Brookdale Yorba Linda

F-F812, example #3.a.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 3. a. On 4/1/25 at 0850 hours, an observation of the main kitchen and concurrent interview was conducted with the Culinary Director. There was no thermometer observed inside the walk-in freezer. The walk-in Level of Harm - Minimal harm or freezer was observed with a thick ice build-up from floor to the ceiling on the interior part of the freezer near potential for actual harm the door. There were several food items in the freezer that were covered with ice. The Culinary Director verified the above findings. The Culinary Director stated there was something wrong with the freezer door Residents Affected - Few and a new freezer door had been ordered.

On 4/3/25 at 0949 hours, an interview and concurrent facility document review was conducted with the Director of Maintenance. The Director of Maintenance stated there was an ice build-up because the needed to be replaced and stated a there was a lead time of four to six weeks when the freezer door will be delivered. When asked when the freezer door was inspected and the walk-in freezer cleaned, the Director of Maintenance stated they removed the ice build-up and cleaned the walk in area a couple of days ago.

Review of the facility's document titled Freezer Door Cleaning Log showed it was signed off on 3/3, 3/10, 3/17, 3/24, and 3/31/25.

b. On 4/1/25 at 0821 hours, during the initial tour of the satellite kitchen, ice build-up was observed inside the freezer. The Dietary Aide verified the above findings.

c. On 4/1/25 at 1133 hours, an inspection of the refrigerator used for the residents' food brought from outside and concurrent interview was conducted with RN 1. An ice-build up was observed inside the freezer and a brownish discoloration was observed on the shelves of the refrigerator used for the residents' food brought from the outside source. RN 1 verified the above findings.

On 4/3/25 at 0949 hours, an interview was conducted with the Director of Maintenance. The Director of Maintenance stated the housekeeping staff was responsible for the weekly cleaning of the refrigerator used for the residents' food brought from the outside sources, which was usually on Mondays.

On 4/3/25 at 1016 hours, an interview was conducted with the CDM. The CDM stated the dietary staff was responsible for the weekly cleaning of the refrigerator used for residents' food brought from outside sources.

4. According to the FDA Food Code 2022, section 4-502.11, showed food temperature measuring devices shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy.

Review of the Lonicera Thermometer User Instruction (undated) showed to calibrate, take a cup of water and insert the probe into the ice water to touch the ice. When the final temperature is reached, hold down the CAL button for five seconds. After five seconds, the display will flash CAL on the screen, then the digit will flash, then press the C/F button to increase the digit or the HOLD button to decrease the digit until 0C or 32 F is reached.

Review of the facility's P&P titled How to Calibrate Thermometers: Bi-Metallic Stem and Digital revised 12/12/19, showed calibration of thermometers is a must in order to assure the temperature displayed on the thermometer is accurate. The method of calibration for bi-metallic stem and digital thermometers includes the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 - Fill a medium size glass with clean ice;

Level of Harm - Minimal harm or - Add 1/2 cup clean water to the ice and wait for two minutes; potential for actual harm - Using the case as a handle, place the thermometers in the middle of the ice water and wait for three Residents Affected - Few minutes while stirring the water occasionally. The thermometer must be two inches deep in the water and ice

in order for the sensing area to be covered completely;

- If the temperature reading is 32 degrees F, the thermometer is calibrated accurately. If the thermometer does not record 32 degrees F, then an adjustment Is needed. For digital thermometer, leave it in ice water. Press the reset button. If it does not read 32 degrees F, add a battery and recheck or replace the thermometer.

On 4/2/25 at 1117 hours, a thermometer calibration observation and concurrent interview was conducted with the Dietary Aide, and the CDM was present. The Lonicera thermometer was observed in a cup with ice and water. The Dietary Aide stated to calibrate the thermometer, the C/F button needed to be pressed and then wait for the temperature to go down to 32 degrees F. The Dietary Aide was observed pressing the C/F button. Then, the Dietary Aide was observed repeatedly pressing the C/F and HOLD buttons. The thermometer showed 33.4 degrees F temperature. The Dietary Aide was observed using the thermometer to check the food temperature. The CDM verified the above findings.

On 4/3/25 at 1016 hours, an interview was conducted with the CDM and RD. The CDM verified the Dietary Aide did not calibrate the thermometer correctly. The CDM stated the Dietary Aide was supposed to push the calibrate button for five seconds, and let the thermometer sit in the cup with water and ice, then lift the thermometer up and pushed the button more to get the temperature down to 32 degrees F.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39453

Residents Affected - Few Based on observation, interview, medical record review, facility document review, and facility P&P review,

the facility failed to ensure the residents' beds were inspected and the entrapment assessments were conducted when identifying areas of possible entrapment with the use of bed rails for two of four final sampled residents (Residents 26 and 339) investigated related to the use of side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Findings:

1. According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space

in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards.

The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are:

- Zone 1: within the rail;

- Zone 2: under the rail, between the rail supports or next to a single rail support;

- Zone 3: between the rail and the mattress;

- Zone 4: under the rail, at the ends of the rail;

- Zone 5: between split bed rails;

- Zone 6: between the end of the rail and the side edge of the head or foot board; and

- Zone 7: between the head or foot board and the mattress end.

Review of the facility's P&P titled Bed Safety revised 12/2007 showed to try to prevent deaths/ injuries from

the beds and related equipment including the frame, mattress, side rails, headboard, footboard, and bed accessories, the facility shall promote the following approaches:

- Inspection by the maintenance staff of al beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks;

- Review that gaps within the bed system are within the dimensions established by the FDA. The review shall consider situations that could be caused by the resident's weight, movement or bed position; and

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 - Identify additional safety measures for residents who have been identified as higher than usual risk for injury including entrapment such as altered mental status, restlessness, etc. Level of Harm - Minimal harm or potential for actual harm On 4/1/25 at 0904 hours, 4/3/25 at 1412 hours, 4/4/25 at 1030 hours, and 4/7/25 at 0942 hours, Resident 339 was observed lying in bed with the bilateral grab rails elevated. Residents Affected - Few Medical record review for Resident 339 was initiated on 4/1/25. Resident 339 was admitted to the facility on [DATE REDACTED].

Review of Resident 339's Order Summary Report showed a physician's order dated 3/31/25, for the bilateral deluxe assist bed handles while in bed for turning and positioning.

Review of Resident 339's Skilled Nursing - Admission Initial Eval - V 13 dated 3/31/25, showed the following:

- The Cognition/ Mental Status section showed Resident 339 was alert and oriented;

- The Functional GG section showed Resident 339 required supervision from the facility staff for mobility and transfers; and

- The Side/ Bed Rail Evaluation, Evaluation of Entrapment Risk section showed there were gaps between

the resident's mattress and side/ bed rail, headboard and footboard.

On 4/7/25 at 1027 hours, an interview and concurrent medical record for Resident 339 was conducted with

the DON. The DON verified the initial evaluation for Resident 17 showed there were gaps between the resident's mattress and side/bed rail, headboard, and footboard.

On 1/24/25 at 1225 hours, a concurrent interview and facility document review for Resident 339 was conducted with the Director of Maintenance. The Director of Maintenance stated the maintenance department was responsible for the yearly bed inspection of all the beds in the facility, including the Entrapments Zones 1 to 4. When asked if he inspected the bed when there was a change of bed or mattress or a new resident to determine if any areas of possible entrapment are present based on the change of the bed, or mattress, or user, the Director of Maintenance stated he did not go back to check, not unless the resident had a low air loss mattress. The Director of Maintenance also stated they would only check the bed frame when the nurses reported to have it repaired. When asked to show documentation of his bed inspection, the Director of Maintenance showed and verified the following documents:

- The facility document titled Bed Safety Action Grid dated 6/1/18, showed Entrapment Zones 1 to 4 were encircled.

- The facility document titled Bed Rail Inspection dated 1/25/25, showed Resident 339's bed passed.

- The facility document titled Entrapment Measurements for Resident 339's bed dated 1/25/25, showed Zones 1 to 4 were marked P. The areas to show entrapment measurements between the mattress and the headboard and footboard were left blank.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 The Director of Maintenance verified the above findings. When asked if the nurses reported the initial evaluation on 3/31/25, for Resident 17 showing there were gaps between the resident's mattress and Level of Harm - Minimal harm or side/bed rail, headboard, and footboard and if he conducted a bed inspection and entrapment assessment potential for actual harm for Resident 17, the Director of Maintenance answered no. The Director of Maintenance stated he only conducted the bed inspection with the entrapment assessments on 1/25/25, for all the beds in the facility. Residents Affected - Few 50787

2. On 4/1/25 at 1048 hours, during the initial tour of the facility, Resident 26's bed was observed to have the bilateral enablers.

Medical record review for Resident 26 was conducted on 4/7/25. Resident 26 was admitted to the facility on [DATE REDACTED].

Reviewed Resident 26's Order Summary Report dated 4/7/25, showed a physican's order dated 3/3/25, for deluxe assist bed handles up times two while in bed for turning and positioning.

Review of Resident 26's Skilled Nursing - Admission Initial Evaluation dated 3/3/25, the section for Side/Bed Rail Evaluation - Evaluation of Entrapment Risk, showed, yes to all the questions if the side rails had gaps between mattress, and side/bed rail, headboard or footboard.

On 4/7/25 at 1307 hours, a concurrent observation, interview and facility document review was conducted with the Director of Maintenance. The Director of Maintenance stated the side rails were being inspected annually and as needed when a low air pressure mattress was used. When asked for the bed entrapment measurement documentation for Resident 26, the Director of Maintenance stated he performed the assessment on all the beds on 1/25/25. However, the Director of Maintenance was unable to provide the documentation of the bed entrapment measurements for Resident 26. Resident 26's Evaluation of Entrapment Risk dated 3/3/25, was reviewed with the Director of Maintenance. The Director of Maintenance stated he was not aware of any reported gaps between the mattress, and side/bed rail, headboard or footboard.

On 4/7/25 at 1330 hours, an interview was conducted with the Administrator and DON. The Administrator and DON was made aware and acknowledged the above findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 38 555768

F-F908 #2.

b. On [DATE REDACTED] at 0821 hours, during the initial tour of the satellite kitchen and concurrent interview was conducted with the Dietary Aide. The following was observed:

- A ice cream scoop was observed chipped and corroded;

- A gray scoop was observed with food debris;

- The can opener and peeler were observed with rust;

- The white scoop, black serving spoon, and red adaptive spoon were observed with white stain; and

- The storage bins for the scoops was observed with white stain.

The Dietary Aide verified the findings.

c. On [DATE REDACTED] at 1044 hours, during the inspection of the main kitchen, five cupcake pans were observed with brownish discoloration. The Culinary Director verified the findings.

d. On [DATE REDACTED] at 0925 hours, the microwave used to warm the residents' food in the satellite kitchen was observed with a brownish discoloration and food debris. The CDM verified the findings.

4. According to the 2022 FDA Food Code, ,d+[DATE REDACTED].11, Equipment and Utensils, Air- Drying Required, showed items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganism can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 On [DATE REDACTED] at 0821 hours, during the initial tour of the satellite kitchen, six scoops were stored wet inside a storage bin. The Dietary Aide verified the findings. Level of Harm - Minimal harm or potential for actual harm 5. According to the 2022 FDA Food Code, Section ,d+[DATE REDACTED].12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a Residents Affected - Some result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces.

On [DATE REDACTED] at 0821 hours, a red cutting board was observed to be heavily marred with knife marks. The Dietary Aide verified the findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Potential for **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32179 minimal harm Based on observation, interview, and facility P&P review, the facility failed to implement the P&P to ensure Residents Affected - Some proper storage of food brought in by family members.

* An unlabeled and undated bag of cereal was observed on Resident 29's bedside table. This failure had the potential to result in foodborne illnesses in a highly susceptible resident population.

Findings:

Review of the facility's P&P titled Foods Brought by Family or Visitors dated 3/2022 showed the food brought by family or visitors and left with the resident to consume later must be labeled and stored in a manner that clearly distinguishes it from facility-prepared food. Non-perishable foods must be stored in resealable containers with tightly fitting lids.

Medical record review for Resident 29 was initiated on 4/1/25. Resident 29 was admitted to the facility on [DATE REDACTED].

On 4/2/25 at 0900 hours, an observation and concurrent interview was conducted with LVN 1. There was an undated and unlabeled resealable, transparant plastic bag of dry cereal stored on Resident 29's bedside table. LVN 1 stated they only labeled the wet food, not dry food.

On 4/2/25 at 1032 hours, an interview with the DON. The DON stated the bag of dry cereal should have been labeled and dated. The DON verified the findings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39453

Residents Affected - Few Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' medical records were complete and accurate for six of 13 final sampled residents (Residents 16, 17, 25, 28, 29, and 339) and two nonsampled residents (Residents 640 and 641).

* The facility failed to ensure the signatures on the informed consent for the buspirone (antianxiety medication) medication for Resident 16 matched the printed names on the consent form. Additionally, Resident 16's MAR entries failed to show the job designation of the staff signing.

* The facility failed to ensure the MAR entries showed the job designation of the staff signing the MAR for Residents 17, and 339.

* The facility failed to ensure Resident 28's medication administrations, treatments, and monitorings were documented in the MAR after it was administered or provided. Additionally, the consent to treat and consent for the use lorazepam (antianxiety medication) was incomplete.

* The facility failed to ensure Resident 25's consent for the use of the buspar medication (antianxiety) was complete.

* Resident 2's advance directive was not available in active medical record.

* The facility failed to document the physician's name, date and time when the physician was notified and name of the nurse who notified the physician when Residents 29, 640, and 641 did not meet the McGeer's criteria but received the antibiotic treatments.

These failures posed the risk for the resident care needs not being met as their medical record information were inaccurate and incomplete.

Findings:

Review of the Health and Human Services Agency, California Department of Public Health AFL (All Facilities Letter) 24-07 showed under the examination and signatures: before prescribing a psychotherapeutic drug,

the prescriber must personally examine the resident and obtain the informed written consent signed by the resident or the resident's representative along with, the signature of the health care professional declaring

the required material information has been provided. If the resident or resident's representative cannot sign

the form, a licensed nurse can sign the form and document the name of the person who gave consent and

the date.

1. Medical record review for Resident 16 was initiated on 4/1/25. Resident 16 was readmitted to the facility

on [DATE REDACTED].

* Review of Resident 16's Order Summary Report showed a physician's order dated 3/18/25, to administer buspirone 5 mg one tablet two times a day, to start on 3/25/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Review of Resident 16's Skilled Nursing - Psychotropic Consent - V1 dated 3/24/25, showed a verbal consent was obtained from Resident 16. The consent form, under the Verbal Consent section, showed the Level of Harm - Minimal harm or names of RN 1 and the DON printed as the healthcare professional/ facility staff. Further review of the potential for actual harm consent form did not show the signatures of RN 1 and the DON, and there was no signature of the physician.

Residents Affected - Few On 4/3/25 at 1337 hours, an interview and medical record review was conducted with the Medical Records Director. The Medical Records Director stated the informed consent forms were kept in an accordion file folder in her office, and the informed consent forms and all other medical records were uploaded to the resident's electronic health records as soon as the physician had signed it, and all the information on the medical record forms was completed. When asked about Resident 16's informed consents, the Medical Records Director stated, everything has been uploaded to PCC.

On 4/3/25 at 1350 hours, an interview and medical record review was conducted with the DON. When asked about Resident 16's informed consent for buspirone medication, the DON verified the form in the resident's electronic health record did not show the signatures of RN 1 and the DON.

On 4/3/25 at 1520 hours, the Medical Records Director gave a copy of Resident 16's Skilled Nursing - Psychotropic Consent - V1 dated 3/24/25, for the buspirone medication. The consent form showed the names of RN 1 and the DON printed as the healthcare professional/ facility staff, with signatures below their printed name, and also a signature of the physician.

On 4/4/25 at 1045 hours, a follow-up interview and concurrent medical record review was conducted with the DON. Review of Resident 16's Skilled Nursing - Psychotropic Consent - V1 dated 3/24/25, for buspirone medication showed the names of RN 1 and the DON printed as the healthcare professional/ facility staff, with signatures below their printed name, and a signature of the physician. When asked about the signatures on

the consent form, the DON stated the MDS Coordinator and another LVN signed the consent form. The DON acknowledged the signatures were not signed by the healthcare professional/ facility staff who actually verified the resident's informed consent for the buspirone medication.

On 4/4/25 at 1100 hours, an interview and medical record review was conducted with the MDS Coordinator. When asked about the residents' informed consent. The MDS Coordinator stated the informed consents for psychotropic medications were obtained by the nurses, and if missed, she would follow up with the resident. When asked about the informed consent for buspirone medication for Resident 16, the MDS Coordinator stated RN 1 and the DON already spoke to the resident about the buspirone medication, and she did not speak to Resident 16 about the buspirone medication, but she acknowledged she signed the consent form.

On 4/4/25 at 1110 hours, an interview and medical record review was conducted with LVN 1. When asked about the informed consent for buspirone medication for Resident 16, LVN 1 stated he did not speak with Resident 16 about the buspirone medication, but he acknowledged he signed the consent form.

* Review of Resident 16's MAR for March 2025, under the Staff Administration Legend section, did not show

the professional titles for seven of 10 staff who signed the MAR.

Review of Patient 16's MAR for April 2025, under the Staff Administration Legend section, did not show the professional titles for two of four staff who signed the MAR.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 On 4/7/25 at 1027 hours, an interview and concurrent medical record review for Patient 16 was conducted with the DON. The DON verified the above findings. Level of Harm - Minimal harm or potential for actual harm 2. Medical record review for Resident 17 was initiated on 4/1/25. Resident 17 was readmitted to the facility

on [DATE REDACTED]. Residents Affected - Few

Review of Resident 17's MAR for March 2025, under the Staff Administration Legend section, did not show

the professional titles for 12 of 14 staff who signed the MAR.

Review of Patient 17's MAR for April 2025, under the Staff Administration Legend section, did not show the professional titles for four out of four staff who signed the MAR.

On 4/7/25 at 1027 hours, an interview and concurrent medical record review for Patient 16 was conducted with the DON. The DON verified the above findings.

3. Medical record review for Resident 339 was initiated on 4/1/25. Resident 339 was readmitted to the facility

on [DATE REDACTED].

Review of Resident 339's MAR for March 2025, under the Staff Administration Legend section, did not show

the professional titles for one of two staff who signed the MAR.

Review of Patient 339's MAR for April 2025, under the Staff Administration Legend section, did not show the professional titles for three of three staff who signed the MAR.

On 4/7/25 at 1027 hours, an interview and concurrent medical record review for Patient 16 was conducted with the DON. The DON verified the above findings.

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4. Medical record review for Resident 28 was initiated on 4/3/25. Resident 28 was admitted on [DATE REDACTED].

a. Review of Resident 28's Skilled Nursing - Psychotropic Consent dated 2/24/25, for the use of the lorazepam medication every 12 hours showed the provider's signature. However, the form failed to show the date when the provider had signed the consent for the lorazepam medication.

Review of Resident 28's H&P examination dated 2/26/25 showed Resident 28 has the capacity to understand and make decisions. The H&P further showed Resident 28 was on the lorazepam 1 mg tablet, give one tablet by mouth two times daily for14 days.

On 4/7/25 at 900 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified and acknowledged the consents for Resident 28 were incomplete. RN 1 stated, this is not good, all consents should have been completed.

b. Review of the facility's P&P titled Administering Medications revision date April 2019 showed the individual administering the medication, initials the resident's MAR on the appropriate line after giving each medication,

before administering the next one.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Review of Resident 28's MAR for March 2025 showed a blank documentation during the morning shift on 3/5/25, for the following medications, treatments, and monitoring: Level of Harm - Minimal harm or potential for actual harm - the covid 19 monitoring;

Residents Affected - Few - the documentation for the number of times of the urine output;

- the enhanced barrier precaution;

- the lactobacillus oral capsule (a probiotic medication);

- the lactulose oral solution (bowel management) medication;

- the resident ' s intake in ml provided by nursing during each shift;

- the observation for the central venous catheter site for signs and symptoms of infiltration /extravasation, redness, swelling or pain every shift;

- the monitoring for the presence of pain every shift;

- the pain non-pharmacological intervention provided every shift;

- the snacks being provided three times a day;

- the Voltaren (arthritis pain relief) external gel 1%, applied to left and right shoulder topically three times daily;

- the respiratory order for incentive spirometer four times a day; and

- the vancomycin HCL oral suspension (antibiotics) 50 mg/ml by mouth four times a day.

Review of Resident 28's MAR for April 2025 showed a missing or inaccurate documentation for

the monitoring for the signs/symptoms of the anticoagulant (blood thinner medication) complications during

the day and night shift on 4/1/25. The MAR showed documentation 60 for the section to document if the resident with signs and symptoms from the use of the anticoagulant complications.

On 4/7/25 at 0908 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was asked regarding Resident 28's inaccurate documentation of the monitoring for the signs/symptoms of

the anti-coagulant complications during the night shift on 4/1/25. RN 1 stated, I don't know why it was document as 60, it should have been a positive or negative sign.

On 4/7/25 at 1502 hours, an interview and concurrent medical review was conducted with LVN 4. LVN 4 stated, yes, I remember I gave the medications and did all of the treatment left and may have forgotten to click them (to save) after I did. LVN 4 further stated I should have clicked saved after I administered the medications and monitored Resident 28, then rechecked for the completion at the end of the shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 5. Medical record review for Resident 25 was initiated on 4/4/25. Resident 25 was admitted to the facility on [DATE REDACTED]. Level of Harm - Minimal harm or potential for actual harm Review of Resident 25's Skilled Nursing- Psychotropic Consent dated 3/13/25, failed to show the physician's signature and date. Residents Affected - Few

Review of Resident 25's Physician's Progress Note dated 3/31/25, showed Resident 25's mental status was alert, interactive, and cooperative.

Review of Resident 25's Order Summary Report dated 4/2/25, showed a physician's order dated 3/31/24, for bupropion HCl (medication to treat depression) tablet extended release 150 mg one tablet by mouth one time

a day for depression.

On 4/4/25 at 1359 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 stated she would follow up any incomplete consents after a resident's admission. LVN 4 stated she would check the physician's progress notes if the resident or family was notified of the medication, consented or declined to give the consent. LVN 4 further stated if there was no documentation, she would follow up with

the physician and the resident's family member then would complete the consent form. LVN 4 verified and acknowledged Resident 25's informed consent for the buspirone medication was incomplete.

On 4/7/25 at 0900 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified and acknowledged the consent for Residents 25 was incomplete. RN 1 stated, this is not good, all consents should have been completed.

On 4/7/25 at 1330 hours, an interview was conducted with the DON and Administrator for Residents 25, 26, and 28. The DON and Administrator were made aware and acknowledged the above findings.

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6. Medical Record review for Resident 2 was initiated on 4/1/25. Resident 2 was admitted to the facility on [DATE REDACTED].

Review of Resident 2's H&P examination dated 3/18/25, showed Resident 2 had the capacity to understand and make decision.

Review of Resident 2's POLST dated 3/17/25, under section D for the advance directive, showed no documented evidence whether the advance directive had been discussed, if unavailable, or not applicable.

On 4/2/25 at 1450 hours, an interview and concurrent medical record review was conducted with the SSD.

The SSD was asked whether Resident 2 had been offered an advance directive and to provide documentation of it. The SSD stated Resident 2 had the capacity but was unable to provide documentation of the resident's advance directive. The SSD further stated upon admission, the admission coordinator should have uploaded the advance directive to Resident 2's medical record. The SSD verified the above findings.

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 7. Review of the facility's P&P titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcome revised December 2016 showed the IP or designee will review the antibiotic utilization as a part of Level of Harm - Minimal harm or the antibiotic stewardship program and identify the specific situations that are not consistent with the potential for actual harm appropriate use of antibiotic. The P&P further showed at the conclusion of the review, the provider to be notified of the review findings. Residents Affected - Few

Review of the facility's document titled Infection Surveillance Monthly Report for February 2025 showed Residents 29, 640, and 641 were prescribed with the antibiotics in February but did not meet the McGeer's Criteria. Further review of the Infection Surveillance Monthly Report for February 2025 showed the column for Comments with the following information:

- for Resident 29, per MD continue IV antibiotic,

- for Resident 640, per MD complete antibiotic course, and

- for Resident 641, MD notified still wants to complete course.

Review of Residents 29, 640, and 641's medical records failed to show the name of the physician, date, and time when the physician was notifed; and name of the nurse who notified the physican and received the order and the justification or reason to continue the anitbiotic medication use when the residents did not meet

the McGeer's Criteria.

On 4/3/25 at 1323 hours, an interview and concurrent medical record review was conducted with the IP. When asked when and who notified the physician, the IP was unable to locate the documentation in the Infection Surveillance Monthly Report or in Residents 29, 640, or 641's medical record to show the name of

the physician, date and time when the physician was notified, and name of the nurse who notified the physican and received the order and justification to continue the antibiotic treatments for the residents who did not meet the McGeer's Criteria.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51920 potential for actual harm Based on interview, facility document review, and facility P&P review, the facility failed to ensure the infection Residents Affected - Few control practices were maintained.

* The facility failed to accurately classify which residents met the McGeer's Criteria in the infection control surveillance. This failure posed the risk of inaccurately identifying if the residents met the criteria for true infections and appropriate antibiotic use.

* The facility failed to implement the neutropenic precautions for Resident 17. Fresh flowers were observed at bedside, the door was not kept closed, and the IP was observed entering the room without a mask.

* The facility failed to ensure the enhanced barrier precautions for Resident 591 were observed.

* The sink in Medication Room A was not clean.

These failures posed the risk of potential transmission of communicable diseases to other residents in the facility.

Findings:

1. According to the CDC, unnecessary antibiotic use promotes development of antibiotic-resistant bacteria. Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may be left to grow and multiply. Repeated and improper use of antibiotics is the primary cause of the increase in drug-resistant bacteria.

Review of the facility's P&P titled Antibiotic Stewardship-Order for Antibiotics dated 12/2016 showed the appropriate use of antibiotic included criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending).

Review of the facility's P&P titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcome revised 12/2016 showed the IP or designee will review antibiotic utilization as a part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotic. The P&P further showed at the conclusion of the review, the provider to be notified of the review findings.

On 4/7/25 at 1019 hours, an interview and concurrent facility document review was conducted with the IP.

The IP stated the Infection Surveillance Monthly Reports were the tool the facility to use to track the infections. Review of the December 2024 and January 2025 Infection Surveillance Monthly Reports failed to show the tracking for the residents who did not meet the McGeer's Criteria. The IP verified the above information and was unable to provide alternate documentation to show for the tracking of the resident's McGeer's criteria.

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 2. Review of the facility's P&P titled Isolation - Categories of Transmission-Based Precautions revised 9/2022, under the Neutropenic Precautions (Reverse Isolations) section, showed the following: Level of Harm - Minimal harm or potential for actual harm - Neutropenic precautions, also known as reverse isolation, are implemented to protect immunocompromised residents from potential sources of infection. These residents are at increased risk for acquiring infections Residents Affected - Few from other individuals or the environment due to weakened immune systems;

- The resident is placed in a private room with strict attention to cleanliness and infection control practices;

- Masks may be worn by staff and visitors, especially if there is a known risk of respiratory infection; and

- Fresh flowers, plants, and fruits/vegetables that are not fully cooked or washed are typically restricted due to potential sources of pathogen.

Review of the facility's document titled Neutropenic Precautions showed the following:

- For the visitors to report to the nurses' station before entering the room;

- Private room with closed door;

- Handwashing is required upon entering the room;

- No fresh fruits, vegetables or flowers maybe taken into the room; and

- No visitors or staff with infections illnesses may enter the room.

On 4/1/25 at 0935 hours, during the initial tour of the facility, a sign was observed outside Resident 17's room by the door, notifying the staff and visitors that the resident was on neutropenic precautions. A sign showing the sequence for putting on PPE was also posted outside Resident 17's room by the door. The door was observed open and Resident 17 was observed in bed. Two vases with fresh flowers were observed at bedside.

Medical record review was initiated on 4/1/25. Resident 17 was readmitted to the facility on [DATE REDACTED].

Review of Resident 17's Order Summary Report showed a physician's order dated 2/18/25, for neutropenic precautions related to cancer post chemo treatment.

On 4/1/25 at 1130 and 1604 hours, on 4/2/25 at 0848 and 1406 hours, a neutropenic isolation sign was observed posted outside the resident's door. The door was observed open.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 4/2/25 at 1409 hours, an observation for Resident 17 and concurrent interview was conducted with the IP. A neutropenic isolation sign was observed posted outside the resident's door. The door was observed Level of Harm - Minimal harm or open. Resident 17 was observed in bed and asked for assistance with repositioning her arm. Two vases with potential for actual harm fresh flowers were observed at bedside. The IP was observed going into the room with gown and gloves but without a mask on. The IP was observed assisting Resident 17. The IP verified she did not wear a mask Residents Affected - Few when she entered the room and had assisted Resident 17. The IP also verified the door was open, and there were two vases with fresh flowers at the resident's bedside. The IP stated the mask, gloves, and gown should be worn when entering the room on neutropenic precaution and the door should be closed at all times.

50787

3. On 4/7/25 at 832 hours, Resident 591 was observed being transferred by CNA 2 from the bed to the wheelchair inside her room. CNA 2 was observed not wearing a gown during the transfer. A signage was observed outside Resident 591's room for the Enhanced Barrier Precautions and the instructions included

the donning of the PPE.

On 4/7/25 at 0837 hours, interview was conducted with CNA 2. When asked what PPE to use during the care of Resident 591, CNA 2 stated, I wear a gown and gloves when I am changing her and not during transfers. CNA 2 was shown the signage outside the room regarding the Enhanced Barrier Precautions which included dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting care, device care or use including urinary catheter and wound care.

Medical record review for Resident 591 was initiated on 4/7/25. Resident 591 was admitted to the facility on [DATE REDACTED].

Review of Resident 591's Order Summary Report showed a physician's order dated 3/22/25, for the Enhanced Barrier Precautions secondary to the presence of the indwelling medical device.

On 4/7/25 at 0844 hours, an interview was conducted with LVN 2. LVN 2 was asked regarding Resident 591's enhanced barrier precaution order. LVN 2 stated, we have to wear a PPE when taking care of Resident 591. LVN 2 was made aware that CNA 2 did not wear a gown during Resident 591's transfer from

the bed to the wheelchair. LVN 2 stated CNA 2 should have worn a gown.

On 4/7/25 at 1315 hours, an interview was conducted with the IP. The IP stated a gown must be worn when taking care of a resident on an enhanced barrier precautions including the transfers. The IP acknowledged

the above findings.

On 4/7/25 at 1330 hours, an interview was conducted with the Administrator and DON. The Administrator and DON was made aware and acknowledged the above findings.

48332

4. Review of the facility's P&P titled Storage of Medications revised 11/2020 showed the facility stores all the drugs and biologicals in a safe, secure, and orderly manner. The nursing staff is responsible for maintaining

the medication storage and preparation areas in a clean, safe and sanitary manner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 4/2/25 at 0910 hours, an interview and concurrent observation of Medication Room A was conducted with RN 1. RN 1 verified the sink in Medication Room A was dirty, the sink strainer had brown color discoloration, Level of Harm - Minimal harm or the circular portion surrounding the drainage had bluish discoloration measuring approximately 5 cm x 7 cm potential for actual harm in its widest diameter, and the elongated dirt materials were soaked in water at the base of the strainer. There was also whitish streak discoloration at the top of the sink on the right side of the faucet. RN 1 stated Residents Affected - Few the water was leaking from the faucet and sink was stained blue. RN 1 verified the sink needed maintenance and needed to be cleaned.

On 4/2/25 at 0920 hours, an interview and concurrent observation of Medication Room A's sink was conducted with the DON. The DON verified the findings and stated it should be clean all the time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 48332 potential for actual harm Based on observation, interview and facility P&P review, the facility failed to ensure the equipment was Residents Affected - Few maintained in a safe and operable manner.

* The sink faucet in Medication Room A was leaking.

* The facility failed to ensure the ice machine in the main kitchen was cleaned and sanitized as per the manufacturer's specifications.

* The facility failed to ensure there was no ice build-up in the walk-in freezer in the main kitchen, the freezer

in the satellite kitchen, and the freezer of the refrigerator used for residents' food brought from outside source.

* The facility failed to ensure the thermometer used in the satellite kitchen was calibrated properly.

These failures had the potential for the equipment to not function in the way it was intended.

Findings:

1. Review of the facility's P&P titled Maintenance Service revised 12/2009 showed the maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds and equipment are maintained in a safe and operable manner.

On 4/2/25 at 0910 hours, an interview and concurrent observation of Medication Room A was conducted with RN 1. RN 1 verified the sink faucet in Medication Room A was leaking, the sink strainer had brown color discoloration, the circular portion surrounding the drainage had bluish discoloration measuring approximately 5 cm x 7 cm in the widest diameter, and the base of the strainer was soaked with water. RN 1 verified water was leaking from the faucet and the sink was stained blue. RN 1 stated maintenance should have fixed the leakage, and nurses should have reported when they found the leakage.

On 4/2/25 at 0920 hours, an interview and concurrent observation of Medication Room A sink was conducted with the DON. The DON verified the leaking faucet from the sink. The DON stated they would discuss with

the Administrator and maintenance staff to fix it.

On 4/2/25 at 1005 hours, an interview was conducted with the Director of Maintenance. The Director of Maintenance verified the leaking faucet and stated it could have been fixed if the nurses had reported the leakage.

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 38 555768 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555768 B. Wing 04/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 2. According to the FDA Food Code 2022 Section 4-501.11 showed equipment shall be maintained in good repair and proper adjustment. Proper maintenance of equipment to manufacturer specifications helps ensure Level of Harm - Minimal harm or that it will continue to operate as designed. potential for actual harm

Review of the facility's P&P titled Ice Machines and Ice Storage Chests revised 1/2012 showed the facility Residents Affected - Few has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions.

Review of the Manitowoc Indigo NXT Ice Machines Installation, Operation and Maintenance Manual dated 5/11/18, under Maintenance section showed the following:

- Clean and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment. An extremely dirty ice machine must be taken apart for cleaning and sanitizing;

- Manitowoc Ice Machine Cleaner and Sanitizer are the only products approved for use in Manitowoc ice machines;

- For exterior cleaning, clean the aera around the ice machine as often as necessary to maintain cleanliness and efficient operation. Wipe surface with a damp cloth rinsed in water to remove dust and dirt from the outside of the ice machine. If a greasy residue persists, use a damp cloth rinsed in a mild dish soap and water solution, and wipe dry with a clean, soft cloth; and

- The cleaning and sanitizing procedure must be performed a minimum of once every six months. The ice machine and bin must be disassembled, cleaned and sanitized.

Review of the facility's document titled Invoice from the facility's outside vendor showed a preventative maintenance cleaning and sanitizing was performed on the ice machine in the main kitchen on 2/20/25.

Review of the facility's document titled Ice Machine Cleaning Log showed the ice machine in the main kitchen was cleaned on 3/8/25.

On 4/2/25 at 0942 hours, an inspection of the ice machine in the main kitchen, interview and concurrent facility document review was conducted with the Director of Maintenance. The ice machine was observed with black particles on the ice machine deflector and on the groove in front of deflector when wiped with a white paper towel. The Director of Maintenance verified the above findings. The Director of Maintenance stated an outside vendor provided cleaning service to the ice machine quarterly. The Director of Maintenance also stated the dietary staff was responsible for cleaning the exterior of the ice machine, and

the bin of the ice machine. The Director of Maintenance stated the dietary staff used a food-grade multi-quat sanitizing solution to clean the bin of the ice machine. The Director of Maintenance verified the dietary staff was not using the Manitowoc Ice Machine Cleaner and Sanitizer solution as indicated in the manufacturer's manual to clean the ice storage bin of the ice machine in the main kitchen nor the exterior of the ice machine.

Cross-reference to