income for discharge. The Social Services Director (SSD) failed to assist with disability paperwork, despite the resident's request, and did not provide adequate support for discharge planning. This lack of assistance was confirmed by the facility's administrator, who stated that the SSD should have helped the resident with their financial needs. The facility also failed to make timely referrals for outside services for another resident, who required an ophthalmology consultation for a visual deficit. The SSD did not send the necessary referral, and the resident expressed concern about losing their vision due to the lack of timely intervention. Furthermore, dental services were not provided promptly for another resident, who had teeth extracted but did not receive dentures due to insurance issues. The SSD did not follow up on the dental services until prompted by the resident's family, resulting in a significant delay.
Medication and Supply Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications and medical supplies were stored and labeled according to professional standards. During an inspection of medication cart 2, two loose pills were found in a drawer, which was confirmed by the Assistant Director of Nursing (ADON) as inappropriate. Additionally, six medications being dispensed were opened but not dated, including two bottles of Tuberculin, one tube of Muscle Rub Cream, two bottles of Enulose, and a bottle of Geri tussin DM. The Director of Nursing (DON) and ADON confirmed that it was the facility's policy to date medications upon opening and discard them within 30 days. Furthermore, the facility stored expired medical supplies and medications. Four Foley drainage bags in the medication storage room were past their expiration date, and Pro-Stat concentrated liquid protein medical food was being dispensed despite being expired. The DON confirmed that expired items should be discarded and not available for use. The facility's policy indicated that no expired medication should be administered, and opened medications should be dated, which was not adhered to in these instances.
Deficiencies in Food Preparation and Service
Penalty
Summary
The facility failed to prepare and serve food that was palatable, attractive, and at a safe and appetizing temperature for several residents. Resident 77, who is the President of the Resident Council, reported that the food was consistently overcooked, such as burnt sausage, and cold, like the gravy served. Despite raising these issues with the Dietary Manager over several months, no effective solution was implemented. Resident 84 experienced undercooked pork, which led to digestive issues, and Resident 11 received melted ice cream, indicating improper food handling and timing during meal service. Resident 35 reported that his meals were often cold, his ice cream melted, and his biscuits burnt, which he found nauseating. The Dietary Manager acknowledged the complaints about cold food and mentioned that a new plate warmer had been acquired but not yet utilized. Observations during meal service confirmed that food carts were delayed, and the food was not maintained at appropriate temperatures, as evidenced by a pizza slice being served at 95 degrees, below the recommended 135 degrees for hot food. Resident 215 was served burnt pizza, which she found unpalatable, and this was confirmed by a CNA. The facility's policy and procedure for food preparation and meal distribution were not adhered to, as meals were not maintained at the required temperatures. The Dietary Manager admitted to being overwhelmed by complaints and recognized the need for better food temperature management. The report highlights systemic issues in the facility's food service operations, affecting the quality and safety of meals provided to residents.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to honor the residents' rights to a dignified existence and self-determination, as evidenced by several incidents involving six residents. Staff members were observed speaking in their native language in front of residents who did not understand, causing discomfort and feelings of disrespect. Residents 46, 90, and 100 reported feeling uncomfortable and disrespected when staff conversed in a language they did not understand, which was against the facility's policy that required staff to speak English in areas where residents could hear them. Additionally, the facility's night shift staff were reported to be loud, disturbing residents' sleep. Residents and their family members expressed concerns about the noise levels at night, which affected their well-being. Resident 106, who was not her own responsible party, expressed feelings of worthlessness and distress due to the noise, indicating a failure to maintain a peaceful environment conducive to rest and recovery. Furthermore, Resident 101 was not provided privacy during personal care, as observed when a CNA assisted the resident in dressing without drawing the privacy curtain or closing the door. This lack of privacy was acknowledged by the CNA, who admitted to forgetting to provide it. Resident 40 was instructed by a housekeeper to clean her own toilet, which was inappropriate and led to feelings of paranoia and distress. The housekeeper's actions were not reported immediately, contributing to the resident's emotional distress.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to investigate and protect residents from alleged abuse in three separate incidents involving Residents 22, 35, and 40. In the first incident, Certified Nurse Assistant (CNA) M did not report suspicions of abuse when Resident 22 exhibited fear during care, despite the resident's roommate corroborating rough handling by night shift CNAs. Resident 22, who had a moderately impaired memory, did not voice concerns directly, but CNA M noticed a change in behavior and failed to report it. In the second incident, Resident 40, who had no cognitive impairment, alleged that Housekeeper A instructed her to clean her own toilet after an episode of diarrhea. Despite informing CNA J of the incident, CNA J did not report it to the administration. The housekeeper was later suspended pending investigation, but the initial failure to report left Resident 40 in a state of emotional distress. The third incident involved Resident 35, who had intact cognition but required full assistance with daily activities. Resident 35 reported that CNA E held him down during care, which was corroborated by another CNA. Despite this, the incident was not reported or investigated, and CNA E continued to be assigned to care for Resident 35. The facility's administration was unaware of the incident until it was brought to their attention during the survey, highlighting a significant lapse in reporting and investigation procedures.
Incomplete Documentation for Resident Transfer
Penalty
Summary
The facility failed to ensure accurate and complete documentation for a resident who was transferred to an acute care hospital. Specifically, the facility did not document the date and time of the transfer, the destination hospital, the mode of transportation, or the disposition of the resident's personal effects and medications. This lack of documentation was identified during a review of the resident's clinical record and was confirmed by the Director of Nurses (DON). The resident involved had been admitted to the facility with diagnoses including right hip joint replacement surgery, anxiety, and depression, and was their own healthcare decision maker. A Change in Condition Assessment/SBAR noted a change in the resident's condition, including pain and swelling in the right hip, which was assessed by a licensed nurse. However, the nursing progress note did not reflect the transfer details, and the DON acknowledged that the documentation should have included an assessment, intervention, and the doctor's order for the transfer.
Failure to Provide Non-Skid Footwear for Fall-Risk Resident
Penalty
Summary
The facility failed to ensure that Resident 101, who was at risk for falls, was wearing non-skid footwear as per his care plan. Resident 101 was admitted with diagnoses including stroke, muscle weakness, difficulty in walking, and major depressive disorder. His cognitive status was severely impaired, requiring maximal assistance for daily activities such as dressing and transferring. The care plan specifically indicated that Resident 101 should have appropriate footwear when out of bed or mobilizing in his wheelchair to prevent falls. During observations, Resident 101 was seen in his room without shoes or socks, struggling to dress himself, and his call light was on the floor, out of reach. A CNA assisted him with his pants but did not ensure he had footwear on, as the CNA was not assigned to him that day. Resident 101 expressed difficulty in finding his call light and mentioned a previous fall when trying to get up by himself. The Director of Staff Development confirmed that Resident 101 should have been wearing non-skid socks or shoes to prevent falls.
Deficiencies in G-Tube Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate care for two residents with gastrostomy tubes (g-tubes), leading to significant deficiencies in their care. For Resident 87, Licensed Nurses (LNs) did not adhere to the Physician's orders regarding the prescribed amounts of liquid nutrition, hydration, and water flushes. The documentation of intake amounts was inaccurate, with instances of both excessive and insufficient fluid administration compared to the Physician's orders. Additionally, LNs provided g-tube care without a Physician's order and failed to document the care provided, including assessments of g-tube placement and residuals. Resident 214 experienced a similar lapse in care, receiving an excessive amount of fluids due to a failure to discontinue outdated orders. The Registered Dietitian (RD) had recommended a specific fluid intake, but the resident received significantly more than this amount, leading to fluid overload. This oversight was compounded by the fact that the RD was unaware of the excessive fluid administration, and the Nurse Practitioner (NP) confirmed the excessiveness of the fluid intake. The Assistant Director of Nursing (ADON) acknowledged that the order for 300 mL of water every four hours should have been discontinued but was not. These failures placed both residents at risk for serious health complications. Resident 87 was at risk for fluid overload and g-tube malfunction, while Resident 214 was sent to the emergency room due to formula leakage and was diagnosed with aspiration pneumonia. The deficiencies in care for both residents highlight significant lapses in following Physician's orders and ensuring accurate documentation and communication among the care team.
Incomplete Physician Documentation and Missed Visits
Penalty
Summary
The facility failed to ensure that physician progress notes were complete, signed, and dated at each required visit for two residents. Resident 34, who was admitted with chronic obstructive pulmonary disease, dementia, and bipolar disorder, had no physician notes for June and September 2024. Despite being in the facility for two years, Resident 34 reported never having seen a doctor. Resident 98, admitted with end-stage renal disease and a benign neoplasm on the right eyelid, had only one incomplete physician note without a date or assessment of the right eye. Resident 98 also reported that the doctor never visited, and his eye surgery was missed three times. During interviews, the Director of Nursing confirmed the absence and incompleteness of physician notes for both residents. The Medical Record Assistant revealed that the previous medical provider, who left the facility at the end of September 2024, often did not complete or date his notes, and his assessments were not always accurate. This lack of proper documentation and physician visits had the potential to negatively affect communication between disciplines and result in inappropriate care and service for the residents.
Deficiencies in Nursing Competencies and Reporting in LTC Facility
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated appropriate competencies in caring for residents, leading to several deficiencies. Licensed Nurses (LNs) did not reassess or notify the physician about a potentially infected right eye of a resident, who had been admitted with end-stage renal disease and a benign tumor on the right eyelid. Despite the resident's intact cognition and self-reported infection, there was no documentation or follow-up on the condition, and the Director of Nursing confirmed the lack of assessment and communication regarding the resident's eye condition. Additionally, the facility did not report suspicions or allegations of abuse for multiple residents. One resident reported rough handling by CNAs during personal care, which was witnessed by a roommate. A CNA suspected potential abuse due to the resident's change in behavior but failed to report it. Another resident reported emotional distress caused by a housekeeper's actions, which were not reported by a CNA who was informed of the incident. The facility's administrator confirmed that these incidents should have been reported immediately. Furthermore, LNs did not adequately monitor gastrostomy tube feedings, resulting in discrepancies between the physician's orders and the actual intake recorded. The LNs provided incorrect amounts of water flushes and did not document assessments of g-tube placement and residuals. Additionally, LNs failed to check meal trays properly, leading to a resident receiving a meal that included a disliked food item. The LN responsible admitted to not reviewing the meal trays for resident food preferences, resulting in the resident not eating the meal provided.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The deficiency involves the failure of a long-term care facility to adhere to regulations regarding the use of psychotropic medications for a resident, identified as Resident 61. The resident had both a routine and a PRN order for Ativan, an anti-anxiety medication, which was available for five months without an order end date. This was despite recommendations from the consulting pharmacist to discontinue the PRN order or limit it to 14 days, as per CMS regulations. The facility's policy required PRN orders for psychotropic drugs to be limited to 14 days unless the attending physician examined the resident and documented the necessity for continuation. Resident 61, who had a history of multiple medical conditions including schizoaffective disorder, dementia, and anxiety disorder, was at risk of adverse effects from the excessive use of psychotropic medications. The resident's care plans indicated the use of Ativan for anxiety and aggressive behaviors, with interventions including monitoring for side effects and effectiveness. However, the facility failed to address the Ativan PRN order in the resident's medication regimen reviews, and the PRN order was not discontinued until four months after the initial recommendation by the consulting pharmacist. Interviews with facility staff revealed that the resident exhibited daily aggressive verbal behaviors and had experienced unwitnessed falls, which were not consistently documented. The consulting pharmacist noted the increased risk of serotonin syndrome toxicity due to the combination of medications the resident was receiving. Despite these risks, the facility did not conduct a Benefits v. Risks Review with physician documentation to justify the continuation of the PRN Ativan order, leading to the deficiency in medication management for Resident 61.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding dental services for a resident, leading to a deficiency. The policy required that residents needing dental services be promptly referred to a dentist. However, the facility did not ensure that a resident who had teeth extracted received the necessary follow-up care to obtain dentures. The resident, who was readmitted with multiple diagnoses including lung disease, depression, and left-sided paralysis, had his teeth extracted by a facility-contracted dental service. Impressions and x-rays for dentures were taken, but the process was halted due to an insurance change that the contracted dental service would not honor. The deficiency was further compounded by the facility's lack of timely follow-up. The Social Service Director admitted to not contacting the dental service to follow up on the resident's dentures until prompted by the resident's daughter during a care conference, five months after the extractions and impressions. This inaction resulted in the resident being unable to chew food properly, as he was left without dentures, impacting his ability to eat comfortably.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor food preferences for five residents, leading to dissatisfaction and potential negative impacts on their psychosocial health. Resident 46, who has type 2 diabetes and anxiety, reported a dislike for eggs but continued to receive them for breakfast. Despite having a BIMS score indicating good memory, the resident's dietary profile did not reflect this preference. Similarly, Resident 90, also with type 2 diabetes and high blood pressure, expressed a dislike for rice, which was documented in their dietary profile, yet rice was frequently served. Resident 100, diagnosed with heart failure and depression, consistently received tomatoes despite a documented dislike. The resident expressed frustration, feeling that complaints about food led to worse service. An observation confirmed that tomatoes were served with their meal, and the facility's Infection Preventionist acknowledged the oversight. Resident 106, with dysphagia and poor memory, was served a tuna fish sandwich and an egg and cheese omelet, both of which were on their dislike list. The responsible Licensed Nurse admitted to not checking the meal trays for preferences due to being in a hurry. Resident 104, who often requested alternative meals like hamburgers and hot dogs, was served overcooked vegetables, including carrots, peas, and corn, which they disliked. The Dietary Manager confirmed that residents received items on their dislike lists due to corporate menu controls and the kitchen being rushed during a state survey. These failures to accommodate food preferences were documented in resident council meeting notes and satisfaction surveys, indicating ongoing issues with food service in the facility.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, leading to emotional distress and mental anguish. In the first case, a Certified Nursing Assistant (CNA) grabbed and held a resident's arm during personal care, despite the resident's clear distress and request for the CNA not to enter his room. The resident, who had intact cognition and could make his own decisions, reported the incident to a nurse, but the CNA continued to be assigned to his room. The incident was not reported or investigated by the facility, and the CNA admitted to grabbing the resident's wrist during an altercation over the resident's personal items. In the second case, a housekeeper made a resident clean her own toilet after an episode of diarrhea, causing the resident to feel unwell and emotionally distressed. The resident, who had no cognitive impairment, reported that the housekeeper pointed to the toilet and handed her paper napkins to clean it. The resident informed a family member, who provided cleaning supplies, and reported the incident to a CNA, who did not escalate the complaint for investigation. The housekeeper continued to be assigned to the resident's room until the issue was brought to the attention of the housekeeping manager. Both incidents highlight a failure in the facility's abuse prevention program, as staff did not report or investigate the allegations of abuse. The facility's policies and procedures were not followed, resulting in continued exposure of the residents to the staff members involved in the incidents. The lack of immediate action and investigation contributed to the residents' emotional distress and the potential for ongoing abuse.
Failure to Report Abuse Allegations in LTC Facility
Penalty
Summary
The facility failed to report suspicions and allegations of abuse for three out of five sampled residents, which included incidents involving Residents 22, 35, and 40. Certified Nurse Assistant (CNA) M did not report suspicions of abuse when Resident 22 showed fear during care, despite acknowledging a change in behavior that suggested potential abuse. Resident 22, who had a BIMS score indicating moderate memory impairment, expressed concerns about being handled roughly by night shift CNAs, which was corroborated by a roommate. However, CNA M did not escalate these suspicions to the appropriate authorities. In another incident, Resident 40, who had no cognitive impairment, reported that Housekeeper A instructed her to clean her own toilet after an episode of diarrhea. Despite being informed of this by Resident 40, CNA J failed to report the incident to the facility management. The resident expressed fear of Housekeeper A, who was also accused of waking her up by hitting the bed with a mop. The facility's administrator confirmed that the incident should have been reported and investigated, but it was not. Additionally, Resident 35, who had intact cognition, reported being physically restrained by CNA E during care. The resident expressed distress over the incident, which was not reported or investigated by the facility. CNA E admitted to holding down the resident and informed the Infection Preventionist and a charge nurse, but no further action was taken. The Director of Staff Development confirmed that the incident occurred and that there should have been an investigation, but none was conducted.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Yuba City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Yuba City Post Acute | 0.5 mi | — | 24 | 0 |
| Fountains, The | 0.6 mi | — | 1 | 0 |
| Marysville Post-acute | 2.1 mi | — | 0 | 0 |
| River Valley Care Center | 7.7 mi | — | 1 | 0 |
| Gridley Post Acute | 15.1 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.