YORBA LINDA, CA - Federal inspectors documented multiple infection control violations at Bayshire Yorba Linda Post-Acute during an April 7, 2025 survey, including critical breaches in neutropenic precautions designed to protect an immunocompromised cancer patient recovering from chemotherapy treatment.
Critical Breach of Neutropenic Precautions
The most concerning violation involved a resident on neutropenic precautions following cancer chemotherapy treatment. Despite clear signage posted outside the room indicating special isolation requirements, staff and visitors failed to follow essential protective protocols.
During multiple observations between April 1-2, 2025, inspectors documented that the resident's door remained open rather than closed as required. Two vases with fresh flowers were observed at the resident's bedside, despite explicit restrictions prohibiting flowers, plants, and unwashed fruits or vegetables due to potential pathogen exposure.
Neutropenic precautions, also called reverse isolation, exist specifically to protect residents with severely weakened immune systems from infection sources that pose minimal risk to healthy individuals. Cancer chemotherapy destroys rapidly dividing cells, including those in the immune system, leaving patients temporarily unable to fight off bacteria, fungi, and other microorganisms that occur naturally in the environment.
Fresh flowers and plants carry soil-based organisms including Aspergillus species, a type of fungus that can cause life-threatening lung infections in immunocompromised individuals. For a person with normal immunity, exposure causes no harm. For someone recovering from chemotherapy with depleted white blood cell counts, the same exposure can result in invasive aspergillosis, a serious infection requiring aggressive antifungal treatment.
The facility's own policy specified that masks should be worn by staff and visitors, especially when respiratory infection risk exists. The room should remain private with a closed door, strict attention to cleanliness, and no fresh flowers or inadequately washed produce.
During an April 2 observation at 1409 hours, the Infection Preventionist entered the resident's room wearing gown and gloves but no mask. The IP assisted the resident with repositioning while unmasked. When questioned, the IP acknowledged the mask should have been worn and verified the door was open with fresh flowers present at bedside.
Enhanced Barrier Precaution Violations
Inspectors observed another infection control lapse on April 7 at 832 hours when a certified nursing assistant transferred Resident 591 from bed to wheelchair without wearing required protective equipment. The resident had physician orders for enhanced barrier precautions due to an indwelling medical device.
Enhanced barrier precautions represent an evidence-based approach to preventing transmission of multidrug-resistant organisms in nursing homes. These precautions require staff to wear gowns and gloves during high-contact care activities including dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, and device care.
Signage posted outside Resident 591's room clearly outlined the requirement to don personal protective equipment for these activities. When interviewed at 837 hours, the CNA stated: "I wear a gown and gloves when I am changing her and not during transfers."
This reflects a fundamental misunderstanding of transmission risk. Transferring a resident involves close physical contact and handling of surfaces the resident regularly touches. Indwelling medical devices like urinary catheters create entry points for bacteria. Without proper barrier precautions during transfers, staff can carry organisms from one resident to another on their clothing and hands.
The licensed vocational nurse responsible for the resident confirmed that gowns must be worn during transfers for residents on enhanced barrier precautions. The facility's Infection Preventionist and Director of Nursing acknowledged the violation.
Contaminated Equipment and Surfaces
The April inspection revealed multiple instances of unclean equipment in food preparation and medication areas, creating additional infection risks.
In Medication Room A, inspectors found a sink with brown discoloration on the strainer, bluish discoloration measuring approximately 5 cm x 7 cm around the drainage area, and dirt materials soaked in water at the base of the strainer. The faucet was leaking, and whitish streaks marked the sink surface. The registered nurse and Director of Nursing both verified the sink should be maintained in clean condition at all times.
Medication preparation areas require particularly high sanitation standards. Nurses use these sinks for handwashing before handling medications, cleaning equipment, and other tasks critical to resident safety. A dirty sink with standing water provides an ideal environment for bacterial growth and biofilm formation.
In the satellite kitchen, dietary staff stored six scoops wet inside a storage bin, contrary to FDA Food Code requirements that items must air-dry before storage. Stacking or storing wet items prevents complete drying and creates conditions where microorganisms can multiply.
Additional kitchen violations included an ice cream scoop that was chipped and corroded, a gray scoop with visible food debris, a can opener and peeler with rust, multiple serving utensils with white staining, and a microwave with brownish discoloration and food debris.
The main kitchen ice machine showed black particles on the deflector and groove when wiped with a white paper towel. The manufacturer's manual specifies that only approved Manitowoc Ice Machine Cleaner and Sanitizer should be used for cleaning and sanitizing, with procedures performed at minimum every six months. The maintenance director acknowledged dietary staff were using a different food-grade sanitizer rather than the manufacturer-specified product.
Incomplete Medical Records Create Safety Risks
The facility failed to maintain complete and accurate medical records for six sampled residents and two additional residents, creating potential gaps in care coordination.
For Resident 28, the medication administration record showed blank documentation during an entire morning shift on March 5, 2025 for essential medications, treatments and monitoring including COVID-19 monitoring, antibiotic administration, pain monitoring, central venous catheter site observation, and bowel management medication.
Missing documentation for a central venous catheter is particularly concerning. These devices provide direct access to major blood vessels and require careful monitoring for signs of infection, blood clots, or displacement. Failure to observe and document catheter site condition every shift can delay recognition of serious complications.
The facility's policy requires staff to initial the medication administration record immediately after giving each medication, before administering the next one. The nurse who worked that shift acknowledged administering the medications and treatments but stated she may have forgotten to save the electronic documentation entries.
Multiple residents' medication records lacked proper professional title designations for staff who signed the MAR, making it impossible to verify which licensed professionals administered controlled substances and other critical medications.
Three residents received antibiotic treatment in February 2025 despite not meeting McGeer's Criteria, the standardized definitions for infections in long-term care facilities. While physicians ordered continuation of antibiotics, the facility failed to document the physician's name, date and time of notification, the nurse who made the notification, or the clinical justification for continuing treatment without meeting infection criteria.
Incomplete Psychotropic Medication Consents
California regulations require specific informed consent procedures before prescribing psychotherapeutic drugs. The prescriber must personally examine the resident and obtain written consent signed by the resident or representative, along with signature of a healthcare professional declaring the required information was provided.
For Resident 16, the informed consent form for buspirone (an anti-anxiety medication) showed printed names of two staff members who supposedly obtained consent, but the signatures below those names belonged to different staff members entirely. The MDS Coordinator acknowledged signing the form despite never discussing the medication with the resident. An LVN also signed without speaking to the resident about the medication.
This practice undermines the entire purpose of informed consent. The requirement exists to ensure residents or their representatives receive accurate information about medication risks, benefits, and alternatives before treatment begins, allowing them to make educated decisions about their care.
For Resident 25, the psychotropic consent form for bupropion (an antidepressant) lacked the physician's signature and date entirely, despite the resident being alert, interactive and cooperative according to physician progress notes.
Industry Standards and Expectations
Federal regulations require nursing homes to maintain an infection prevention and control program that prevents, identifies and manages infections. Staff must receive appropriate training and demonstrate competency in infection control practices.
The Centers for Disease Control emphasizes that unnecessary antibiotic use promotes development of antibiotic-resistant bacteria. Every antibiotic exposure kills sensitive bacteria while potentially allowing resistant organisms to survive and multiply. Proper surveillance systems help facilities identify when antibiotics are prescribed appropriately versus situations requiring clinical review.
Medical record accuracy represents a fundamental aspect of patient safety. Complete documentation enables care coordination across shifts and disciplines, provides evidence of care delivery, supports clinical decision-making, and creates accountability for healthcare decisions.
The April 2025 inspection identified violations at the minimal harm level, meaning they had potential to cause more than minimal harm but did not result in actual resident injury. The facility submitted correction plans to address the identified deficiencies.
Residents and families can access the complete inspection report and facility correction plans by contacting Bayshire Yorba Linda Post-Acute at 17803 Imperial Highway, Yorba Linda, CA 92886, or reviewing publicly available inspection records through Medicare's Nursing Home Compare website.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brookdale Yorba Linda from 2025-04-07 including all violations, facility responses, and corrective action plans.
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