Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Yuba City Post Acute during CMS and state inspections, most recent first.
A resident with impaired mobility and multiple medical conditions was transported in a facility van to a medical appointment without a required lap belt, despite facility policy to protect residents from abuse and neglect and staff expectations for safe transport. The resident’s wheelchair was secured with a four-point system, but no lap belt was applied, and when the resident alerted staff that the lap belt was missing, he was told it was not needed. The resident, who was cognitively intact, reported feeling unsafe and afraid and held onto his wheelchair during the ride. The facility driver later stated that a lap belt is required to secure the resident, and the DSD confirmed that an alternate driver had transported the resident and that only the wheelchair, not the resident, had been secured.
Medication error rate exceeded 5% after two errors were observed during med pass. An RN failed to administer a resident’s ordered inhaled COPD medication but marked it as given on the MAR, and another RN shook an insulin vial before drawing up and giving sliding-scale insulin to a resident with DM II. The DON stated nurses were expected to follow prescriber orders and professional standards of practice.
Improper Medication Refrigerator Temperature: The medication refrigerator in the med room was found at 29 F, with visible ice on the back wall and multiple meds stored inside, including insulin vials. The DON verified the temperature was below the normal 36 F to 46 F range, and one insulin vial had a crystalline, almost frozen appearance. The facility P&P required proper temperature storage, and the insulin label stated to refrigerate at 36 F to 46 F and not to freeze.
The facility failed to develop comprehensive care plans for two residents with identified needs. One resident had a right heel DTI after a broken ankle and CAM boot use, but no wound care plan was initiated. Another resident had limited natural teeth, needed dentures, and had an oral/dental care area triggered on MDS, but no oral/dental care plan was developed. The DON and SSD confirmed the missing care plans.
Care Plan Not Updated After Cast Changed to CAM Boot: A resident admitted with a broken right ankle and no cognitive deficit had a right foot cast changed to a CAM boot, but the comprehensive care plan was not revised to reflect the equipment change. The DON confirmed the care plan still referenced the cast instead of the CAM boot.
Incomplete Documentation of Resident Diarrhea: A resident with multiple chronic conditions reported significant diarrhea with several episodes over two days, and a CNA confirmed multiple episodes of bad-smelling liquid stool and that the nurse was notified. However, nursing progress notes and bowel documentation did not record the diarrhea or provide a full change-of-condition description, even though the FNP ordered CBC and C-diff testing and later stated there was no documentation concerning the diarrhea.
Two residents had skin changes that were not reported or documented in a timely manner. One resident at risk for pressure sores developed a dark red area on the tailbone, but a CNA did not report it and the LN and treatment nurse were unaware of any sore or treatment. Another resident developed a red rash around the mouth; an RN noticed it during med pass but did not assess or document it, and a CNA later stated she thought staff already knew about it. No treatment was ordered or documented for either skin issue.
The facility failed to complete annual performance evaluations for three of four CNAs. Payroll Personnel confirmed CNA C, CNA E, and CNA F each had a missing annual review based on their hire dates, and the DON confirmed CNA staff evaluations had not been consistent and that she was trying to get caught up on them.
A facility failed to report an incident where a family member exposed himself to a resident in a shared room. The resident, who was cognitively intact, felt uncomfortable but did not perceive it as abuse. Despite the facility's policy requiring all abuse reports to be filed with authorities, no report was made, placing all residents at risk for unreported abuse allegations.
The facility failed to provide adequate nursing staff, resulting in unanswered call lights and delayed assistance for residents. This affected residents with varying cognitive and physical needs, leading to incidents such as prolonged waits for assistance, being left in soiled briefs, and delayed pain management. Interviews revealed that staff breaks often left call lights unanswered, impacting residents' well-being.
Two residents in a facility experienced medication regimen review deficiencies. One resident was prescribed Seroquel without proper evaluation by the Psychotropic IDT, and it was combined with donepezil, potentially causing adverse effects. Another resident received oxybutynin ER instead of the ordered IR formula, leading to potential medication build-up. The facility's policies for medication reviews were not adequately followed, resulting in unreported medication irregularities.
A facility failed to maintain a medication error rate below 5 percent, with errors involving two residents. One resident received the wrong formulation of oxybutynin over several months, while another did not receive pain medication despite expressing severe pain. The errors were due to incorrect administration and failure to follow pain assessment protocols.
The facility failed to properly store and label medications, leading to several deficiencies. Discontinued medications were not removed, and unlabeled medicated creams were found in treatment carts. A used syringe was improperly stored, and expired medications were administered. Additionally, an unlicensed staff member had access to the locked Medication Room, posing risks of medication misuse and drug diversion.
The facility's food services failed to provide palatable meals, with residents frequently receiving cold and unappetizing food. Multiple residents, including those with cognitive impairments and medical conditions like diabetes and COPD, reported dissatisfaction with the meals' temperature and taste. A taste test confirmed the food was served below the expected temperature, and staff were unaware of the residents' complaints, indicating a failure to adhere to the facility's meal service policy.
The facility failed to provide adequate supervision for residents with wandering and agitated behaviors, impacting safety and privacy. A resident with Down syndrome and another with Alzheimer's disease frequently wandered into other rooms without proper care plans. Additionally, a resident with severe cognitive impairment exhibited agitation by throwing items, yet no interventions were documented. Staff were aware of these behaviors, but the DON was not informed, leading to a lack of appropriate interventions.
The facility failed to update care plans for two residents with wandering behaviors, despite reports from other residents and staff observations. Resident 34, with seizures and Down syndrome, and Resident 50, with Alzheimer's and other conditions, wandered into other residents' rooms, causing disturbances. The care plans lacked interventions for these behaviors, and the DON was unaware of the specific incidents, contrary to facility policy requiring care plan revisions when resident information changes.
A resident with dementia and multiple fractures did not receive adequate pain management due to the facility's reliance on a numeric pain scale, which the resident could not consistently use. Despite showing clear signs of pain, the resident was not administered prescribed pain medication, as staff failed to utilize the PAINAD scale for nonverbal pain assessment. Additionally, the facility did not notify the physician about the resident's frequent refusal of pain medications, leading to a deficiency in pain management.
A facility failed to review and attempt Gradual Dose Reduction (GDR) for a resident on four psychotropic medications for 50 days. The resident, admitted with Alzheimer's dementia and other conditions, was on hospice care and unable to make healthcare decisions. Despite policies requiring monthly medication reviews, the resident's medications had not been reviewed by the Psychotropic IDT since admission. The facility's staff acknowledged the need for a review, but it had not been conducted, potentially leading to adverse side effects.
A facility failed to honor a resident's food preferences and did not serve accurate portion sizes. A resident reported being served disliked food, and dietary records confirmed the oversight. Additionally, during meal service, fish portions were not consistently weighed, leading to inaccurate serving sizes. Staff acknowledged the failure to ensure correct portions.
The facility failed to maintain kitchen equipment in good repair, with pots and fry pans showing black buildup and missing protective layers, confirmed by the CDM. The facility's sanitation policy was not followed, and although new equipment was reportedly ordered, documentation did not confirm timely action.
A facility failed to report an abuse allegation involving two cognitively impaired residents to the appropriate authorities. One resident made verbal threats and gestures towards another, but the incident was not communicated to local, state, and federal agencies as required. The Director of Nursing was unaware of the incident until informed by CDPH staff, highlighting a lapse in the facility's internal reporting process.
Failure to Use Required Lap Belt During Wheelchair Transport
Penalty
Summary
The facility failed to ensure adequate supervision and use of safety devices during transport when a resident was taken to a medical appointment in a facility van without a lap seat belt. The facility’s Abuse Prevention Program policy states that residents have the right to be free from abuse and neglect and that the facility will implement measures, including staff training and prevention policies, to ensure resident protection. The resident involved had diagnoses including difficulty in walking, thrombocytopenia, myelodysplastic syndrome, and diabetes, and had a BIMS score of 14/15, indicating cognition was not impaired. During the transport, the resident’s wheelchair was secured with straps, but the lap belt was not applied. The resident reported that he notified staff that the lap belt was not in place and was told it was not needed. He stated that he does not use any securement device in his wheelchair and that during the transport he held onto his wheelchair because he feared he might fall or be projected forward, and he felt unsafe and afraid. The facility driver described that proper wheelchair transport requires a four-point securement system, wheelchair brakes, and placement of a lap belt across the resident, and stated that the lap belt is required to ensure safety because otherwise only the wheelchair is secured and not the resident. The Director of Staff Development confirmed that the resident had been transported without a lap belt, that only the wheelchair was secured, and that an alternate driver had been used that day, which may have contributed to the oversight. The receiving facility notified the DSD that the resident was not properly secured.
Medication Error Rate Exceeded 5% Due to Missed Inhaler Dose and Improper Insulin Preparation
Penalty
Summary
The facility failed to keep the medication error rate below 5% when 2 errors were identified out of 26 opportunities for medication administration, resulting in a 7.69% error rate. During an observation on 9/16/25, RN B prepared and administered Resident 4’s morning medications but did not include the ordered fluticasone furoate, umeclidinium, and vilanterol inhalation powder for oral inhalation use, even though the physician order dated 6/11/25 directed 1 puff inhaled orally once daily for COPD. The MAR showed the inhalation medication as given at 9:00 am, and RN B later stated, “I forgot to give that inhaler.” During another observation the same day, RN G prepared and administered Resident 44’s noon insulin. RN G removed an insulin vial from the medication cart, shook it vigorously, withdrew 2 units of insulin lispro, and administered it to the resident. The physician order dated 9/15/25 directed sliding-scale insulin before meals based on blood glucose levels, and the MAR documented 2 units given at 12:00 pm. RN G acknowledged shaking the insulin vial and stated she did not know why she felt the need to shake it, while the DON stated she expected nurses to administer medications according to professional standards of practice.
Improper Medication Refrigerator Temperature
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when the medication refrigerator in the medication room was found at 29 F, below the normal refrigerated range of 36 F to 46 F. During observation and interview with the DON, there was visible ice on the back wall of the refrigerator, multiple medications were stored inside including insulin vials, and one insulin vial had a crystalline, almost frozen appearance. The facility policy on storage of medications stated that drugs and biologicals are to be stored in a safe, secure, orderly manner under proper temperature and light, but it did not specify the proper refrigerator temperature range. The insulin product label stated to store refrigerated at 36 F to 46 F and not to freeze.
Failure to Develop Comprehensive Care Plans for Wound and Oral/Dental Needs
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents whose assessments identified care needs. Resident 33 was admitted with a broken right ankle and cirrhosis of the liver, was cognitively intact with a BIMS score of 15, and later had a deep tissue injury on the right heel after the cast came off and was replaced with a CAM boot. During wound care observation, the licensed nurse confirmed the right heel DTI, but review of the resident’s care plans showed that no care plan had been initiated for the wound. The DON reviewed the record and confirmed that a care plan for the DTI was not initiated. Resident 9 was admitted with COPD, depression, and stroke-related left-sided weakness and paralysis, and was able to make her own health care decisions with a BIMS score of 14. Her MDS indicated no natural teeth in areas of her mouth and triggered the oral/dental care area. During interview, she stated she had only a few bottom teeth and needed dentures. Review of the admission comprehensive care plan showed that no oral/dental care plan had been developed, and the SSD confirmed that one had not been created even though the resident had limited teeth and was at risk for oral sores.
Care Plan Not Updated After Cast Changed to CAM Boot
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident 33 after the resident’s right foot immobilization changed from a cast to a CAM boot. Resident 33 was admitted with diagnoses including a broken right ankle and cirrhosis of the liver, and was capable of making his own healthcare decisions. The admission MDS dated 8/11/25 showed no cognitive deficit, with a BIMS score of 15 out of 15. During a concurrent observation and interview on 9/16/25, Resident 33 stated that he had previously had a cast and that it was recently replaced with a boot around 9/9/25; the resident was observed wearing a CAM boot on the right foot. A record review of the care plans initiated on 8/11/25 showed that the plan for the right foot cast was not revised to reflect the CAM boot. During a concurrent interview and record review on 9/18/25, the DON confirmed that the care plan for the right foot cast was not revised to reflect the implementation of the CAM boot.
Incomplete Documentation of Resident Diarrhea
Penalty
Summary
The facility failed to ensure services met professional standards of quality when Resident 58 did not have episodes of diarrhea documented in the medical record to provide a full description of a change in condition. Resident 58 was admitted with diagnoses including fracture of the right upper leg, muscle weakness, diabetes, depression, anxiety, and heart failure, and made her own health care decisions. During interview, Resident 58 stated she was having trouble with her bowels and had lots of diarrhea, and later reported bad diarrhea that started the prior day with multiple episodes. A CNA confirmed the resident had four episodes of bad-smelling liquid diarrhea during the shift and said the nurse was informed. Record review showed a progress note documenting a verbal order from the FNP for CBC and C-diff testing, but there was no documentation explaining why the tests were ordered or documenting the diarrhea. Nursing progress notes from 9/15/25 through 9/17/25 contained no documentation concerning diarrhea, and the resident's point of care bowel documentation showed only one documented bowel movement for the day. The IP confirmed there should have been a change of condition note and documentation describing the stool, and the DON confirmed each episode of diarrhea should have been charted by the CNA but was not. The FNP also stated there was no documentation concerning diarrhea for Resident 58.
Failure to Report and Treat Skin Changes
Penalty
Summary
The facility failed to ensure care and services were provided according to orders, resident preferences, and goals for two residents with skin damage. One resident was admitted with diagnoses including a right upper leg fracture, muscle weakness, diabetes, depression, anxiety, and heart failure, and was identified as at risk for pressure sores on a Braden Scale. She told staff her bottom had been sore for a couple of days, and later observation showed a two inch by one inch dark red area on her tailbone. A CNA stated she had noticed the red area the day before but had not reported it to the nurse. The LN and treatment nurse stated they were not aware of the sore and there was no assessment or treatment documented for the area. The DON confirmed the red area and stated there should have been an assessment and treatment, and that CNAs should have reported the skin change when noticed. Another resident, admitted with diagnoses including heart failure, abdominal pain, kidney failure, dehydration, and dysphagia, was observed with a red rash around her mouth. The next day, an RN confirmed she had noticed the red mouth during medication pass but had not assessed or documented it because the resident said she had no pain. The resident was then observed with a large red rash around her entire mouth and stated her lips were numb and the rash hurt. The RN stated there were no treatments ordered and no documentation concerning the rash or numb lips. A CNA stated she thought nurses were already aware of the rash because it had been present for a couple of days and said she should have told the nurses when she noticed it. The CNA daily body check for showers showed no new or existing skin issues documented.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure annual performance evaluations were completed every 12 months for three of four CNAs, identified as CNA C, CNA E, and CNA F. Facility policy titled Performance Evaluations stated that a performance evaluation may be completed on each employee at least annually based on the hire date, and that the supervisor and evaluated employee should sign and date the evaluation form. During a concurrent interview and employee file review, Payroll Personnel confirmed there were no annual performance reviews completed for CNA C, who was hired 11/22/23 and was missing a 2024 annual evaluation; CNA E, who was hired 3/29/22 and was missing a 2023 annual evaluation; and CNA F, who was hired 4/1/23 and was missing a 2024 annual evaluation. The DON later reviewed CNA employee files and confirmed annual staff evaluations had not been consistent, stating she had been at the facility for about a year and was trying to get caught up on annual staff evaluations.
Failure to Report Incident of Exposure by Family Member
Penalty
Summary
The facility failed to report an incident of potential abuse involving a resident and a family member of another resident. The incident occurred when a family member of another resident exposed himself to a resident in their shared room. The resident, who was cognitively intact and capable of making their own medical decisions, reported feeling uncomfortable but did not perceive the incident as abuse. Despite the resident's feelings, the facility's policy required all reports of abuse or mistreatment to be promptly reported to local, state, and federal agencies, which was not done in this case. Interviews with the Social Services Director and the Administrator confirmed awareness of the incident. The Social Services Director had interviewed both the resident and the family member involved, and the resident expressed a desire to be discharged from the facility. The Administrator confirmed that the investigation was complete, and no report was filed because the resident did not wish to pursue the matter or consider it abuse. This inaction was contrary to the facility's policy and placed all residents at risk for unreported allegations of abuse.
Inadequate Staffing Leads to Unanswered Call Lights
Penalty
Summary
The facility failed to provide sufficient and qualified nursing staff to meet the needs of residents, resulting in unanswered call lights and delayed assistance. This deficiency affected 11 out of 30 residents, including those with severe cognitive impairments and those who are cognitively intact but require assistance due to physical limitations. Residents reported waiting for extended periods, sometimes up to two hours, for staff to respond to their call lights, leading to situations where they were left in soiled briefs, on the toilet, or in bed without necessary assistance. Specific incidents included Resident 28, who has severe cognitive impairment, waiting 30 minutes for assistance while on the toilet, and Resident 215, who is cognitively intact, experiencing regular delays of 30 minutes or more for call light responses. Resident 45 reported waiting two hours for assistance, resulting in urination accidents, while Resident 57, who has a history of falls, waited 45 minutes for pain medication. Resident 365, who requires oxygen management, waited 40 minutes for assistance during a breathing issue, highlighting the critical nature of timely staff response. Interviews with residents and resident council members revealed that staff breaks often left call lights unanswered, with entire shifts taking breaks simultaneously, leaving only the medication cart nurse available. This practice contributed to the delays in responding to residents' needs, impacting their physical, mental, and psychosocial well-being. The facility's policies and job descriptions emphasize prompt response to call lights, yet these were not adhered to, resulting in significant deficiencies in care.
Medication Regimen Review Deficiencies
Penalty
Summary
The facility failed to ensure complete Medication Regimen Reviews (MRR) for two residents, leading to potential medication irregularities and adverse effects. For one resident, the use of Seroquel, a psychotropic medication, was deemed appropriate by the Consultant Pharmacist (CPH) despite the lack of evaluation by the Psychotropic Interdisciplinary Team (IDT) 50 days after admission. The resident was receiving Seroquel in combination with donepezil, which could reduce the effectiveness of donepezil and cause nervous system side effects. The CPH did not report any medication irregularities, and the resident's medication regimen was not reviewed for potential adverse effects or the necessity of the psychotropic medication. Another resident received oxybutynin extended-release (ER) tablets instead of the immediate-release (IR) formula ordered by the Medical Director. This error went undetected and unreported by the CPH, resulting in the resident receiving a longer-lasting dose of oxybutynin, which could lead to adverse effects from excessive medication build-up. The error was identified during a medication administration observation, and the CPH acknowledged the mistake, noting that the ER formula should have been questioned by the in-house pharmacists. The facility's policies and procedures for medication regimen reviews and antipsychotic medication use were not adequately followed. The Consultant Pharmacist and other healthcare professionals involved in the medication review process did not identify or address the medication irregularities, leading to potential harm to the residents' physical, mental, and psychosocial well-being. The lack of timely and thorough medication reviews contributed to the deficiencies observed in the care of these residents.
Medication Errors and Pain Management Deficiencies
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by two medication errors identified out of 29 opportunities, resulting in a 6.9 percent error rate. For Resident 25, a Licensed Nurse (LN D) administered oxybutynin extended-release (ER) 5 mg tablets instead of the prescribed oxybutynin chloride immediate-release (IR) 5 mg tablets. This error occurred over a period from June to August, with the ER formula being administered 83 times in August alone. The error was confirmed by the Registered Pharmacist and the Consultant Pharmacist, who noted that the ER formula should only be given once daily, not three times a day as it was administered. For Resident 216, LN D failed to administer scheduled or as-needed pain medications despite the resident expressing a pain level of 10 on a scale of 1 to 10. The resident, who had multiple diagnoses including muscle weakness, repeated falls, and rib fractures, was observed in pain but did not receive any pain medication. LN D did not administer oxycodone, the available pain medication, because the resident could not articulate a pain scale, and LN D did not believe the resident was in pain. Additionally, the resident had refused lidocaine patches and Tylenol on several occasions, but this was not communicated to the physician as required by the facility's policy. The Director of Nursing (DON) acknowledged the medication errors and expressed frustration over the nursing staff's failure to recognize nonverbal indications of pain in Resident 216. The facility's policies on administering medications and pain assessment were not followed, contributing to the deficiencies observed. The report highlights the need for adherence to medication orders and proper pain assessment protocols to prevent such errors.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and supplies, leading to several deficiencies. Discontinued medications were not removed from active medication areas, as observed with potassium chloride packets in Medication Cart A. Additionally, six multi-dose tubes of non-controlled medicated creams were found in Treatment Cart 1 without patient-specific labeling, posing a risk of administering medications without a physician's order. A used oral medication syringe was improperly stored with a bottle of liquid Keppra, raising concerns about infection control. Further deficiencies were noted with an open and undated bottle of glucose test strips, which should have been labeled with an 'Opened on' date to ensure effectiveness. Loose pills were found in Medication Cart A, creating a risk for medication diversion. An expired bottle of ketoconazole shampoo was being used on a resident, and an expired IV line filter was found in Treatment Cart 2, both of which should have been discarded to maintain medication effectiveness and safety. The report also highlighted a security issue where the Housekeeping Supervisor, an unlicensed staff member, had access to the locked Medication Room, which contained emergency medication kits and potentially hazardous medications. This access was against the facility's policy, which states that only authorized personnel should have access to locked medications. These failures collectively posed risks of medication misuse, drug diversion, and exposure to harmful pathogens for all 58 residents.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility's food and nutrition services department failed to provide palatable meals to residents, as evidenced by multiple complaints about the temperature and taste of the food. Observations and interviews revealed that residents frequently received meals that were cold and unappetizing. During a taste test, the Certified Dietary Manager and Registered Dietician found that the food items, such as French fries and pureed fish, were served at temperatures below the expected standard for hot meals, confirming the residents' complaints. Several residents, including those with cognitive impairments and various medical conditions such as diabetes, COPD, and dysphagia, reported dissatisfaction with the meals. They described the food as cold, tasteless, and visually unappealing. Some residents compared the food to hospital meals and expressed frustration over the lack of variety and excessive salt. The dissatisfaction was not limited to individual residents, as a confidential interview with Resident Council members echoed similar concerns about the quality and temperature of the meals. The facility's policy on meal service emphasized the importance of serving hot food hot and cold food cold, yet the staff, including the Food Service Support, Certified Dietary Manager, and Registered Dietician, were unaware of the residents' dissatisfaction. This lack of awareness and failure to adhere to the facility's meal service policy contributed to the deficiency, potentially leading to unintended weight loss among residents.
Inadequate Supervision and Care Planning for Wandering and Agitated Residents
Penalty
Summary
The facility failed to provide adequate supervision for three residents who exhibited wandering and agitated behaviors, leading to potential safety and privacy concerns. Resident 34, diagnosed with seizures, Down syndrome, and developmental disorder of speech and language, was observed wandering into other residents' rooms without a care plan addressing this behavior. Interviews with other residents confirmed that Resident 34's wandering was a frequent occurrence, causing discomfort and requiring staff intervention. Despite awareness of this behavior, the Director of Nursing (DON) was not informed, and no interventions were documented in the care plan. Resident 50, with severe cognitive impairment and multiple diagnoses including Alzheimer's disease, also wandered into other residents' rooms. Although the care plan mentioned elopement, it lacked specific interventions for when Resident 50 intruded on others' privacy. Interviews revealed that Resident 50's behavior was bothersome to roommates and other residents, with one resident expressing a threat of harm if the behavior continued. Staff confirmed the wandering behavior but were unaware of any care plans or interventions to address it. Resident 28, with severe cognitive impairment and a history of agitation, was observed throwing items in the hallway. Despite staff awareness of Resident 28's behaviors, there was no care plan detailing interventions for managing increased agitation and poor impulse control. Interviews with staff and residents indicated that Resident 28's behavior was a regular occurrence, yet the DON was not informed, and no interventions were in place to ensure the safety and well-being of other residents.
Failure to Revise Care Plans for Wandering Behaviors
Penalty
Summary
The facility failed to revise care plans for two residents, Residents 34 and 50, to address their wandering behaviors. Resident 34, who was admitted with diagnoses of seizures and Down syndrome, was observed by other residents to wander into their rooms, causing disturbances. Despite these observations, Resident 34's care plan did not include any interventions for wandering behavior, as confirmed by the Director of Nursing (DON) during a review. Resident 50, diagnosed with Alzheimer's disease, anxiety, depression, and obsessive-compulsive disorder, also exhibited wandering behaviors. Although Resident 50's care plan included an elopement risk, it did not address the resident's tendency to wander into other residents' rooms. This behavior was reported by other residents, including Resident 48, who expressed discomfort and threatened harm if the behavior continued. Staff interviews confirmed awareness of the wandering behaviors but revealed a lack of specific interventions in the care plans. The facility's policy required care plans to be revised when resident information changed, but this was not done for Residents 34 and 50. The DON was unaware of the specific wandering incidents and stated that staff should have reported these changes to her for care plan revision. The failure to update the care plans placed the residents at risk for harm and potentially affected their physical, mental, and psychosocial well-being.
Inadequate Pain Management for Resident with Dementia
Penalty
Summary
The facility failed to manage the pain of Resident 216, who was admitted with fractured lumbar vertebrae, multiple fractured ribs, COPD, and dementia. Despite exhibiting clear signs of pain, such as grimacing, frowning, and rocking in a wheelchair, Resident 216 did not receive appropriate pain medication. The resident was unable to verbalize a specific number on the pain scale due to severe cognitive impairment, which led to the failure to administer pain medication as per the medical doctor's orders. During observations and interviews, it was noted that Resident 216 was in visible discomfort, holding their ribs and exhibiting facial expressions indicative of pain. Licensed nurses repeatedly asked the resident to rate their pain on a numeric scale, but the resident struggled to provide a consistent response. Despite acknowledging the resident's pain, the nurses did not administer the prescribed Oxycodone, as they relied solely on the numeric pain scale and did not utilize alternative assessment tools suitable for residents with dementia. The facility's policy on pain assessment and management was not followed, as the staff failed to use the Pain Assessment in Advanced Dementia (PAINAD) scale, which considers nonverbal cues such as facial expressions and body language. Additionally, the staff did not notify the physician about the resident's frequent refusal of pain medications, as required by the facility's policy on changes in a resident's condition or status. This oversight resulted in inadequate pain management for Resident 216.
Failure to Review Psychotropic Medications and Attempt GDR
Penalty
Summary
The facility failed to review indications for continued use or attempt Gradual Dose Reduction (GDR) for a resident receiving four psychotropic medications for 50 days. The resident, who was admitted with Alzheimer's dementia, mood disturbance, and other conditions, was on hospice care and unable to make healthcare decisions. The medications included lorazepam, Seroquel, trazodone, and sertraline, which were prescribed for anxiety, mood disorder, insomnia, and OCD, respectively. Despite the facility's policy requiring monthly medication reviews, the resident's psychotropic medications had not been reviewed by the Psychotropic Interdisciplinary Team (IDT) since admission. The facility's policies and procedures outlined the need for regular medication regimen reviews to ensure appropriate indications, dosages, and durations of use. However, the Consultant Pharmacist's review in July and August did not result in any recommendations for changes, and the Medical Director was on vacation during August, missing the monthly review. Interviews with staff revealed that the resident's aggressive behaviors had improved, but the Psychotropic IDT had not yet evaluated the need for GDR or the appropriateness of the medications. The Director of Nursing acknowledged that the indication for Seroquel was based on hospice orders and that the Psychotropic IDT would review the medication regimen in October. Despite the resident's improved behavior, the facility had not performed a GDR or reviewed the psychotropic medications for unnecessary use. The report highlights the lack of timely medication review and GDR attempts, which could potentially lead to adverse side effects for the resident.
Failure to Honor Food Preferences and Serve Accurate Portions
Penalty
Summary
The facility failed to honor a resident's food preferences and did not serve accurate portion sizes, leading to potential health impacts. One resident, who was cognitively intact and had a history of gastro-esophageal reflux disease and major depressive disorder, reported that the facility continued to serve broccoli despite their documented dislike for it. The facility's dietary records confirmed that the resident's food preferences were not reflected on meal tickets, indicating a failure to honor the resident's food choices as per the facility's policy. Additionally, during a meal service observation, the facility did not provide the correct portion size of fish to residents. The Certified Dietary Manager instructed staff to weigh the fish portions, but the staff member did not consistently use a scale, resulting in varying portion sizes. The Registered Dietician and Certified Dietary Manager acknowledged that without weighing each portion, there was no assurance that residents received the accurate portion size of three ounces as required by the facility's policy.
Deficient Kitchen Equipment Maintenance
Penalty
Summary
The facility failed to maintain kitchen equipment in good repair, as observed during a survey. The pots and fry pans in the kitchen had a black buildup on the outside, and the protective layer on the inside of the fry pans was missing, exposing the metal. Additionally, one fry pan had a thick, black residue on the inside where food was cooked. This condition was confirmed by the Certified Dietary Manager (CDM) during an observation and interview. The facility's policy and procedure on sanitation required all equipment to be kept clean and in good repair, which was not adhered to in this instance. The CDM stated that new pots and pans had been ordered the previous week, but the provided email, dated the same day as the observation, did not include a date indicating when the order was placed. This discrepancy suggests a lack of timely action to address the equipment's poor condition, which had the potential to contaminate food and negatively impact resident health.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the appropriate local, state, and federal agencies, including the California Department of Public Health (CDPH). The incident involved a Certified Nurse Assistant (CNA) observing one resident making verbal threats and shaking a fist at another resident. Despite the incident being reported to a Licensed Nurse (LN) and subsequently to the Director of Nursing (DON), the allegation was not communicated to the necessary authorities as required by the facility's policy and procedure on abuse investigation and reporting. The residents involved had significant cognitive impairments and were not responsible for their own decisions. One resident, who was on hospice care, was reported to have been touching the other resident, which led to the altercation. The facility's failure to report the incident placed all residents at risk for unreported abuse allegations. The DON was not made aware of the incident until it was brought to attention by CDPH staff, indicating a breakdown in the facility's internal reporting process.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 63 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Bridgeview Post Acute | 0.5 mi | ★★★★★ | 24 | 0 |
| Fountains, The | 0.6 mi | ★★★★★ | 1 | 0 |
| Marysville Post-acute | 2.2 mi | ★★★★★ | 0 | 0 |
| River Valley Care Center | 8.2 mi | ★★★★★ | 1 | 0 |
| Gridley Post Acute | 15.6 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Yuba City Post Acute.
100% money-back within 48 hours.
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.