Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gridley Post Acute during CMS and state inspections, most recent first.
Failure to Assess Pain and Maintain PICC Dressing Care: One resident developed abdominal pain, received Norco without a documented pain assessment or follow-up assessment, then had vomiting and left for hospital evaluation the same day. A second resident with a PICC line had a dressing that was not changed as ordered; the infusion center found multiple layers of tape over an old dressing and sent the resident for ER evaluation and redressing. The DON acknowledged the missed documentation and missed dressing changes.
A resident's readmission MDS did not accurately reflect IV therapy through a PICC line because Section O was left unmarked even though the resident was receiving IV medication during the assessment period. The MDS Coordinator later reviewed the assessment and confirmed the omission, acknowledging that the IV section should have been marked.
A resident who was assessed as an independent smoker was observed smoking in a non-designated outdoor area without a smoking apron or visible cigarette receptacle, and he discarded a lit cigarette butt into rocks with dry grass nearby. The Admin acknowledged the resident had been smoking in the wrong area, that no appropriate receptacles were available there, and that no smoking restrictions or privilege changes had been imposed despite repeated review of the smoking policy.
Failure to honor a resident’s food preferences: a resident with HTN, hx of falls, and adult failure to thrive reported an egg allergy and said she was served eggs multiple times after telling staff. The food preference log showed eggs were added as an allergy, later removed, and only afterward was a no-eggs breakfast preference documented; the DM confirmed the resident continued to receive eggs during that period and that her documented preferences were not being honored.
Failure to provide necessary behavioral health services for two residents. One resident with depression, paranoid personality disorder, and mood disorder reported daily and nightly fear, while staff described ongoing paranoia, isolation, and a lack of consistent counseling and psych services after the facility lost counseling coverage and had limited psychiatrist availability. A second resident with depression and cognitive impairment stated they would rather be dead and reported no mental health services or social services visits, while staff noted the resident was withdrawn, grieving a brother’s death, and waiting for psych services.
Failure to Treat a Resident with Dignity: A resident with stroke, depression, paranoid personality disorder, and severe cognitive impairment reported that a CNA accused them of using the call light too often, crossed their arms, yelled at the resident, and told them to shut up. The resident said they felt fearful and unable to report the incident, and the CNA acknowledged sounding authoritative and possibly aggressive when speaking with residents.
The facility failed to refer two residents for a level II PASARR after they were diagnosed with new serious mental illnesses. One resident, with severe cognitive impairment, had new diagnoses of psychosis, manic episode, and depression, while another resident, with moderate cognitive impairment, was diagnosed with bipolar and anxiety disorders. The DON acknowledged the lack of updated PASARRs, indicating a misunderstanding of the requirements.
A resident with moderate cognitive impairment was transferred to the hospital without receiving a timely bed hold notice, as required by facility policy. The Admissions Director admitted to not issuing the notice promptly, and the DON confirmed that the notice should have been provided immediately upon transfer. The Administrator noted challenges in delivering the notice if the resident is their own responsible party, but emphasized the importance of timely communication with responsible parties.
A facility failed to develop a comprehensive care plan for a resident with bilateral leg edema, despite the resident's medical history of diabetes and hypertension. The resident showed signs of edema, and although orders were in place to monitor the condition and use TED hose, no care plan was documented. Interviews with staff confirmed the absence of a care plan, and the Director of Nursing and Administrator acknowledged that a care plan should have been initiated.
A resident with moderate cognitive impairment and a history of atrial fibrillation and type 2 diabetes experienced an eight-day delay in receiving antibiotic therapy for a urinary tract infection. Despite a urinalysis with culture and sensitivity being ordered and results reported, the prescribed Bactrim DS was not initiated until eight days later. The DON and NP acknowledged the delay, with no reason provided for the lapse.
A resident with moderate cognitive impairment was found to have a space heater in their room, contrary to the facility's policy prohibiting such devices to prevent accidents. The heater was used due to the absence of a heating unit, and staff were unaware of federal regulations against space heaters in skilled nursing facilities. No incidents were reported, but the facility acknowledged the oversight and planned to remove space heaters from resident rooms.
A resident with moderate cognitive impairment and a history of atrial fibrillation and type 2 diabetes was not promptly treated for a urinary tract infection due to the facility's failure to notify the physician of lab results. The urine culture was finalized on 12/22/2024, but the resident was not started on antibiotics until 12/30/2024. Interviews with the DON, NP, and Administrator confirmed the expectation for timely communication, which was not met.
A resident with moderate cognitive impairment was administered Rexulti without informed consent in a language understood by her and her responsible party (RP), both Spanish speakers. The facility's policy required informed consent before administering psychotropic medication, but it was not documented. The RP was not informed by the physician about the medication and only discussed it with a CNA. The RP later requested discontinuation due to the resident's flat expression on the medication. The physician could not recall observing the resident's behavior or signing an informed consent.
A resident with dementia and other conditions was prescribed Rexulti by the MD, who failed to document the need for the medication, its administration, or the reason for its discontinuation. The MD could not recall details about the prescription or observe the resident's behavior, leading to potential miscommunication and unclear care expectations.
A resident with dementia was prescribed Rexulti without documented necessity or monitoring, contrary to facility policy. The DON admitted to not monitoring the resident for side effects or effectiveness, and the RP was not informed about the medication's risks. The MD was unaware of the medication's boxed warning, and the facility's actions put the resident at risk for adverse consequences.
Failure to Assess Pain and Maintain PICC Dressing Care
Penalty
Summary
Licensed nursing staff failed to provide nursing services in accordance with professional standards of quality for two residents. One resident was admitted with diagnoses including high blood pressure, a history of falling, and adult failure to thrive, and was her own health care decision maker. On 6/23/26, she developed abdominal pain at 2:45 p.m. and was given Hydrocodone Acetaminophen (Norco) 5/325 mg, but there was no documentation of a pain assessment or pain level before or after the medication was administered. RN A confirmed that no documentation was completed regarding the resident’s pain assessment, and the medication administration record did not contain an entry showing that Norco had been administered. The same resident continued to have pain, had one episode of vomiting, requested transfer to the hospital, and left the facility at 5:05 p.m. the same day. The DON confirmed that the resident reported abdominal pain, had green-colored vomiting, received Norco as ordered, and then requested hospital transfer for evaluation. The DON later stated that documentation of the resident’s pain should have been entered in the nursing progress notes and that ongoing assessments were required, including use of a pain scale and a full gastrointestinal assessment with bowel sounds and abdominal palpation. A second resident was admitted with diagnoses including UTI, liver disease, and AKI and had physician orders for PICC line dressing changes on admission, then weekly and as needed, and for PICC site assessment every shift. The infusion center documented on 7/20/26 that the resident’s PICC dressing had multiple layers of tape over the original dressing dated 6/27/26, and the infusion center RN recommended emergency room evaluation and a dressing change. The resident stated that staff were not changing the PICC dressing as often as they should have been, and the DON acknowledged that the dressing changes were not performed as required.
Inaccurate MDS Did Not Reflect PICC Line
Penalty
Summary
The facility failed to ensure the accuracy of the MDS for one sampled resident, Resident 3, by not correctly identifying the presence of a PICC line. Resident 3's readmission MDS, dated 7/7/26, showed that under Section O, Special Treatments, Procedures, and Programs, intravenous therapy was not marked even though the resident was receiving IV medication through a PICC line during the assessment period. The facility's MDS Assessment Coordinator Policy Statement, last revised 11/2019, stated that each individual who completes a portion of the assessment must certify the accuracy of that portion by identifying each section completed. During a concurrent interview and record review on 7/31/26 at 12:13 pm, the MDS Coordinator reviewed Resident 3's MDS and confirmed that the IV section had not been marked to reflect the PICC line and acknowledged that it should have been marked.
Smoking Safety and Designated Area Compliance
Penalty
Summary
The facility failed to ensure smoking occurred only in designated areas and failed to provide proper safety equipment, including ashtrays and fire extinguishers, for one sampled resident who smoked independently. The facility policy stated that smoking is permitted only in designated resident smoking areas and that smoking restrictions may be imposed if a resident cannot smoke safely. Resident 2 was admitted with congestive heart failure, high blood pressure, and COPD, and was assessed as an independent smoker who could hold and extinguish a cigarette without assistance and safely extinguish it. During observation, Resident 2 was seen smoking outside on the east side of the facility, which was not the designated smoking area. He removed cigarettes and a lighter from his shirt pocket, lit a cigarette, and smoked without a smoking apron or any visible cigarette receptacle in the area. After finishing, he flicked the still-lit butt into surrounding rocks that contained dry grasses. The next day, multiple cigarette butts were observed scattered in the dirt, rocks, and mulch along the east side walkway. The Administrator acknowledged that Resident 2 had been smoking in a non-designated area, that the east side had no appropriate cigarette receptacles despite residents being known to smoke there, and that no smoking restrictions or privilege changes had been imposed.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of one resident who was admitted with diagnoses of high blood pressure, history of falling, and adult failure to thrive. The resident was her own health care decision maker. During an interview, the resident stated she had an egg allergy and reported that she was served eggs multiple times after informing facility staff of the allergy, and she was unsure why she continued to receive eggs after speaking with staff on several occasions. A review of the resident’s food preference activity log showed that eggs were added as an allergy on 5/27/26, then the allergy was removed on 6/4/26, and later the log indicated a preference for no eggs for breakfast on 6/23/26. During a concurrent interview and record review, the Dietary Manager confirmed that the resident continued to receive eggs during the period after the allergy was removed and before the no-eggs preference was documented, and stated that the resident’s documented food preferences were not being honored during that period.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for two residents. One resident had diagnoses including depression, paranoid personality disorder, and mood disorder, with a BIMS score of 7 indicating severe cognitive impairment. The resident’s care plan addressed sadness, paranoia, social isolation, suicidal thoughts, and withdrawal, and a PASRR Level II recommended psychotherapy or counseling, psychiatric consultation and follow-up care, diagnostic clarification, medication interventions, and monitoring of mental health conditions. During observation and interview, this resident was tearful and stated being in fear of life on a daily and nightly basis. Staff interviews described ongoing depression, paranoia, isolation from social activities, and decline in eating and activities of daily living. The SSD stated the resident was often unsatisfied and complained about not receiving enough psychiatric services, and that a message had been left for the crisis line and county behavioral health, with acknowledgment that follow-up should have occurred sooner. The Admin stated counseling had stopped when insurance no longer covered it, the psychiatrist had limited availability and frequently cancelled appointments, and the facility did not have counseling records. The ADON stated the facility currently did not have psychiatric services and that the psychiatrist had not met residents’ needs since [DATE]. The second resident had diagnoses including cognitive social and emotional impairment and depression, with a BIMS score of 9 indicating moderate cognitive impairment. The resident’s psychosocial assessment noted Zoloft for depression and stated the resident attended activities of choice and individual activities. Nursing notes documented the death of the resident’s brother and an episode of frustration and yelling at another resident. During interview, the resident stated staff did not understand their unhappiness and said they would rather be dead, and also stated the facility did not offer mental health services or social services visits. The SSD described the resident as not social and preferring to keep to themself, and the ADON confirmed the resident was on the list for psychiatric services, had recently lost a brother, no longer had visits from a sister, and slept frequently.
Failure to Treat a Resident with Dignity
Penalty
Summary
The facility failed to ensure that one of three sampled residents was treated in a respectful and dignified manner. Resident 1, who was admitted with diagnoses including stroke, depression, and paranoid personality disorder, had severe cognitive impairment documented on the MDS and was dependent on staff for showering, lower body dressing, personal hygiene, and oral care. The facility policy titled Dignity required staff to speak respectfully to residents at all times and to treat residents with cognitive impairments with dignity and sensitivity. During a concurrent observation and interview in the resident’s room, Resident 1 stated that CNA A accused them of using the call light too often, crossed their arms, yelled at the resident, and told them to shut up. Resident 1 said they could not defend themself and were afraid to report the incident, and their body visibly tensed when CNA A later entered the room during handoff rounds. CNA A acknowledged that the resident pressed the call light often, described the resident as stressed, anxious, and lonely, and stated that sometimes when speaking to residents, they sound authoritative and may be perceived as aggressive, though that was not their intent.
Failure to Conduct Level II PASARR for Residents with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to refer two residents to the appropriate state-designated authority for a level II Preadmission Screening and Resident Review (PASARR) after they were diagnosed with new serious mental illnesses. Resident #2, admitted on 05/22/2018, had a medical history of spastic hemiplegic cerebral palsy and received new diagnoses of psychosis, manic episode, and depression on 12/06/2023. An annual Minimum Data Set (MDS) assessment indicated severe cognitive impairment and active diagnoses of depression, bipolar disorder, and psychotic disorder. However, there was no evidence in the medical record that the facility referred Resident #2 for a level II PASARR evaluation following these new diagnoses. Similarly, Resident #1, admitted on 06/27/2024, had a medical history including atrial fibrillation, hypertension, and muscle weakness, and was diagnosed with bipolar disorder and anxiety disorder on 02/25/2025. A quarterly MDS assessment showed moderate cognitive impairment and active diagnoses of anxiety disorder, depression, and bipolar disorder. The facility also failed to refer Resident #1 for a level II PASARR evaluation after the new mental illness diagnoses. During interviews, the Director of Nursing (DON) acknowledged the lack of updated PASARRs for both residents, indicating a misunderstanding that a new PASARR was only needed for new qualifying diagnoses.
Failure to Provide Timely Bed Hold Notice
Penalty
Summary
The facility failed to provide a bed hold notice upon the transfer of a resident to the hospital, as required by their policy. The policy mandates that residents or their representatives receive written information about bed-hold policies at least twice: once in advance of any transfer and again at the time of transfer, or within 24 hours if the transfer is an emergency. In this case, a resident with a history of atrial fibrillation and type 2 diabetes mellitus, who had moderate cognitive impairment, was transferred to the hospital for further evaluation of blood in their urine and hallucinations. However, there was no evidence of a bed hold notice being provided at the time of transfer. The Admissions Director acknowledged that the bed hold notice was not issued in a timely manner, as it was only addressed after the resident returned to the facility. The Director of Nursing confirmed that the responsibility for sending out bed hold notices lies with the Admissions Director and emphasized that the notice should be issued immediately upon transfer. The Administrator noted that if a resident is their own responsible party, it might be challenging to deliver the notice, but if there is a responsible party, the notice should be given as soon as possible, ideally by the next day after the transfer. The facility's failure to provide the bed hold notice in a timely manner was acknowledged by the staff involved.
Failure to Implement Care Plan for Resident's Edema
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who experienced bilateral leg edema. The resident, who was admitted with a medical history of type 2 diabetes mellitus with diabetic neuropathy and essential hypertension, showed signs of edema as early as December 2024. Despite the presence of orders to monitor the resident for edema and the prescription of thrombo-embolic deterrent (TED) hose to manage the condition, there was no evidence of a care plan addressing the edema in the resident's records. Interviews with facility staff, including a Certified Nursing Assistant, a Registered Nurse, a Licensed Vocational Nurse, the MDS Coordinator, and the Director of Nursing, confirmed the absence of a care plan for the resident's edema. The staff acknowledged that a care plan should have been initiated when the edema was first noted and when the TED hose was ordered. The Director of Nursing and the Administrator both stated that they expected a care plan to be developed and implemented in a timely manner to address the resident's needs.
Delayed Antibiotic Therapy for Resident
Penalty
Summary
The facility failed to timely initiate antibiotic therapy for a resident, leading to a deficiency. The resident, who was admitted with a medical history of atrial fibrillation and type 2 diabetes mellitus, had a moderate cognitive impairment as indicated by a BIMS score of 9. A urinalysis with culture and sensitivity was ordered by the physician on 12/22/2024, and the results were reported on the same day. However, the nurse practitioner did not start the resident on the prescribed antibiotic, Bactrim DS, until 12/30/2024, resulting in an eight-day delay. The Director of Nursing could not provide a reason for this delay, and the nurse practitioner acknowledged that the delay was excessive.
Space Heater Use in Resident Room Against Facility Policy
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, specifically by allowing a space heater in the room of a resident with moderate cognitive impairment. The facility's policy, revised in January 2011, explicitly prohibited portable space heaters to protect residents from potential injuries such as electrocution, burns, and fire. Despite this policy, a space heater was observed in the resident's room on multiple occasions, plugged in and operational, with a sign warning against placing items on it due to fire hazard concerns. The resident, who had a medical history of atrial fibrillation, hypertension, and muscle weakness, was admitted to the facility in June 2024 and had been using the space heater since winter due to the absence of a heating unit in their room. Interviews with facility staff, including registered nurses and the Director of Nursing, revealed that the space heater had been in use for several weeks to a month, and no incidents related to the heater had been reported. The Maintenance Director believed the space heater was compliant with state regulations, citing criteria such as being UL-rated and oil-based. However, he was unaware of the need to adhere to federal regulations prohibiting space heaters in skilled nursing facilities. The Administrator acknowledged the Maintenance Director's efforts to meet the resident's needs but confirmed that space heaters would not be allowed in resident rooms going forward.
Failure to Notify Physician of Lab Results
Penalty
Summary
The facility failed to timely notify the physician of laboratory results for a resident who was admitted with a medical history of atrial fibrillation and type 2 diabetes mellitus. The resident had a moderate cognitive impairment as indicated by a BIMS score of 9. On 12/22/2024, a physician ordered a urinalysis with culture and sensitivity for the resident. The urine culture was collected on 12/20/2024, and the results were finalized and reported on 12/22/2024. However, there was no documentation to indicate that the physician was notified of these results. The deficiency was further highlighted during interviews conducted on 03/27/2025. The Director of Nursing (DON) confirmed the lack of documentation regarding physician notification. The nurse practitioner (NP) expressed that her expectation was for the staff to promptly communicate the results to the provider, as she and other providers were available 24/7. The Administrator also stated that he expected staff to follow through with timely physician notification of laboratory results. Despite these expectations, the resident was not started on the prescribed antibiotic, Bactrim DS, until 12/30/2024, indicating a delay in treatment due to the failure in communication.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to inform a resident and her responsible party (RP) of the risks and benefits of a psychotropic medication, Rexulti, in a language they could understand, which was Spanish. The resident, who had moderate cognitive impairment and was diagnosed with dementia, glaucoma, dysphagia, and type 2 diabetes, was administered Rexulti without documented informed consent. The facility's policy required informed consent to be obtained and documented before administering such medication, but this was not done. The Director of Nursing (DON) and the Administrator confirmed that the informed consent was not present in the resident's medical record. The resident's RP stated she was not informed by the physician about the medication and only discussed it with a Certified Nursing Assistant (CNA). The RP agreed to the medication without understanding its risks and benefits, and later requested its discontinuation due to the resident's flat expression while on the medication. The physician who prescribed Rexulti could not recall observing the resident's behavior before or during the medication administration and did not remember signing an informed consent. The DON admitted to suggesting the medication to the physician, but no informed consent was located for the resident.
Inadequate Documentation and Oversight by Medical Director
Penalty
Summary
The Medical Director (MD) failed to provide adequate progress notes for a resident, which should have reflected a comprehensive review of the resident's care, current condition, and the appropriateness of the medical regimen. The resident, who was admitted with diagnoses including dementia, glaucoma, dysphagia, and type 2 diabetes, was prescribed Rexulti for psychotic behaviors associated with dementia. However, the MD did not document the behaviors that warranted the medication, nor did they document the administration of the medication in the progress notes for September, October, and November 2024. Additionally, the MD did not provide a rationale for discontinuing the medication in November 2024. The MD admitted to prescribing Rexulti due to aggression and agitation issues but could not recall specific details about the prescription timeline or the resident's behavior before and during the medication period. The MD also failed to observe the resident's behavior prior to prescribing the medication and did not remember if informed consent was obtained. This lack of documentation and oversight had the potential to result in miscommunication regarding the resident's medical diagnosis and treatment, as well as unclear expectations for direct care staff.
Inadequate Documentation and Monitoring of Psychotropic Medication
Penalty
Summary
The facility failed to adequately document the necessity of a psychotropic medication, Rexulti, for a resident with dementia, glaucoma, dysphagia, and type 2 diabetes. The resident, who had a moderate cognitive impairment, was prescribed Rexulti by the Medical Director without documented behaviors indicating the need for the medication. The medication was administered from early September to early November, but there was no documentation of the reason for its discontinuation. The facility's policy required a comprehensive assessment and documentation of the necessity for psychotropic medications, which was not followed in this case. The Director of Nursing (DON) admitted that the facility did not monitor the resident for at least three days after starting the medication, as required by their policy. The DON also failed to enter monitoring parameters into the resident's Medication Administration Record (MAR) for behaviors and side effects. The facility did not assess the effectiveness of the medication or attempt to reduce the dosage. The DON did not communicate relevant information regarding medication monitoring to other staff members, and the Interdisciplinary Team (IDT) did not determine which behaviors to monitor. Interviews revealed that the resident's Responsible Party (RP) was not informed about the risks and benefits of the medication and only learned about the resident's condition through a housekeeper. The RP requested the discontinuation of the medication due to the resident's flat expression. The Medical Director was unaware of the boxed warning associated with Rexulti and did not observe the resident's behavior before or during the medication period. The facility's failure to document and monitor the use of Rexulti put the resident at risk for adverse consequences, as the medication is not approved for dementia-related psychosis due to increased mortality risks.
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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 Gridley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Valley Care Center | 7.4 mi | ★★★★★ | 1 | 0 |
| Oroville Hospital Post-acute Center | 12.6 mi | ★★★★★ | 23 | 0 |
| Feather River Care Center | 12.6 mi | ★★★★★ | 6 | 0 |
| Country Crest Post-acute | 12.8 mi | ★★★★★ | 17 | 0 |
| Bridgeview Post Acute | 15.1 mi | ★★★★★ | 21 | 0 |
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