Other·August 5, 2019

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the RECERTIFICATION survey. Representing the California Department of Public Health: Surveyor 39683, HFEN; Surveyor 38489, HFEN; Surveyor 41316, HFEN; Surveyor 41324, HFEN; and Surveyor 41941, HFEN. The surveyors entered the facility on 6/17/19 at 0730 hours. The resident census was 41. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS: ADL - activities of daily living ADON - Assistant Director of Nursing CDC - Centers for Disease Control and Prevention CNA - Certified Nursing Assistant DON - Director of Nursing IDT- Interdisciplinary Team LVN - Licensed Vocational Nurse SBAR - Situation Background Assessment Response P&P - policy and procedure POLST - Physician Orders for Life-Sustaining Treatment Pressure Ulcer-are injuries to skin and underlying tissue resulting from prolonged pressure on the skin RD - Registered Dietician RN - Registered Nurse

F565 SS=D Resident/Family Group and Response CFR(s): 483.10(f)(5)(i)-(iv)(6)(7)

F565 07/25/2019 §483.10(f)(5) The resident has a right to LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 1 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE organize and participate in resident groups in the facility. (i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner. (ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation. (iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings. (iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. (A) The facility must be able to demonstrate their response and rationale for such response. (B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group. §483.10(f)(6) The resident has a right to participate in family groups. §483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility. This REQUIREMENT is not met as evidenced by: Based on interview and document review, the facility failed to act promptly upon grievances addressed by residents during the Resident Council meetings (an organized group of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 2 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents meeting on a regular basis to discuss facility concerns and areas for improvement). This deficient practice had the potential for a decline in quality of life for the residents. Findings: Review of the Resident Council Minutes for the last three months, dated 3/19 - 6/19 showed there was no documentation to show what facility administrative actions were taken for concerns regarding medications, call lights, and if residents' past concerns were resolved. a. Review of the Resident Council Minutes dated 3/5/19 at 1115 hours, showed a resident stated she never received her second insulin shot. The minutes showed the staff would follow up on the concern. On 6/18/19 at 1120 hours, an interview was conducted with the ADON. The ADON stated she had attended the Resident Council Meeting on 3/5/19. The ADON stated no follow-up concern sheet was given to her regarding this issue and concern sheets were brought to her during monthly QAPI (Quality Assurance Performance Improvement) meetings. b. Review of the Resident Council Minutes dated 4/2/19 at 1115 hours, showed a resident stated she asked for her pain pill and waited for 30 minutes before she received the medication. During a concurrent interview and record review on 6/18/19 at 1025 hours, with the DON, the DON stated she was not made aware of the concern regarding the pain medication being given late. On 6/18/19 at 1130 hours, during a concurrent interview and record review, the Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 3 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Program Coordinator confirmed she did not bring up resident concerns until the end of the month at the QAPI meetings. When asked about the late pain pill, the Resident Program Coordinator stated the DON was not notified of this concern and confirmed there was no documentation and a concern form was not filled out. The Resident Program Coordinator stated she understood the importance of resolving resident concerns in a timely manner. c. Review of the QAPI Minutes titled "Resident Council Minutes QAPI Report for January, February and March 2019" and the Resident Council Minutes dated 5/8/19, showed residents expressed their concerns of not having their call lights answered in a timely manner. There was no documentation to show what facility administrative actions were taken to address the long call light wait times and if residents' past concerns were resolved. During a concurrent interview and record review on 6/18/19 at 1025 hours, the DON stated she was made aware of call light concerns at monthly QAPI meetings, at which point the residents were usually discharged. The DON confirmed all resident concerns from resident council meetings were not brought to her attention until the end of the month during the QAPI meetings.

F578 SS=E Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir CFR(s): 483.10(c)(6)(8)(g)(12)(i)-(v)

F578 07/25/2019 §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 4 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time. This REQUIREMENT is not met as evidenced by: 2. On 6/20/19 at 1515 hours, review of forms was conducted at the nurses' station. Three POLST forms with DNR (do not resuscitate) status were discovered amongst a stack of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 5 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE forms awaiting physicians' signatures. Resident 194's POLST form dated 6/4/19, showed the resident wished to be DNR code status. Resident 143's POLST form dated 6/13/19, showed the resident wished to be DNR code status. Resident 142's POLST form, showing the resident wished to be DNR code status was not dated. On 6/19/19 at 1420 hours, an interview was conducted with LVN 1. LVN 1 stated if no advance directive or POLST was located in the medical record, a full code would be initiated. LVN 1 stated 911 would be contacted, family would be notified and wishes for life sustaining measures would then be obtained. On 6/19/19 at 1435 hours, an interview was conducted with LVN 2. LVN 2 stated if a code status was not communicated via advance directive or POLST, a full code had to be initiated, the family would be notified of a code and wishes for life sustaining measures would be obtained at that time. On 6/19/19 at 1535 hours, an interview was conducted with the Admissions Clerk. The Admissions Clerk stated all residents were asked if they had an advance directive or any specific care needs documentation. The Admissions Clerk stated, upon receipt, information had to be placed in the resident's medical record. On 6/20/19 at 1517 hours, an interview was conducted with the DON. The DON verified the three POLST forms each identifying a DNR status. The DON verified there were no orders for code status in any of the three residents' medical records. The DON reported Resident 142 was already discharged from the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 6 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 6/20/19 at 1530 hours, Resident 194's medical record was reviewed. Resident 194 was admitted to the facility on 6/4/19. Resident 194 had no advance directive located in the medical record. Resident 194's Order Summary Report dated 6/19/19, did not contain a code status order. Based on interview and medical record review, the facility failed to obtain a copy of an advance directive for two of 12 final sampled residents (Residents 194 and 292) and two nonsampled residents (Residents 142 and 143). This had the potential for the residents' advanced care planning decisions regarding their health care and treatment options not being honored. Findings: According to the facility's P&P titled Advance Directive, the Admission department or designee will notify and provide information to each resident or resident representative regarding his/her right to make an advance directive. Under the section Policy Detail, the resident/representative should be asked at the time of admission if an advance directive has been executed. If yes, a copy of the advance directive will be obtained and placed in the resident's medical record. Residents who are competent at the time of admission with no advance directive will be assisted in preparing one. 1. Medical record review for Resident 292 was initiated on 6/19/19. Resident 292 was admitted to the facility on 6/17/19. Review of the History and Physical Examination dated 6/19/19, showed Resident 292 had the capacity to make decisions. Review of Resident 292's Admission Record showed a blank space under the section FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 7 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Advance Directive. Review of the Medication Administration Record dated 6/1/19-6/30/19, showed the Advance Directive was left blank. Review of the medical record did not show if Resident 292 had an advance directive. There was no documentation to show Resident 292 was provided information regarding formulating an advance directive. On 6/19/19 at 1413 hours, a concurrent interview and medical record review was conducted with LVN 2. LVN 2 verified Resident 292's Admission Record did not show a response for Advance Directive. LVN 2 verified the Medication Administration Record under the section Advance Directive did not show Resident 292's care preference. LVN 2 stated residents who had no advance directive on file were to be treated as full code. LVN 2 pulled Resident 292's pink POLST form from a file in the nurses' station. LVN 2 verified Resident 292 had signed the POLST on 6/19/19, which showed a check mark on Do Not Resuscitate. LVN 2 verified the POLST was not signed by the physician. LVN 2 stated the advance directive should be available at admission. LVN 2 stated the information about the resident's preference of intensity of care should be available just in case something happened to the resident. LVN 2 verified Resident 292's advance directive was not available to the staff. LVN 2 acknowledged, without the advanced directive information, staff would not be able to provide the preferred care during an emergency. On 6/19/19 at 1423 hours, an interview was conducted with the DON. The DON stated, upon admission, the admission staff had to notify the resident or responsible party about FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 8 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the advance directive. If the resident did not have an advance directive, the opportunity to formulate an advance directive had to be offered to the resident. The DON stated Resident 292 did not have an advance directive. The DON acknowledged the information to formulate an advanced directive should have been offered to Resident 292 upon admission.

F604 SS=D Right to be Free from Physical Restraints CFR(s): 483.10(e)(1), 483.12(a)(2)

F604 07/25/2019 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 9 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure one of 12 final sampled residents (Resident 194) was free from physical restraints when positioning wedges were placed under Resident 194's mattress bilaterally. This failure had the potential to cause the resident psychological and physical harm. Findings: On 6/19/19 at 1529 hours, an interview and concurrent observation of Resident 194 was conducted with CNA 6. CNA 6 stated Resident 194 had a recent fall in the facility. When asked if Resident 194 is considered a fall risk, CNA 6 stated Resident 194 was a fall risk and they were using floor mats and wedges to keep him safe. Resident 194 was observed sleeping in bed laying down on his side. CNA 6 was observed inserting wedges bilaterally underneath Resident 194's mattress reaching from approximately his shoulders to his hips placing the mattress in a concave position. CNA 6 stated it was to keep the resident safe. CNA 6 then placed floor mats on either side of Resident 194's bed. Review of Resident 194's Falls Investigation Worksheet dated 6/7/19, showed the resident had an unwitnessed fall on 6/7/19 at 0415 hours, while getting out of bed. The Investigation Worksheet showed Resident 194 was found lying on the floor on the side of the bed on his right side, denied having to use the toilet, and stated he just wanted to get up. On 6/20/19 at 1101 hours, an interview was conducted with the DON concerning the placement of Resident 194's mattress in a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 10 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE concave position. The DON stated she was unaware of the wedges being used in this way for Resident 194. The DON verified there was no documentation in the care plan or in Resident 194's medical record showing wedges should be used for positioning the resident. The DON stated wedges were not to be used in such a way causing the resident to be "cocooned" in bed, and should only be used for positioning a resident. During a concurrent interview, medical record review and observation with the DON on 6/20/19 and 1515 hours, the DON verified there was no assessment, consent, or care plan in Resident 194's medical record regarding the use of wedge cushions under the mattress. The DON acknowledged the wedges placed under the mattress restricted Resident 194 from getting out of bed. The DON verified the wedges were in the residents' closet. The DON removed the wedges from the room.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 07/25/2019 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 11 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on observation, interview, and medical record review, the facility failed to provide the services and necessary interventions to identify, treat, and prevent the development of pressure ulcers for one of 12 final sampled residents (Residents 39). Resident 39 was admitted to the facility at low risk for developing a pressure ulcer. * The facility failed to ensure Resident 39's sacral redness was assessed when it was reported by the acute care hospital during transfer. * The facility failed to ensure Resident 39's back and buttocks areas were assessed when he complained of pain. * The facility failed to ensure Resident 39 was provided a pressure relieving device in his wheelchair. * The facility failed to develop a plan of care to address Resident 39's risk for developing pressure ulcers. * The facility failed to ensure hand hygiene was performed when skin treatments were provided to Resident 39. This posed the risk for Resident 39 to develop a wound infection. A Stage 3 (Full thickness loss of skin, in which adipose [fat] is visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present. Slough and/or eschar [dead tissue] may be visible.) coccyx (tail bone) pressure ulcer was discovered 16 days from admission. Resident 39 experienced additional pain, surgical debridement and daily dressing changes. Findings: According to the 2014 Clinical Practice Guideline: Skin Assessment and Preventive Skin Care Extract by the National Pressure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 12 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Ulcer Advisory Panel, under the section Interventions for Prevention of Pressure Ulcers, skin and tissue assessment was important in the prevention, classification, diagnosis and treatment of pressure ulcers. The presence of nonblanchable erythema (redness of the skin) is a risk factor for Category/Stage II pressure ulcers. Under the section Conducting Skin and Tissue Assessment, a comprehensive skin assessment with a focus on bony prominences such as the sacrum (bone at the base of the spine) had to be conducted to individuals at risk for pressure ulcers. Accurate documentation of findings is essential for monitoring the progress of the individual. Inspect skin erythema. Skin redness and tissue edema is a response to pressure, especially over bony prominences. Differentiate whether the skin redness was blanchable or nonblanchable. A blanchable erythema is visible skin redness that becomes white when pressure is applied and reddens when pressure is relieved. A nonblanchable erythema is visible skin redness that persists with the application of pressure. It indicates structural damage to the capillary microcirulation and is an indication for Category/Stage 1 pressure ulcer. Nonblanchable erythema is a predictor for Category/Stage II pressure ulcer development. Assess for localized pain as part of every skin assessment. Pain is a factor for patients with pressure ulcer. Pain over the site suggest tissue breakdown. Individuals have to be assessed for pain to identify areas of discomfort. a. Review of Resident 39's medical record was initiated on 6/19/19. Resident 39 was admitted to the facility on 5/21/19. Review of the admission MDS dated 5/28/19, showed Resident 39 was cognitively intact. Resident 39 needed extensive assistance from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 13 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE one person for bed mobility. Resident 39 had frequent episodes of pain. Resident 39 had a colostomy and was continent of urine. Resident 39 had no pressure ulcer on admission. Review of a facility transfer report document showed Resident 39 had mild sacral redness. Review of the Nursing Admission Data Collection dated 5/21/19, under the section Skin Integrity Review showed Resident 39 had a colostomy on the left lower quadrant of the abdomen with a drain site incision on the right lower quadrant. Resident 39 had a surgical incision on the mid abdomen and multiple discolorations on the bilateral upper extremities. Under the section Braden Scale showed Resident 39 had no sensory and mobility impairment. Resident 39 was chairfast (ability to walk is severely limited or nonexistent). Resident 39 had adequate nutrition. Resident 39 had the potential problem for friction and shear. Resident 39's Braden Score was over 16. For a Braden Score of 16 or less, initiate skin integrity interventions and document on interim care plan. Under the section Narrative Summary, showed Resident 39 was continent of bladder and had a new colostomy. Resident 39's skin had sacral redness. There was no response on the Interim Care Plan-skin. There was no interim care plan initiated to address Resident 39's sacral redness and skin findings. Review of the Braden Scale assessments dated 5/29/18, 6/4/19 and 6/11/19, showed Resident 39 had a Braden Score of 19. Review of the Weekly Wound Data Collection Flow Sheet dated 5/21/19, showed Resident 39 had a surgical wound on the abdomen. There was no mention about Resident 39's sacral FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 14 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE redness. There was no documentation to show Resident 39's sacral redness was assessed. There was no care plan developed to address Resident 39's risk for pressure ulcer development. Review of the progress notes showed the following: - Resident 39 had complained of back pain on 5/22, 5/23, 5/24, 5/25, 5/26, 5/28, 5/29, 5/30, 5/31,6/1, and 6/5/19. - On 5/27/19 at 0043 hours, Resident 39 complained of generalized body pain and lower back pain on a scale of 6/10 (on a pain scale of 0-10, 0 = no pain, 10 = worst pain). - On 6/2/19 at 0245 hours, Resident 39 was given pain medication when the resident complained of pain of 8/10 to the neck, back, and buttocks area. There was no documentation showing Resident 39's back and buttocks were assessed. Review of SBAR communication Form and Progress dated 6/6/19, showed Resident 39 had a coccyx wound with 100% slough, linear in shape and painful to touch. Review of the Treatment Administration Record dated 6/1/19-6/30/19, showed an order dated 6/8/18, showing a coccyx pressure injury Stage 3 - cleanse with normal saline, pat dry, apply Santyl ointment (a debridement agent) and cover with dry dressing every day. Review of the Surgical Consult dated 6/13/19, showed Resident 39 had a coccyx pressure injury, which measured 3.2 cm x 0.8 cm x undetermined (UTD) depth. Resident 39 underwent muscle tissue debridement due to the presence of slough. Under the section FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 15 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Assessment and Plan, offloading pressure on the wound included the use of additional cushioning in the wheelchair. The physician documented he did a surgical excision of devitalized skin, subcutaneous, muscle, facia, and tendon tissue. Hwe Review of the Provide Communication Log for Daily Rounds dated 6/13/19, showed Resident 39 had a 3.2 cm x 0.8 cm x UTD depth with 100% slough, mild serosanguinous exudate (clear liquid mixed with red blood). The Provider Communication Log for Daily Rounds dated 6/20/19, showed Resident 39's Stage 3 pressure ulcer measured 2.3 cm x 0.3 cm x UTD depth with 90% slough and 10% granulation tissue. Resident 39 underwent debridement and the post debridement measurements were 2.4 cm x 0.4 cm x UTD depth. Review of the Nutrition Risk Review by the RD dated 5/28/19, showed Resident 39 was within normal body mass index. Resident 39 had 4.6 pounds weight loss (2.8%) since admission. Resident 39 had a reported decrease in appetite because of a mouth sore. The RD recommended to change the diet to a regular diet with snacks at 1400 and 2000 hours and Med Pass (a calorie and protein supplement) 120 ml three times a day. Review of the Progress Notes showed an entry dated 6/7/19, addressing a Weight Change Note. The entry showed Resident 39 had a 1.4 pounds (0.9%) weight loss for one week - not a significant change. The RD notes showed the weight loss may have been due to possible fluid shift from Lasix (diuretic) therapy and decreased intake secondary to intake of antibiotics. Resident 39's BMI (body mass index) was normal. Resident 39 had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 16 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE developed a Stage 3 coccyx pressure ulcer. The RD recommendation was to start Resident 39 on multivitamins, zinc sulfate (supplement for wound healing) and vitamin C. Review of the Collaborative Care Review dated 6/6/19, showed Resident 39 had a change in condition. Resident 39 was identified with a coccyx wound on 6/6/19, and with a foul smelling drainage from the rectum on 6/10/19. The rest of Resident 39's Collaborative Care Review was not completed. Review of the Types of Bath showed Resident 39 preferred to bathe on Monday and Thursday mornings. Resident 39 was provided a shower on 5/27/19, and 6/3/19. Resident 39 refused to be bathed on 5/30/19. On 6/19/19 at 1110 hours, Resident 39 was observed awake, lying on his back. A low air loss mattress was observed on Resident 39's bed. Resident 39 was observed turning on his right side. Resident 39 stated he was able to reposition himself while in bed. Resident 39 stated he had a colostomy and was continent of urine. A urinal was observed at Resident 39's bedside. Resident 39 stated he developed a bed sore on his back when he got admitted to the facility. Resident 39 stated the bed sore on his back was painful and he had to turn himself frequently to relieve pressure on the wound. Resident 39 stated he had complained of pain to the back and buttock areas a few days after he was admitted. Resident 39 stated the staff gave him pain medications to relieve the pain but did not take a look at his back " crack" nor provided treatment for it. Resident 39 stated the staff did not check his bottom during showers since he had a colostomy. Resident 39's wheelchair was observed at the bedside. No cushion was observed in the wheelchair. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 17 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 6/20/19 at 0850 hours, Resident 39 was observed lying on his back, awaiting his skin treatment. Resident 39's wheelchair and walker were at the bedside. No cushion was observed in the wheelchair. On 6/20/19 at 0857 hours, a concurrent treatment observation and interview was conducted with LVN 7. Resident 39 had a Stage 3 coccyx wound which measured 2.4 cm x 0.4 cm x ITD depth. Resident 39's wound was observed at midline and the wound bed was pinkish with minimal serousanguinous discharge. LVN 7 stated Resident 39's wound was a Stage 3 pressure ulcer since it had extended to the muscles. On 6/20/19 at 0919 hours, an interview was conducted with LVN 7. LVN 7 stated Resident 39 was admitted on 5/21/19, and had no pressure ulcer. On 6/6/19, Resident 39 complained of pain on the back area when the Stage 3 coccyx pressure ulcer was first discovered. LVN 7 stated he did not know what happened. LVN 7 stated he was informed about the wound and assessed it to be a Stage 3 pressure ulcer. LVN 7 stated Resident 39 was alert with no mobility issues, continent with the colostomy and was at low risk for developing pressure ulcers. On 6/20/19 at 1100 hours, Resident 39 was observed lying in bed. Resident 39's pillows were observed in his wheelchair. On 6/20/19 at 1502 hours, an interview was conducted with Resident 39. Resident 39 was sitting his wheelchair. Resident 39 stated his mattress was changed to a special one when he developed the pressure ulcer. When asked why he had pillows in his wheelchair, Resident 39 stated he had to sit on the pillows to ease the pain when he used the wheelchair. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 18 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 39 stated he sat in his wheelchair during meals and when he needed to go out for his therapy and appointments. On 6/20/19 at 1530 hours, a concurrent observation and interview was conducted with CNA 7. CNA 7 stated Resident 39 was alert, oriented, and continent of urine, and had a colostomy. CNA 7 stated Resident 39 was quite independent with his ADLs but needed assistance when he needed to get out of bed. Resident 39 used his wheelchair. CNA 7 verified Resident 39 had regular pillows in his wheelchair. On 6/21/19 at 0736 hours, a concurrent interview and medical record review was conducted with LVN 8. LVN 8 stated he worked the night shift on 6/2/19. LVN 8 stated Resident 39 was alert, oriented and able to move independently. LVN 8 stated he took his break when Resident 39 complained of buttocks pain. Resident 39 was given pain medication by RN 3. LVN 8 acknowledged RN 3 told him about Resident 39's buttocks pain. LVN 8 acknowledged he did not check Resident 39's buttocks when he complained of buttocks pain. On 6/21/19 at 0838 hours, a concurrent interview and medical record review was conducted with LVN 7. LVN 7 stated he performed the skin assessment when Resident 39 was admitted. LVN 7 stated he was not aware of a report from the hospital about Resident 39's sacral redness. When asked what sacral redness meant, LVN 7 stated there was redness on Resident 39's back area possibly from a pressure ulcer. LVN 7 stated Resident 39 had to be assessed to see if it was a Stage 1 pressure ulcer. When asked what needed to be done when there was a report of sacral redness, LVN 7 stated he had to assess FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 19 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE if it was nonblanchable or blanchable. LVN 7 stated if Resident 39's area of redness was nonblanchable, it had to be classified as Stage 1. LVN 7 stated a Stage 1 pressure ulcer was to be monitored and provided treatment to prevent further skin deterioration. When asked if there was documentation in the medical record to show Resident 39's sacral redness was assessed, LVN 7 stated there was none. When asked about Resident 39's plan of care, LVN 7 stated Resident 39's Braden Score was more than 16, which meant he had a low risk for developing a pressure ulcer. LVN 7 stated Resident 39 was alert, able to move by himself, was continent and hardly moist and fell under the category of low risk on the Braden Scale. LVN 7 stated Resident 39 had remained low risk based on his Braden score of more than 16. LVN 7 stated, since he was not likely to develop a pressure ulcer, a care plan was not necessary. When asked what interventions were provided to prevent Resident 39 from developing a pressure ulcer, LVN 7 stated there was no care plan developed to show Resident 39 was at risk for developing a pressure ulcer. When asked how Resident 39 developed a Stage 3 pressure ulcer, LVN 7 stated he did not know. LVN 7 stated Resident 39's pressure ulcer should have been caught at an earlier stage to prevent it from getting worse. When asked about Resident 39's wheelchair, LVN 7 stated Resident 39 did not have his own wheelchair. LVN 7 stated he provided Resident 39 a cushion in his wheelchair but the staff may have given the wheelchair to another resident. LVN 7 acknowledged Resident 39 had no pressure relieving cushion in his wheelchair. LVN 7 stated Resident 39 needed to have a pressure relieving cushion in his wheelchair to prevent deterioration of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 20 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pressure ulcer, as recommended by the wound consultant. When asked if a skin assessment was performed when Resident 39 complained of buttocks pain of 8/10 on 6/2/19 at 0245 hours, LVN 7 stated he was not aware of Resident 39's buttocks pain. LVN 7 stated it was not usual for Resident 39 to complain of buttocks pain. LVN 7 acknowledged the buttocks area should have been assessed. LVN 7 verified there was no documented evidence Resident 39's skin to the buttocks area was assessed when he complained of pain On 6/21/19 at 0943 hours, a telephone interview was conducted with RN 3. RN 3 stated she remembered when Resident 39 complained of buttocks pain. RN 3 stated she gave Resident 39 his pain medication. RN 3 stated she told LVN 8, who was in charge for Resident 39, about the buttocks pain. When asked if she checked Resident 39's buttocks area, RN 3 stated she did not remember assessing Resident 39's buttocks. RN 3 acknowledged there was no documentation in the medical record to show Resident 39's buttocks were assessed. On 6/21/19 at 0948 hours, a concurrent interview and medical record review was conducted with the MDS Coordinator. The MDS Coordinator stated an interim care plan was not initiated because the area on skin issue was not answered on the Nursing Admission Data Collection dated 5/21/19. The MDS Coordinator stated the assessing nurse should have triggered skin impairments on the Admission Assessment since Resident 39 had skin impairments. The MDS Coordinator stated the assessment was not completed properly. The MDS Coordinator stated Resident 39 had mobility issues, with a recent surgery, which FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 21 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE put him at risk for pressure ulcer development. The MDS Coordinator acknowledged a care plan was not developed to address Resident 39's risk for developing a pressure ulcer. The MDS Coordinator stated when care plans were not developed, the staff was not made aware of the care residents needed. The MDS Coordinator acknowledged Resident 39 had a Stage 3 pressure ulcer to the coccyx. The MDS Coordinator stated Resident 39's pressure ulcer could have been prevented if a care plan was developed and interventions were in place. On 6/21/19 at 1031 hours, a concurrent interview and medical record review was conducted with the ADON. The ADON stated the Collaborative Care Review dated 6/6/19, was created when the IDT had to address Resident 39's change in condition. The ADON stated Resident 39 was discovered to have a Stage 3 coccyx pressure ulcer. The ADON stated the IDT had discussed Resident 39's concern. When asked what the IDT's recommendation was for Resident 39, the ADON stated to heal the wound to at least a Stage 2. The ADON acknowledged the Collaborative Care Review was not completed. The ADON stated the Collaborative Care Review should have been completed to reflect a full assessment of Resident 39's situation and the IDT recommendations. On 6/21/19 at 1050 hours, an interview was conducted with the RD. The RD stated Resident 39's weight loss on 5/28/19, was not considered significant. The RD stated she recommended additional calorie/protein source to ensure Resident 39 was meeting his nutritional needs. The RD stated the weight loss on 6/7/19, may be considered significant since the resident had lost 5.8% in 11 days. The RD stated the weight loss must have been FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 22 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE from his diuretic therapy and some decrease in his intake. The RD stated Resident 39's intake was at 57% and was accepting his snacks and Med Pass supplements. The RD stated she had recommended to start Resident 39 on multivitamins, zinc sulfate, and Vitamin C to aid in wound healing. The RD stated Resident 39 had the potential risk for developing a pressure ulcer considering his diagnoses. On 6/21/19 at 1135 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 verified she received Resident 39's transfer report from the acute care hospital and wrote it on a transfer report form. RN 1 stated she provided Resident 39's report to the admitting nurse. RN 1 stated the nurse from the acute care hospital reported Resident 39 had sacral redness. RN 1 stated Resident 39's sacral redness had to be assessed to make sure it was not a pressure ulcer. RN 1 stated the treatment nurse was in charge of checking the resident's skin. On 6/21/19 at 1143 hours, a concurrent interview and medical record review was conducted with RN 2. RN 2 acknowledged he had written sacral redness in Resident 39's admission notes. RN 2 stated the report from the hospital showed Resident 39 had sacral redness. RN 2 stated Resident 39's sacral redness had to be assessed to see if it was blanchable or nonblanchable. RN 2 stated Resident 39's sacral redness may have been a Stage 1 pressure ulcer and had to be treated. RN 2 stated the treatment nurse had to assess Resident 39's sacral area. On 6/25/19 at 0759 hours, an interview was conducted with CNA 8. CNA 8 stated Resident 39 needed assistance during showers. CNA 8 stated she did body checks on Resident 39 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 23 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE when he showered. CNA 8 stated she did not remember seeing any skin problems on Resident 39. CNA 8 stated she used to write her body check findings on a paper but it was not used anymore. CNA 8 stated she had to inform the nurse if there were any skin findings. CNA 8 stated Resident 39 had refused showers. When asked how Resident 39's body was checked when he refused showers, CNA 8 stated she had to do it when he needed to be changed. When asked if Resident 39 was incontinent, CNA 8 stated Resident 39 was continent and had a colostomy. CNA 8 stated Resident 39 was using a urinal. When asked if Resident 39 was wearing incontinence briefs, CNA 8 stated no, and smiled. On 6/25/19 at 1207 hours, an interview was conducted with the DON. The DON stated the nurses receive a transfer report from the hospital. The DON acknowledged Resident 39 was reported by the acute care hospital to have sacral redness. The DON stated the admitting nurse or the treatment nurse had to assess the skin. The DON stated Resident 39's sacral area had to be checked to see if the redness was blanchable or nonblanchable. The DON verified there was no documentation to show Resident 39's sacral redness was assessed. The DON acknowledged a more thorough assessment should have been done to ensure Resident 39' s skin was checked for a pressure ulcer. The DON verified there was no documentation an assessment was performed when Resident 39 complained of buttock pain on 6/2/19, and back pain since May 2019. The DON stated the nurses should have assessed Resident 39's back and buttocks to see what was going on. The DON stated it could have been part of the developing pressure ulcer. The DON stated she had talked to Resident 39 about the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 24 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE pressure ulcer and was told he had been complaining of back pain but the nurses did not check. The DON acknowledged Resident 39's pressure ulcer was discovered when it was already a Stage 3. The DON stated the pressure ulcer could have been prevented or discovered early. When asked about Resident 39's care plan, the DON stated Resident 39's Braden Score was above 16 and did not require a plan of care. The DON stated a score of 16 and below on the Braden Scale meant the resident was a high risk and a care plan was to be initiated, whereas a score of over 16 meant a low risk for pressure ulcer development. The DON stated a care plan to address Resident 39's low risk for pressure ulcer development was not developed. When asked if Resident 39's pressure ulcer was avoidable since he had a low risk score, the DON acknowledged Resident 39's pressure ulcer was avoidable. The DON acknowledged the lack of a thorough assessment by the nursing staff prevented the early identification and treatment of Resident 39's pressure ulcer. b. According to the CDC Guideline for Hand Hygiene in Health Care Settings in 2002, the practice of handwashing decreases the transmission of pathogenic microorganisms to patients and healthcare workers. Hand washing is recommended a) prior to direct contact with a patient, b) after contact with a patient's skin, c) after contact with patient's body fluids, excretions, non-intact skin and wound dressings, and d) after removal of gloves. On 6/20/19 at 0857 hours, a concurrent treatment observation and interview was conducted with LVN 7. A black plastic folder cover with a white towel was observed on top FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 25 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE of LVN 7's treatment cart. LVN 7 prepared normal saline and Santyl ointment in two separate cups. LVN 7 took pieces of gauze and gloves and placed them on top of the white towel. LVN 7 put on clean gloves without performing hand hygiene. LVN 7 picked up his folder and went inside Resident 39's room. LVN 7 closed Resident 39's privacy curtain. LVN 7 asked Resident 39 to turn on his side. LVN 7 put down his folder at Resident 39's bedside. While using the same pair of gloves, LVN 7 removed the old dressing from Resident 39's wound. LVN 7 cleansed the wound with normal saline. LVN 7 removed his gloves and donned a new pair of gloves. LVN 7 did not perform hand hygiene prior to donning new gloves. Resident 39's wound measured 2.4 cm x 0.4 cm x UTD depth. LVN 7 stated Resident 39 had just underwent wound debridement. LVN 7 stated Resident 39 had a Stage 3 pressure ulcer. LVN 7 applied Santyl ointment to the wound and dressed the wound. LVN 7 told Resident 39 the treatment was over. LVN 7 threw the used dressings in a plastic bag, took off his gloves and went out of the room. LVN 7 stood in front of his treatment cart and stated the treatment was over. On 6/20/19 at 0919 hours, an interview was conducted with LVN 7. LVN 7 acknowledged he did not perform hand hygiene prior to preparing his equipment and prior to starting skin treatment. LVN 7 stated he did not know he had to wash his hands when he had to change gloves. LVN 7 acknowledged he had to perform hand hygiene when providing skin treatments.

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 09/11/2019 § 483.25(i) Respiratory care, including FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 26 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure necessary services for respiratory care needs were provided for one of 12 final sampled residents (Resident 292). CNA 5 removed Resident 292's nasal cannula during ADL care when the physician had ordered to administer oxygen at 2 liters per minute. This posed a risk for Resident 292 to develop respiratory complications from the lack of oxygen. Findings: On 6/18/19 at 0847 hours, Resident 292 was lying in bed, asleep. Resident 292 was receiving oxygen at 2 liters per minute via nasal cannula (a tube with two prongs to place in the nostrils for the administration of oxygen). Review of Resident 292's medical record was initiated on 6/18/19. Resident 292 was admitted to the facility on 6/17/19. Review of the History and Physical Examination dated 6/19/19, showed Resident 292 had pleural effusion (an unusual amount of fluid around the lungs). Review of the Order Summary Report date 6/8/19, showed an order dated 6/17/19, to administer oxygen at 2 liters per minute per FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 27 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE nasal cannula to Resident 292. Review of the Nursing Admission Data Collection dated 6/17/19, under Section 3 Systems Review - Respiratory, showed Resident 292 had continuous oxygen. The Section on Interim Care Plan showed Resident 292 needed assistance with ADLs. The care plan did not address Resident 292's oxygen therapy. On 6/19/19 at 1000 hours, Resident 292 was observed being wheeled out of her room by CNA 5. CNA 5 stated Resident 292 was going to have a shower. Resident 292 did not have the resident's oxygen on her. On 6/19/19 at 1015 hours, a concurrent observation and interview was conducted with the DON. The DON verified Resident 292 had an order for oxygen at 2 liters per minute. The DON stated Resident 292 had been on continuous oxygen since she was admitted. The DON verified Resident 292 was brought to the shower room without oxygen. When asked if CNA 5 was allowed to remove Resident 292's oxygen source, the DON stated it depended on the physician's order. The DON stated CNA 5 had to check with the charge nurse and see if there was an order to discontinue the oxygen during showers. The DON stated the charge nurse had to check Resident 292 prior to discontinuing Resident 292's oxygen. On 6/19/19 at 1030 hours, CNA 5 brought Resident 292 back to her room. The DON assessed Resident 292's oxygen saturation and it was at 91%. The DON replaced Resident 292's oxygen cannula at 2 liters per minute. On 6/19/19 at 1035 hours, an interview was conducted with CNA 5. CNA 5 acknowledged FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 28 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE she took off Resident 292's oxygen. CNA 5 stated she was not sure if she asked the charge nurse if it was appropriate to turn off Resident 292's oxygen. CNA 5 acknowledged she was not familiar with the care of Resident 292 since she was new in the facility. On 6/19/19 at 1040 hours, an interview was conducted with Resident 292. Resident 292 stated CNA 5 offered her to take a shower. Resident 292 stated CNA 5 took off her oxygen. Resident 292 stated she felt more comfortable with her oxygen on. On 6/19/19 at 1043 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 verified Resident 292 had an order for continuous oxygen. LVN 1 stated CNA 5 was not supposed to turn off Resident 292's oxygen without a physician's order. LVN 1 stated CNA 5 did not ask her about Resident 292's oxygen when she had to go to the shower. LVN 1 stated Resident 292 needed oxygen to breathe comfortably.

F697 SS=D Pain Management CFR(s): 483.25(k)

F697 07/25/2019 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and medical record review, the facility failed to ensure effective pain management was provided for one of 12 final sampled residents (Resident 39). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 29 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE * Resident 39's hydrocodone (opioid pain medication) had no distinct pain parameters. Resident 39's hydrocodone for sever pain was administered at lower pain levels. Resident 39 was not consistently provided nonpharmacological interventions prior to the administration of pain medications. These had the potential of the resident not receiving effective treatment for their pain. Findings: Review of Resident 39's medical record was initiated on 6/19/19. Resident 39 was admitted to the facility on 5/21/19. Review of the MDS dated 5/28/19, showed Resident 39 had frequent pain, with pain levels at 7/10. Review of Resident 39's Medication Review Report dated 6/1/19, showed the following orders: * An order dated 5/21/19, to administer hydrocodone-acetaminophen tablet 5-235 mg, one tablet as needed for moderate pain. * An order dated 5/21/19, to administer hydrocodone-acetaminophen tablet 5-235 mg, two tablets as needed for severe pain. Review of the Medication Administration Record dated 6/1 - 6/30/19, showed Resident 39 was given hydrocodone-acetaminophen 5325 mg, two tablets for pain levels of 5/10, and 6/10 (pain scale of 0-10, 0 = no pain, 10 = severe pain). Review of the Progress Notes showed Resident 39 was inconsistently offered nonpharmacological pain interventions prior to giving pain medications. Examples were as follows: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 30 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE -On 6/19/19 at 1604 hours, Resident 39 complained of severe pain on a scale of 8/10. The progress notes did not reflect nonpharmacological interventions. -On 6/18/19 at 1641 and 6/17/19 at 1607 hours, Resident 39 complained of pain on a scale of 7/10. Non-pharmacological interventions not documented. On 6/19/19 at 1110 hours, an interview was conducted with Resident 39. Resident 39 stated he had been experiencing a lot of pain from his bed sore and his back. On 6/25/19 at 0901 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 39 was able to report pain. LVN 1 stated mild pain levels were from 1-3, moderate pain level was 4-6 and severe pain levels were from 7-10. LVN 1 acknowledged Resident 39's hydrocodone did not show the numerical pain scale for mild, moderate and severe pain. LVN 1 stated non-pharmacological interventions had to be provided when residents reported pain. LVN 1 stated the non-pharmacological interventions were documented in the progress notes. On 6/25/19 at 0913 hours, a concurrent interview and medical record review was conducted with the ADON. The ADON stated non-pharmacological interventions were provided to residents every shift. The ADON stated the non-pharmacological interventions had to be documented in the Medication Administration Record or in the Progress Notes. The ADON verified the Medication Administration Record did not reflect nonpharmacological interventions provided to Resident 39. The ADON verified nonpharmacological interventions were not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 31 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE consistently provided to Resident 39 when he was in pain. The ADON stated hydrocodoneacetaminophen, two tablets were to be given for severe pain and had to be given when pain levels were between 7/10 to 10/10. The ADON acknowledged Resident 39 was given two tablets of hydrocodone-acetaminophen when the pain level was at 5/10 and 6/10. The ADON stated respiratory depression was an adverse effect of the medication and had to be given only as ordered by the physician.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 07/25/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 32 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to accurately account for the destruction and documentation of tablets received of Resident 196's controlled medication. This deficient practice had the potential for diversion of controlled medications. Findings: Review of Resident 196's Controlled or Antibiotic Drug Record for clonazepam (an antiseizure drug used also to treat panic disorder) 0.5 mg showed a quantity of 120 clonazepam 0.5 mg tablets were prepared by the pharmacy on 3/25/19. At the bottom of the form showed 139 tablets of clonazepam 0.5 mg were disposed of on 5/29/19. On 6/21/19 at 0837 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the process for receiving and disposing of controlled medications was to document the number of received tablets on the Controlled or Antibiotic Drug Record sheet. The DON stated the discontinued medications were kept locked in the medication room in a cabinet only accessible to her until they were disposed of with the pharmacists. DON stated controlled medications were then signed off by both her and the pharmacist. The DON confirmed there was no documentation of the amount of tablets received and signed out by the facility for Resident 196's clonazepam. The DON confirmed the Controlled or Antibiotic Drug Record sheet showed 139 doses of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 33 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE clonazepam 0.5 mg were disposed of for Resident 196. On 6/21/19 at 1006 hours, the DON stated she could not explain why the Controlled or Antibiotic Drug Record showed 139 tablets were disposed of and confirmed there was no other documentation to explain the discrepancy.

F757 SS=D Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 07/25/2019 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure one of 12 final sampled resident (Resident 5) was free from unnecessary medications. This had the potential for the resident to experience side FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 34 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE effects related to long term medication use. Findings: Medical record review for Resident 5 was initiated on 6/18/19. Resident 5 was admitted to the facility on 6/11/18. Review of the pharmacist's Consultation Report recommendation dated 3/29/19, showed a recommendation to discontinue naproxen sodium (a NSAID, non-steroidal antiinflammatory, pain medication) and to initiate Tylenol (pain medication). The rationale showed when a NSAID is used for greater than 10 days, there can be an increased risk for adverse affects. The report showed if the medication therapy is to continue, it is recommended the facility interdisciplinary team monitor for effectiveness and potential adverse consequences (e.g., excessive bleeding, bruising, presence of blood in stool or urine.) Review of the Order Summary Report dated 6/21/19, showed Resident 5's physician's order dated 6/22/18, for naproxen sodium 220 mg twice a day for pain management. The report failed to show an order to monitor for excessive bleeding, bruising, presence of blood in stool or urine. On 6/21/19 at 1132 hours, an interview and document review was conducted with the DON regarding Resident 5. The DON reviewed the pharmacist's recommendation for Resident 5 and stated she was unable to find documentation to show the recommendation was followed up on.

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 09/11/2019 §483.45(g) Labeling of Drugs and Biologicals FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 35 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure medication storage area and medication cart 1 were free of expired medications. Failure to remove expired medications from current stock, could potentially subject residents to minimized therapeutic effects or medication error. Findings: On 6/21/19 at 1125 hours, an observation and interview was conducted in the medication storage area with LVN 4. The following is a list of expired medications found and verified by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 36 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE LVN 4. * Milk of Magnesia with an expiration date of 5/2019 * Elder Tonic MTV Suppositories with an expiration date of 5/2019 * Folic Acid 400 mcg with an expiration date of 2/2019 * Oyster Shell Calcium 500 mg with an expiration date of 3/2019 * Geri-care Slow Magnesium Chloride with Calcium with an expiration date of 5/2019 On 6/21/19 at 1145 hours, during an observation of medication storage area, LVN 4 stated the licensed nursing staff are responsible for placing expired medication in the discontinued storage cabinet. LVN 4 stated expired controlled medications are to be given directly to the DON. On 6/21/19 at 1150 hours, an observation of the Medication Cart 1 was conducted with LVN 3. Several discontinued medications were located inside the medication cart. * Erythromycin 5mg/gm 1 application to left eye; medication discontinued on 6/15/19 * Heparin Sodium 5000units/ml; resident discharged on 6/13/19 * Amicare Amica Cream (homeopathic product); resident discharged on 6/13/19 * Jevity 1.5 (enteral Cal expiration date 6/1/19 LVN 3 verified these medications and stated they should not be in the medication cart. On 6/21/19 at 1215 hours, observation of influenza vaccine showed an expiration date of 5/2019. The DON verified the findings.

F790 SS=E Routine/Emergency Dental Srvcs in SNFs CFR(s): 483.55(a)(1)-(5)

F790 09/11/2019 §483.55 Dental services. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 37 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must assist residents in obtaining routine and 24-hour emergency dental care. §483.55(a) Skilled Nursing Facilities A facility§483.55(a)(1) Must provide or obtain from an outside resource, in accordance with with §483.70(g) of this part, routine and emergency dental services to meet the needs of each resident; §483.55(a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services; §483.55(a)(3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; §483.55(a)(4) Must if necessary or if requested, assist the resident; (i) In making appointments; and (ii) By arranging for transportation to and from the dental services location; and §483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 38 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, medical record review, facility document review and facility P&P, the facility failed to provide routine and emergency dental services for four of four residents residing at the facility for three final sampled residents (Residents 3, 5 and 15) and one non sampled resident (Resident 4). This had the potential for a delay in identifying potential dental decline and treatment for these residents. Findings: Review of the facility's P&P titled Oral Health Care and Dental Services revised in 11/2017, showed a consultant dentist will provide a dental assessment of each resident within 90 days of admission and perform or supervise an annual dental examination of each resident. 1. Medical record review for Resident 3 was initiated on 6/18/19. Resident 3 was admitted to the facility on 11/25/15. A SBAR Communication form and progress note dated 5/20/19, showed Resident 3's front tooth had fallen out. A physician's order dated 5/20/19 was received for Resident 3 to have a dental consult. On 6/20/19 at 1607 hours, an interview was conducted with LVN 5. LVN 5 stated they were filling in for Social Service staff, who had been on leave since 5/30/19. LVN 5 stated they were unable to find documentation the dentist was contacted for Resident 3 by the Social Service staff. LVN 5 stated they called the dentist's office last week and left a message. LVN 5 was unable to locate any documentation to show a call had been placed to the dental office. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 39 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 6/20/19 at 1648 hours, an interview and observation was conducted of Resident 3 with LVN 6. Resident 3's right front tooth was observed missing and there was a small yellowish tooth like fragment noted. The left front tooth was present and observed to have whitish/yellowish color opaque patches. On 6/21/19 at 1004, a telephone interview was conducted with the Dental office staff. The Dental office staff stated they had received a message for Resident 3's dental consult a few days earlier. The Dental office staff reviewed their office records and said Resident 3 had not been seen by their dentist in the past. On 6/21/19 at 0951 hours, an interview was conducted with the facility's Medical Records staff. The Medical Records staff stated they were unable to locate documentation to show Resident 3 had a dental consult performed since the resident's admission to the facility in 2015. On 6/21/19 at 1025 hours, an interview was conducted with the DON. The DON stated the facility utilized Dentist 1 for all routine dental visits. 2. Medical record review for Resident 15 was initiated on 6/18/19. Resident 15 was admitted to the facility on 2/10/18. Review of the Resident 4's medical record failed to show a dental consult had been completed. On 6/21/19 at 1553, Medical Records staff stated they were unable to locate documentation to show Resident 15 had had a dental consult. 3. Medical record review for Resident 4 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 40 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE initiated on 6/18/19. Resident 4 was admitted to the facility on 2/17/16. Review of the Resident 4's medical record failed to show a dental consult had been completed. On 6/21/19 at 1553, Medical Records staff stated they were unable to locate documentation to show a dental consult for conducted for Resident 4. On 6/25/19 at 0831 hours, a telephone interview was conducted with the Dental Office staff. The Dental Office staff reviewed their records and stated Resident 4 was last seen by Dentist 1 in 12/2015. 4. Medical record review for Resident 5 was initiated on 6/18/19. Resident 5 was admitted to the facility on 6/11/18. On 6/21/19 at 1553, Medical Records staff stated they were unable to locate documentation that a dental consult was conducted for Resident 5. On 6/25/19 at 0831 hours, a telephone interview was conducted with the Dental Office staff. The Dental Office staff reviewed their records and stated Resident 5 was first seen by Dentist 1 prior to 6/24/19.

F812 SS=F Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 07/25/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 41 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to maintain safe food handling practices. The facility failed to ensure the main kitchen and satellite kitchen were kept clean and in sanitary condition as evidence by: * A water leak from the ceiling near the food preparation area. * The facility failed to ensure food products were labeled and dated. * The ice machine was dirty with black slimy residue in the ice maker area. * A thick dust covered the ice machine digital panel and filter grill. * The facility failed to ensure handwashing was observed prior to staff handling food. * The facility failed to ensure all dietary staff wore hair nets. * Soiled towels were placed on the clean surface area of the dishwasher. These failures had the potential to result in foodborne illnesses in the highly susceptible resident population. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 42 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: Review of the CMS-672 Resident Census and Conditions of Residents form, completed by the facility on 6/19/19, showed 40 of 42 residents received food prepared by the facility. 1. On 6/18/19 at 0740 hours, a tour of the satellite kitchen was conducted with the Dining Services Director. A rectangular shaped opening in the ceiling was observed. with an exposed air duct. From this exposed air duct was a silver colored material with water dripping from it. A red bucket was placed on the floor directly under the dripping water to catch the water. A puddle of water of observed immediately surrounding the red bucket. There were two Dietary Aides observed plating food from the steam table, which was located approximately three to four feet from the water leak. Dietary Aide 2 was observed pouring coffee and juices into cups. The Dining Services Director stated she was aware of the water dripping from the ceiling and the facility's Maintenance Director had been working on it. The Dining Services Director stated the satellite kitchen was used to plate residents' food at breakfast, lunch and dinner. When asked how the water leak affected food preparation, the Dining Services Director stated the leak was not in the food preparation area. When asked if there was a potential for food to be contaminated, she did not respond. When asked how long the water leak had been observed, the Dining Services Director stated it has been a while. The Dining Services Director stated, the water leak was being addressed by the maintenance department and was expected to resolve as soon as possible. Staff continued to work and were observed to avoid the water leak area. On 6/18/19 at 0900 hours, an interview was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 43 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE conducted with Dietary Aide 2. Dietary Aide 2 stated there had been water leak from the ceiling for several months and the ceiling tile was removed and left open for approximately two weeks. Dietary Aide 2 stated she avoided the water leak when preparing drinks and meals for the residents. On 6/18/19 at 1001 hours, an interview was conducted with the Maintenance Director. The Maintenance Director verified the water leak was from the facility's air conditioning duct. The Maintenance Director stated the water leak started about 3 months ago and he had been working on but it kept on recurring. The Maintenance Director stated the leak was evaluated by an air condition service staff and was waiting for their recommendation. On 6/18/19 at 1310 hours, a concurrent observation and interview was conducted with the facility's Executive Director. The Executive Director acknowledged he was aware of the water leak in the kitchen and the maintenance department had been working on the problem. The Executive Director stated the satellite kitchen was used to plate the residents' food. He acknowledged the water leak had to be addressed as soon as possible to improve due to the potential of impaired sanitary conditions. 2. Review of the facility's P&P titled Storage of Perishable Food-Safety and Sanitation showed refrigerated items shall be covered, labeled to identify product name, and dated when product was received or prepared. All pre-dished items must be covered, labeled and dated to prevent off-flavors, drying or cross contamination while refrigerated. On 6/18/19 at 0740 hours, an observation of the satellite kitchen was conducted with the Dining Services Director. The Dining Services FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 44 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Director verified the following observations and findings. a. Observation of the dry storage area identified the following: - an open 8-ounce bottle of drinking water, no date, unlabeled - a gallon of pancake waffle syrup was open with no open date - a 35-ounce bag of toasted oats and corn flakes were open with no open dates - a plastic container with eight dinner rolls with no label, no dates - bread crumbs and black colored materials was observed in the plates and kitchen scoop bins. b. Observation of Satellite Kitchen Refrigerator #1 identified the following: - a one-liter box of almond milk had no open date - a pitcher of thousand island dressing had no used by date - a pitcher of tartar sauce and Caesars salad dressing with no used by date - a tub of cottage cheese with an expiration date of 5/2019 - an open tub of cottage cheese with no open date c. Observation of Satellite Kitchen Refrigerator # 2 identified the following: - a plastic bag containing 3 bagels with no open date - a plastic bag filled with cut baguette bread with no open date - A bucket of cut up fruits with no used by date - three full cups of fruit juice with no label or date(s) - a small plate with slices of cake with no date - a bag of cut lettuce with used by date of 6/17/19 - A garbage bin filled with trash with no lid FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 45 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cover was observed by the dishwashing machine. On 6/18/19 at 0830 hours, a concurrent interview and observation of the facility's main kitchen was conducted with the Dining Services Director. The Dining Services Director verified the following observations and findings. - a plastic bag filled with crackers had no label and no open date was observed in the clean equipment rack. - a bag of chips with no label and open date in the dry storage area The Main Kitchen Refrigerator was observed to have the following: - two trays of gelatin with no cover, unlabeled, and not dated - two containers of tartar sauce prepared on 5/4/19 and with expiration date of 5/21/19 - a round pan of blueberry cake with no cover, unlabeled, and not dated The Dining Services Director stated it is the facility's policy to label and date food products. The Dining Services Director acknowledged food had to be labeled and dated for safe consumption. The Dining Services Director acknowledged the garbage bin was full of trash and should have been covered to prevent pests. 3. On 6/25/19 at 0957 hours, a concurrent observation and interview was conducted with the Dining Services Director and the Maintenance Director. Observation of the ice machine identified the following: a. Outside the ice machine * the digital panel on the exterior and filter grill were observed to be covered with a thick, greasy, black material. * a thick layer of dust observed at the back FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 46 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE portion of the machine, on the side walls and ceiling. b. Inside the ice machine identified the following; * the upper inside cabinet layer of black material. * a slimy, blackish material was observed coming out from the compartment where water was coming from The Dining Services Director acknowledged the findings and stated the machine will be closed down and all ice will be disposed. On 6/25/19 at 1031 hours, an interview was conducted with the Registered Dietician. The Registered Dietician stated she performed kitchen inspection at the end of the month and the last time she conducted an inspection was in May of 2019. 4. On 6/18/19 at 1003 hours, Dietary Aide 1 was observed wearing gloves while scraping food off from the dirty dishes. Dietary Aide 1 placed the plates in the dishwasher and turned it on. After the dishwasher cycle was complete, Dietary Aide 1 pulled the clean tray of plates from the dishwasher. Dietary Aide 1 picked up the clean plates from the tray while wearing the same gloves. Dietary Aide 1 held the plates against her body and piled it in the clean bin. On 6/18/19 at 1007 hours, an interview was conducted with Dietary Aide 1. Dietary Aide 1 stated she had to wash her hands and don new gloves when she touched the clean plates. Dietary Aide 1 acknowledged she carried the clean plates against her body as she moved it from the dishwasher to the storage. These dishes were rewashed. 5. On 6/18/19 at 1015 hours, Dietary Aide 2 was observed carrying a bin filled with clean FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 47 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE spoons and forks which she removed from the dishwasher. Dietary Aide 2 placed the utensils on top of a cart, and left it uncovered in the dining area. There were clean pitchers and cups stored uncovered in a plastic cabinet in the dining area. Residents, facility staff and visitors were observed passing by this area. On 6/18/19 at 1025 hours, an interview was conducted with the Dining Services Director. The Dining Services Director stated the pitchers, cups, spoons and fork were used during food service. The Dining Services Director acknowledged the dining room was a busy area and acknowledged the utensils, pitcher, cups should have been covered. 6. On 6/18/19 1215 hours, the satellite kitchen window was observed to be open to the outside. A black material was observed covering the entire screen and what looked to be food particles and black debris on the window sill. On 6/18/19 at 1217 hours, an interview was conducted with Dietary Aide 2. Dietary Aide 2 verified the debris on the window sill and blackish material on the window screen. On 6/18/19 at 1225 hours, an interview was conducted with the Maintenance Director. The Maintenance Director verified the black dirt on the window screen and the leftover food particles on the window sill. The Maintenance Director stated the housekeeper were in charge of cleaning the windows. 7a. On 6/18/19 at 1145 hours, during dining observation, facility staff were observed giving the residents' meal tickets to Dietary Aide 1. Dietary Aide 1 would take the meal tickets, then pick up a clean plate from the plate warmer and place the meal ticket on top of the clean plate. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 48 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE After reading the meal ticket, Dietary Aide 1 would place the cooked food item on the plate and set the plate on the kitchen ledge for serving. When Dietary Aide 1 was asked if it was appropriate for the meal ticket to be placed on top of the clean plate, the dietary aide acknowledged she should not have placed the meal tickets on top of the plates. 7b. On 6/21/19 at 1645 hours, Dietary Aide 3 and CNA 4 were observed sorting residents' meal tickets on top of a soiled linen bin. When asked what the tickets were for, Dietary Aide 3 stated the residents get to choose their food for dinner and was logged in the meal tickets. This had a potential to cross-contaminate At 1705 hours, Dietary Aide 3 was observed to place the sorted meal tickets on top of the plate warmer and the food preparation table inside the kitchen. Dietary Aide 3 acknowledged the meal tickets were earlier sorted on top of the soiled linen bin. On 6/21/19 at 1707 hours an interview was conducted with the Dining Services Director. The Dining Services Director stated sorting the meal tickets on top of the soiled linen bin was not appropriate. The Dining Services Director stated the residents' meal tickets should be sorted on a clean surface to prevent contamination 8. On 6/18/19 at 1310 hours, a concurrent observation and interview was conducted with the Executive Director. Insects were observed on the satellite kitchen wall just right above the window and by the food preparation area. An open garbage can was observed near the window. The Executive Director verified the presence of insects in the kitchen. The Executive Director stated the sanitary condition would be addressed immediately. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 49 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 9. On 6/21/19 at 1240 hours, during dining observation, the Certified Dietary Manager entered the satellite kitchen from the dining room. The Certified Dietary Manager went to the steam table and started preparing food. The Certified Dietary Manager then retrieved food from the refrigerator. The Certified Dietary Manager did not wash her hand prior to handling residents' food. On 6/21/19 at 1245 hours, an interview was conducted with the Certified Dietary Manager. The Certified Dietary Manager acknowledged she did not wash her hands prior to handling food. The Certified Dietary Manager stated she had to wash her hands prior to handling food to prevent food contamination. 10. On 6/25/19 at 0942 hours, a concurrent observation and interview was conducted with Dietary Aide 4. Two white towels stained with a yellowish material were observed on top of the clean area of the dishwasher. Dietary Aide 4 stated the clean area was for the clean dishes coming out from the dishwasher and had to be kept clean. Dietary Aide 4 acknowledged the two yellow stained towels were dirty and removed them. 11. On 6/25/19 at 0950 hours, Dietary Aide 5 entered the kitchen without donning a hair net. Dietary Aide 5 acknowledged she did not put on her hair net. Dietary Aide 5 stated she should have cover her hair with a hair net before entering the kitchen. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 50 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F814 Dispose Garbage and Refuse Properly CFR(s): 483.60(i)(4)

F814 07/25/2019

F867 07/25/2019 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.60(i)(4)- Dispose of garbage and refuse properly. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure the garbage was disposed of properly. The dumpster was overflowing with garbage, which prevented the cover from closing. A trash filled garbage can was pushed in the hallway without a cover. These failures had the potential to harbor pests. Findings: 1. On 6/25/19 at 1020 hours, during environmental tours with the Maintenance Supervisor, one of the four dumpsters outside was observed to be overflowing with garbage with the lid partially closed. There were pieces of trash on the ground. There were three other dumpsters were only partially filled. The Maintenance Director acknowledged the dumpster lid had to be fully closed to prevent exposing the garbage from pests and rodents. 2. On 6/18/19 at 1428 hours, Dietary Aide 2 was observed in the resident's hallway pushing an uncovered garbage bin filled with trash. When asked about the garbage bin lid, Dietary Aide 2 just smiled and did not respond. On 6/25/19 at 1020 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated staff had to cover the garbage bin with when moving trash from the kitchen to the dumpster.

F867 SS=D QAPI/QAA Improvement Activities CFR(s): 483.75(g)(2)(ii) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 51 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; This REQUIREMENT is not met as evidenced by: Based on interview and facility document review, the facility failed to implement their Quality Assessment and Assurance Plan (QAPI) of action. There was no documentation to show the facility was accurately monitoring the effects of the action plans to identify if they had achieved and sustained improvement for a repeated deficient practice cited at F812 in accordance with their POC for a concurrent Recertification and Relicensing surveys completed on 7/16/18. This had the potential to affect the food safety and put the residents at risk of foodborne illness. Findings: Review of the Plan of Correction (POC) submitted by the facility to the CDPH, L&C Program for a concurrent Recertification and Relicensing surveys on 7/16/18 showed the Dining Director and/or designee will conduct random audits of food storage three times a week for 30 days, and if compliant, random audits will be conducted twice a week for the next sixty days. The POC showed Crandall Weekly Sanitation Assurance review will be done weekly throughout the year. On 6/25/19 at 1028 hours, an interview and facility document review was conducted with both the Administrator and the DON. Review of the QAPI report for August, September and October 2018 showed 100% for the monitoring FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 52 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE set in place for F812. The DON stated since the monitoring showed 100% compliance for 90 days, the monitoring was removed from the QAPI agenda. The facility was unable to produce data to support 100% compliance for those months. On 6/25/19 at 1132 hours an interview and facility document review was conducted with the Dining Service Director, the Administrator and DON were present. The Dining Service Director reviewed the process for completing the Crandall Corporate Dieticians Sanitation Quality Assurance Review form. The Dining Service Director stated if only one expired food item was found during the inspection, the the Dining Service Director would discard the item, counsel the staff, and document the inspection criteria as compliant. The Dining Service Director stated if two or more expired items were found, then she would document the noncompliance. For food debris and other criteria on the form, the Dining Service Director stated if she can quickly fix an identified noncompliance, she will fix it and count it as compliant. The data from the form was utilized for QAPI. The Dining Service Director verified the tool was not used appropriately to help identify and monitor deficient practices.

F881 SS=E Antibiotic Stewardship Program CFR(s): 483.80(a)(3)

F881 07/25/2019 §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 53 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and a system to monitor antibiotic use. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility review, the facility failed to accurately identify true infection and monitor antibiotic use for one of 12 final sampled residents (Resident 15) and two residents (Residents 16 and 246). * Resident 16's skin infection was incorrectly identified as not meeting McGeer's Criteria (a set of criteria used in long-term care facilities to identify if residents' symptoms meet the criteria of a true infection). * Residents 15 and 246 were being treated for conditions which did not meet McGeer's Criteria. These had the potential to expose the residents to unnecessary antibiotic use and incorrect data used for facility monitoring and reporting. Findings: According to the CDC, unnecessary antibiotic use promotes development of antibioticresistant 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. 1. On 6/20/19 at 0914 hours, an interview, medical record review and facility record review was conducted with the ADON. The ADON stated the facility used McGeer's Criteria, a surveillance data collection tool to determine if the resident has an infection. The ADON pulled up the infection log for May 2019, on their computer. The ADON stated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 54 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 16's infection did not meet McGeer's criteria. The ADON reviewed the Resident 16's documented symptoms utilizing the McGeer's Criteria tool and stated the infection did in fact meet McGeer's Criteria and had been documented incorrectly in the infection log. 2. On 6/20/19 at 1151 hours, an interview, medical record review and facility record review was conducted with the ADON. The infection log for May 2019, showed Resident 246 was treated with antibiotics for an urinary tract infection (UTI) which did not meet McGeer's criteria. The ADON stated she did not notify the physician the infection did not meet McGeer's criteria. 3. On 6/20/19 at 0914 hours, an interview, medical record review and facility record review was conducted with the ADON. The infection log for May 2019, showed Resident 15 was treated with antibiotics for an UTI which did not meet McGeer's criteria. The ADON stated she did not notify the physician the infection did not meet McGeer's criteria.

F921 SS=D Safe/Functional/Sanitary/Comfortable Environ CFR(s): 483.90(i)

F921 07/25/2019 §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the residents smoking area was safe and clean. This failure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 55 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE had the potential to affect staff safety and increased the risk of injury. Findings: On 6/19/19 at 1237 hours, an environmental tour was conducted with the Maintenance Director. The Maintenance Director verified the following findings in the residents smoking area: * Cigarette butts and ashes were observed on the ground * The four concrete posts in the smoking area had chipped and ragged sharp edges. * The fire blanket inside a red cabinet was covered with cobwebs and dust. * The smoking apron on top of the fire blanket box was covered with cobwebs and thick black material. * Cobwebs and thick layers of black dust were observed on the wall and ceiling in the smoking area. The Maintenance Director stated the smoking area was used by residents who smoke. The Maintenance Director acknowledged the sharp ragged edges on the concrete posts could potentially cause skin tears. The Maintenance Director acknowledged the smoking area was dirty. On 6/19/19 at 1250 hours, a concurrent observation and interview was conducted with the Administrator. The Administrator verified the same findings and acknowledged the smoking area had to be cleaned. The Administrator acknowledged the ragged edges of the concrete posts had to be repaired to prevent residents from sustaining a skin injury FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 59H611 Facility ID: 060001718 If continuation sheet 56 of 57 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555768 (X3) DATE SURVEY COMPLETED 06/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BAYSHIRE YORBA LINDA POST-ACUTE 17803 Imperial Hwy Yorba Linda, CA 92886 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: 59H611 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: 060001718 (X5) COMPLETE DATE If continuation sheet 57 of 57