Health inspection·January 13, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the physician's order for a pommel (a device to support seating and assist with proper posture) cushion when up in wheelchair was followed for one of nine final sampled residents (Resident 3). This failure had the potential for not providing the appropriate care to the resident. Residents Affected - Few Findings: Medical record review for Resident 3 was initiated on 1/10/23. Resident 3 was admitted to the facility on [DATE]. Review of the Order Summary Report dated 11/4/22, showed an order to have a pommel cushion for Resident 3 when up in the wheelchair due to leaning forward. Review of Resident 3's medical record titled Generations Care Conference - V3 dated 11/4/22, showed Resident 3's physician's order list was reviewed and discussed with a new order for pommel cushion in wheelchair. On 1/13/23 at 1040 hours, an observation was conducted with Resident 3. Resident 3 observed in bed and the resident's wheelchair was inside the bathroom with a cushion on the seat of the wheelchair. On 1/13/23 at 1120 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 3 was sitting on a regular cushion, not a pommel cushion. On 1/13/23 at 1136 hours, an interview was conducted with LVN 3. LVN 3 stated Resident 3 had a pommel cushion when she was in her wheelchair due to leaning over. On 1/13/23 at 1150 hours, a concurrent observation and follow-up interview was conducted with LVN 3. When asked if Resident 3 had a pommel cushion, LVN 3 was observed asking the Treatment Nurse. The Treatment Nurse stated it looked like a pommel cushion. LVN 3 verified and acknowledged the above findings and further stated Resident 3 should have a pommel cushion because of the physician's order. On 1/13/23 at 1239 hours, an interview was conducted with the DON. The DON acknowledged the above findings and further stated the physician's orders should be followed. On 1/13/23 at 1408 hours, a follow-up interview was conducted with the Treatment Nurse. The Treatment Nurse verified and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 2 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for three of nine final sampled residents (Residents 14, 273, and 426). Residents Affected - Few * The facility failed to follow and clarify the order for oxygen administration for Resident 14. The physician's order showed to administer oxygen at two lpm via nasal cannula; however, the order did not indicate whether the oxygen should be continuous or as needed. This failure put the resident at risk of not having their care needs met. * The facility failed to ensure Resident 426's nebulizer tubing was labeled as per the facility's P&P. This had the potential for increased risks of infection. * The facility failed to ensure Resident 273's CPAP machine was cleaned and the cleaning was documented in the resident's record as per the facility's P&P. This failure placed the resident at risk for infection. Findings: 1. Review of the facility's P&P titled Equipment-Oxygen Administration dated 1/1/21, showed to verify there is a physician's order for this procedure and review the physician's orders or facility protocol for oxygen administration. On 1/10/23 at 1038 hours, Resident 14 was observed in bed with an oxygen concentrator at the bedside; however, the oxygen was not being administered to the resident. Resident 14 stated she sometimes used oxygen. On 1/11/23 at 1245 hours, Resident 14 was again observed in bed with an oxygen concentrator at the bedside, but the oxygen was not being administered to the resident. Medical record review for Resident 14 was initiated on 1/10/23. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's Order Summary Report showed an order dated 10/13/22, to administer oxygen at two lpm via nasal cannula. Review of Resident 14's Weights and Vitals Summary showed Resident 14 was administered oxygen via nasal cannula on multiple occasions since 10/13/22, but was on room air at times. For example: Resident 14 was administered oxygen via nasal cannula on the following dates and times: - On 10/15/22 at 1039 hours, - On 10/16/22 at 1710 hours, - On 10/17/22 at 1723 hours, - On 10/18/22 at 1852 hours, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 3 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 - On 11/5/22 at 1611 hours, Level of Harm - Minimal harm or potential for actual harm - On 11/30/22 at 1930 hours, - On 12/21/22 at 1907 hours, and Residents Affected - Few - On 1/2/23 at 1304 hours. Resident 14 was noted to be on room air on the following dates and times: - On 10/20/22 at 2315 hours, - On 11/4/22 at 2344 hours, - On 12/2/22 at 1226 hours, and - On 1/9/23 at 1617 hours. On 1/11/23 at 1427 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 was asked about Resident 14's use of oxygen. LVN 1 stated Resident 14 sometimes received oxygen via nasal cannula. LVN 1 reviewed Resident 14's physician's orders and verified there was an order for oxygen at two lpm. LVN 1 stated she should clarify the order to say continuous or as needed, as it was not specific. 2. Review of the facility's P&P titled Administering Medications through a Small Volume (Handheld) Nebulizer (a small machine that turns liquid medicine into mist) revised date October 2010 showed it is the facility's policy to safely and aseptically administer aerosolized particle of medication into the resident's airway. Further review of the facility's P&P, under Steps in the Procedure section, number 29, showed to store the equipment in a plastic bag with the resident's name and the date. Review of Resident 426's medical record was initiated on 1/10/23. Resident 426 was admitted to the facility on [DATE]. Review of Resident 426's Order Summary Report showed an order dated 1/9/23, to administer ipratropium-Albuterol solution (medications used to treat and prevent symptoms of wheezing (to breathe with difficulty and with a whistling sound) 0.5-2.5(3) mg/3 ml one unit inhale orally every six hours for wheezing for five days around the clock. Review of Resident 426's MAR dated January 2023 showed to administer ipratropium-Albuterol solution 0.5-2.5(3) mg/3 ml one unit inhale orally every six hours for wheezing for five days around the clock. Further review of Resident 426's medical record showed the nebulizer treatment was administered on 1/10/23 at 0600 hours. On 1/10/23 at 1105 hours, during the initial tour of the facility, a nebulizer machine was observed on top of Resident 426's bedside table. Resident 426's nebulizer tubing was observed inside the plastic bag and was unlabeled (no name and not dated). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 4 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/10/23 at 1117 hours, an observation and concurrent interview and medical record review was conducted with LVN 2. When asked if Resident 426 was on the nebulizer treatment, LVN 2 stated she would like to check Resident 426's medical record. LVN 2 checked Resident 426's physician's orders and stated Resident 426 had an order for the nebulizer treatment and was last received the treatment on 1/10/23 at 0600 hours. LVN 2 acknowledged the nebulizer tubing was unlabeled. LVN 2 further stated it should be labeled for infection control reasons. LVN 2 was observed discarding the nebulizer tubing and plastic bag in the trash can. On 1/13/23 at 1239 hours, an interview was conducted with the DON. The DON acknowledged the above findings and further stated it should be labeled and dated for infection control reasons. 3. Review of the facility's P&P titled CPAP Administration dated 4/12/21, showed each day when the resident is removed from the machine, the reservoir should be emptied and left to air dry. Once weekly, the reservoir should be washed with warm soapy water and rinsed well, then left to air dry. Weekly cleaning should be documented in the resident record. Medical record review for Resident 273 was initiated on 1/10/23. Resident 273 was admitted to the facility on [DATE]. Review of the Order Audit Report dated 1/18/23, showed a physician's order dated 12/31/22, for CPAP at bedtime, remove when awake at bedtime and remove per schedule. Review of the H&P examination dated 12/31/22, showed Resident 273 had a diagnosis of OSA (obstructive sleep apnea-intermittent airflow blockage during sleep). The H&P examination also showed Resident 273 had the capacity to understand and make medical decisions. Review of Resident 273's Treatment Administration Record from 1/1-1/31/23, failed to show documentation the CPAP was being cleaned as per the facility's P&P. On 1/10/23 at 1137 hours, an observation and concurrent interview was conducted with LVN 1. A CPAP machine was observed at Resident 273's bedside. When asked about the facility's process in cleaning the CPAP machine, LVN 1 stated the CPAP machine was being cleaned daily using warm water then air dry. LVN 1 also stated the nurses routinely cleaned the machine when they documented in the Treatment Administration Record for applying and removing the CPAP from Resident 273. On 1/11/23 at 1034 hours, an interview was conducted with the IP. The IP was asked about the risk factors to a resident when using an unclean or dirty CPAP machine. The IP stated there was a risk for developing infection. When asked how the staff verified the CPAP machine was cleaned, the IP stated the LVNs routinely cleaned the CPAP machine every day, before and after the resident's use. When asked to show documentation of the LVNs cleaning Resident 273's CPAP machine, the IP stated they did not do any documentation for cleaning of the CPAP machine. On 1/11/23 at 1100 hours, an interview was conducted with Resident 273. When asked if the staff were cleaning her CPAP machine before and after use, Resident 273 stated no. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 5 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure pain management included non-pharmacological interventions for one of nine final sampled residents (Resident 14). The facility failed to provide non-pharmacological interventions prior to administration of the narcotic pain medication (a prescription medication/controlled substance which relieves pain). This failure had the potential for Resident 14 to receive unnecessary pain medication. Residents Affected - Few Findings: Medical record review for Resident 14 was initiated on 1/12/23. Resident 14 was admitted to the facility on [DATE]. Review of the facility's P&P titled Pain Assessment and Management revised 3/2020 showed non-pharmacological interventions may be appropriate alone or in conjunction with medications. Review of the Order Summary Report dated 1/12/23, showed a physician's order dated 10/13/22, for non-pharmacological pain interventions as needed. The document showed the Intervention Codes as follows: 1=Redirect; 2=1:1; 3=See nurses notes; 4=iPad to Go; 5=Relaxation Techniques; 6=Food/Fluids; 7=Music; 8=Change position; 9=Adjust room temperature; 10=Backrub/Massage; 11=Pet Therapy; 12=Minimize noise and light; 13=Other; and 14=Other. Review of the Order Summary Report dated 1/12/23, showed the following physician's orders dated: - 10/13/22, to administer Butalbital-ASA-Caffeine Capsule 50-325-40 mg one capsule by mouth every 4 hours as needed for headaches/migraine; - 10/13/22, to administer Gabapentin Capsule 300 mg two capsules by mouth three times/day for nerve pain; - 11/3/22, to apply Dicolfenac Sodium Gel 1% to the back topically three times/day for pain management, apply 2GM=2.25 inches; - 10/21/22, to administer Oxycodone HCL ER 12 hour Abuse Deterrent 20 mg one tablet by mouth every 12 hours for lumbar pain; and - 1/9/23, to administer Oxycodone HCL tablet 10 mg one tablet by mouth every 6 hours as needed for back and/or sacral pain. Review of Resident 14's MAR from October 2022 through January 2023, showed Resident 14 received Oxycodone HCL PRN on the following dates: - 10/14, 10/17, 10/18, 10/19, 10/20, and 10/21/22. - from 11/1 -11/19, 11/21-11/27, 11/29 and 11/30/22. - from 12/8-12/19, 12/21-12/27, 12/29 and 12/30/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 6 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 - 1/1 -1/8/23 Level of Harm - Minimal harm or potential for actual harm However, further review of the MAR failed to show documentation of non-pharmacological pain interventions attempted as ordered. Residents Affected - Few On 1/12/23 at 1147 hours, an interview was conducted with LVN 2. When asked if the non-pharmacological interventions were offered or attempted to Resident 14 for pain management prior to the administration of the pain medication, LVN 2 stated they did, such as repositioning; however, Resident 14 asked for her pain medication right away. When asked to show documentation of the non-pharmacological interventions offered or provided to Resident 14, LVN 2 stated she would consult with the DON. On 1/1/2/23 at 1150 hours, an interview was conducted with the DON. When asked to show the documentation for non-pharmacological interventions, the DON verified in the PCC MAR, the dates when the PRN pain medication were administered to Resident 14, the non-pharmacological interventions sections were blank and the staff did not document their attempts of providing non-pharmacological interventions prior to administering the PRN pain medication. On 1/12/23 at 1318 hours, an interview was conducted with Resident 14. Resident 14 was asked if she was offered non-pharmacological pain relief, such as massages. Resident 14 stated nothing was offered to her. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 7 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review the facility failed to follow the physician's orders and obtain an indication for the use of medication for one of nine final sampled residents (Resident 472), and failed to monitor for the medication side effects for one of five unnecessary medication sampled residents (Resident 274). * LVN 2 placed a pain medication patch on Resident 472's lower back instead of anterior ribs as per the physician's orders. This failure put Resident 472 at risk for adverse effects. * Resident 274 was administered Eliquis (an anticoagulant medication used to treat or prevent blood clots) without any monitoring in place for adverse effects such as bleeding and bruising. This failure put Resident 274 at risk for dangerous side effects to go unnoticed. * Resident 472 was given Enoxaparin injections (a blood thinner medication) without an indication for use listed on the medication order. This failure had the potential to cause Resident 472 harm from unnecessary use of a blood thinner. Findings: Review of the facility's P&P titled Administering Medications revised date 4/19 showed the medications are administered in accordance with the prescriber's orders. 1. Medical record review for Resident 472 was initiated on 1/11/23. Resident 472 was admitted to the facility on [DATE]. Review of the Order Summary Report showed an order dated 1/9/23, for lidocaine patch 5% (a medication used to treat pain) one patch intradermally (within the skin) one time a day, apply to anterior (situated before or toward the front) ribs for 12 hours, on at 0900 hours and off at 2100 hours and remove per schedule. On 01/11/23 at 0905 hours, a medication administration observation was conducted with LVN 2. LVN 2 prepared the medications to administer to Resident 472 including a lidocaine 5% patch. LVN 2 explained to Resident 472 that she would apply the lidocaine patch. Resident 472 told LVN 2 to place the patch on her lower back. LVN 2 applied the lidocaine patch to Resident 472's lower back, just above the gluteal (buttocks) fold. On 01/11/23 at 1425 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 was asked about the placement of Resident 472's lidocaine patch. LVN 2 stated she applied the patch to the lower back because Resident 472 requested her to do so, but stated she should have clarified the physician's order. On 1/13/23 at 1419 hours, an interview was conducted with the DON. The DON was asked about the process when a resident requested for a patch to be placed somewhere other than what was in the physician's order. The DON stated the licensed staff should follow the physician's order and clarify any orders with the physician before changing the site of administration. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 8 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. According to Lexicomp (an online medication database), under Nursing Physical Assessment/Monitoring for Eliquis, the following should be done: - Check ordered labs and report any abnormalities. Monitor for signs and symptoms of bleeding (bruising or bleeding that is not normal, changes in menstrual periods like lots of bleeding, spotting, or bleeding between cycles, nosebleeds that won't stop, bowel movements that are red or black like tar, throwing up blood or liquid that looks like coffee grounds). - Educate patients on bleeding precautions including avoiding invasive procedures, activities that could cause injuries, and how to handle bleeding emergencies. - Educate patients that grapefruit juice may increase the effects of the medication. Instruct patients not to discontinue medication prematurely. Advise patients to tell all doctors and dentists about use of an anticoagulant. Medical record review for Resident 274 was initiated on 1/13/23. Resident 274 was admitted to the facility on [DATE]. Review of Resident 274's Order Summary Report showed an order dated 1/6/23, to administer Eliquis 2.5 mg one tablet twice per day as a blood thinner, deep vein thrombosis preventing knee replacement. Review of Resident 274's medical record failed to show any monitoring for side effects such as excess bleeding or bruising. On 1/13/23 at 1052 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 was asked if there were any special considerations when a resident received an anticoagulant. LVN 1 stated the residents on anticoagulants should be monitored for bleeding. LVN 1 was asked to review Resident 274's medical record. LVN 1 verified Resident 274 received Eliquis 2.5 mg twice daily. When asked to show documentation of monitoring was in place, LVN 1 was unable to show. On 1/13/23 at 1209 hours, an interview was conducted with the DON. The DON was asked for the process when a resident was on an anticoagulant. The DON stated the residents on anticoagulants should be monitored for side effects such as bleeding and it would be documented on the MAR. Cross reference: F756 3. Medical record review for Resident 472 was initiated on 01/10/23. Resident 472 was admitted to the facility on [DATE], with the diagnosis of anemia. Review of Resident 472's Order Summary Report for the month of January showed Resident 472 was ordered Enoxaparin injections (a blood thinner medication) daily. The medication order showed, ppx (abbreviation for prophylaxis) and did not show any further indication for use. Review of Resident 472's MAR for the month of January showed Resident 472 received Enoxaparin every day since admission on [DATE]. On 01/13/23 at 1218 hours, an interview and concurrent medical record review was conducted with LVN 3 who stated she had given Resident 472 Enoxaparin injections. When asked what the indication for use was, LVN 3 stated she did not know why Enoxaparin was ordered and further explained during (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 9 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medical record review that the physician's order did not list the indication for use. LVN 3 stated the physician order should show the prophylaxis reason. On 01/13/23 at 1303 hours, an interview was conducted with the DON who stated an indication for use of the medication was the most important part of the medication order. When asked if prophylaxis alone would suffice as an indication, she stated no and explained that a medication order should show what the prophylaxis was for. On 01/13/23 at 1400 hours, an interview was conducted with Consultant Pharmacist 1. When asked what the minimum components of medication order were, the Consultant Pharmacist stated the medication orders should include the indication for use. On 01/13/23 at 1500 hours, the DON and Administrator were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 10 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the pharmacist reported irregularities in the medical record to the attending physician, medical director, and DON for two of five unnecessary medication sampled residents (Residents 274 and 472). * Resident 274 received an anticoagulant medication without any order for side effects monitoring. The pharmacist failed to notice and provide a recommendation to the facility. This failure had the potential for Resident 274's side effects to go unnoticed. * Resident 472 was given Enoxaparin injections (a blood thinner medication) without an indication for use listed on the medication order. The pharmacist failed to flag and provide recommendations for this medication. This failure had the potential to cause Resident 472 harm from unnecessary use of a blood thinner. Findings: 1. According to Lexicomp (an online medication database), under Nursing Physical Assessment/Monitoring for Eliquis, the following should be done: - Check ordered labs and report any abnormalities. Monitor for signs and symptoms of bleeding (bruising or bleeding that is not normal, changes in menstrual periods like lots of bleeding, spotting, or bleeding between cycles, nosebleeds that won't stop, bowel movements that are red or black like tar, throwing up blood or liquid that looks like coffee grounds). - Educate the patients on bleeding precautions including avoiding invasive procedures, activities that could cause injuries, and how to handle bleeding emergencies. - Educate the patients that grapefruit juice may increase the effects of the medication. - Instruct the patients not to discontinue medication prematurely. - Advise the patients to tell all doctors and dentists about use of an anticoagulant. Medical record review for Resident 274 was initiated on 1/13/23. Resident 274 was admitted to the facility on [DATE]. Review of Resident 274's Order Summary Report showed an order dated 1/6/23, to administer Eliquis 2.5 mg one tablet twice per day as a blood thinner, deep vein thrombosis preventing knee replacement. Review of Resident 274's medical record failed to show any monitoring for the side effects such as excess bleeding or bruising. Review of the Pharmacist's Consultation Report dated 1/9/23, showed Resident 274's medication regimen review with no new irregularities, and there were no recommendations. On 1/13/23 at 1209 hours, an interview was conducted with the DON. The DON was asked the process (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 11 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for medication regimen review. The DON stated the Consultant Pharmacist would review all resident's medication orders on a monthly basis. The pharmacist then would shares the recommendations with the facility. The DON verified Resident 274 had an order for Eliquis in place since 1/6/23. On 1/13/23 at 1217 hours, a telephone interview and concurrent medical record review was conducted with Consultant Pharmacist 1. Consultant Pharmacist 1 was asked her process when she did the medication regiment review, specifically for Eliquis. Consultant Pharmacist 1 stated she would look for interactions. Consultant Pharmacist 1 stated when a resident on an anticoagulant, they should be monitored for signs and symptoms of bleeding and bruising. Consultant Pharmacist 1 verified Resident 274's medical record was reviewed on 1/9/23, but no recommendations were given. Consultant Pharmacist 1 stated the side effect monitoring was normally and should be included in the reviews. Cross reference to F755, example #2. 2. Medical record review for Resident 472 was initiated on 01/10/23. Resident 472 was admitted to the facility on [DATE], with the diagnosis of anemia. Review of Resident 472's Order Summary Report for the month of January 2023 showed Resident 472 was ordered Enoxaparin injections (a blood thinner medication) daily. The medication order showed, ppx (abbreviation for prophylaxis) and did not show further indication for use. Review of Resident 472's MAR for the month of January 2023 showed Resident 472 received Enoxaparin every day since admission on [DATE]. Review of Resident 472's pharmacy consultation report dated 01/11/23, showed the pharmacist reviewed Resident 472's medication regimen with no recommendations for change. On 01/13/23 at 1303 hours, an interview was conducted with the DON who stated an indication for the use of the medication was the most important part of the medication order. When asked if prophylaxis alone would suffice as an indication, she stated no and explained a medication order should include what the prophylaxis was for. On 01/13/23 at 1400 hours, an interview was conducted with Consultant Pharmacist 1 who stated the pharmacists reviewed the resident's medication orders monthly and upon admission. Consultant Pharmacist 1 further stated during the medication reviews, the pharmacists checked if the medication orders were complete. Consultant Pharmacist 1 stated they had to ensure the medications with an appropriate diagnosis. When asked what the minimum components of a medication order were, Consultant Pharmacist 1 stated the medication orders should list the indication for use. Consultant Pharmacist 1 stated if the indication was missing from an order, the facility would be notified through the pharmacy consultation report. On 01/13/23 at 1500 hours, the DON and Administrator were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 12 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and facility P&P review, the facility failed to ensure the expired medications in the Medication Room were disposed. This failure had the potential for the expired medications to be administered to the residents. Findings: Review of the facility's P&P titled Storage of Medication revised date 11/20 showed discontinued, outdated, or deteriorated drugs or biological's are returned to the dispensing pharmacy or destroyed. On 1/11/23 at 0941 hours, an observation and concurrent interview was conducted with RN 1 in the Medication Room. Various over the counter medications were observed stored in the cupboards. One bottle of Co Q-10 (a supplement used for heart health) was observed in the cupboard with an expiration date of 9/22. When asked how the medications were stored, RN 1 stated they used a first in first out system, so the medications with soonest expiration date were placed to the front. RN 1 stated all licensed staff were responsible to rotate the medications and dispose of the expired medications, and the expired medication should not have been there. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 13 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and facility document review, the facility failed to have a full-time qualified individual employed to oversee the day-to-day food service operations in the SNF. This failure posed a risk of lack of adequate supervision of the daily kitchen functions which could lead to food borne illness for the 16 residents who received food from the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 3/10/23, showed 16 of 18 residents received food prepared in the kitchen. According to the California Code, Health, and Safety Code - HSC § 1265.4: A licensed health facility, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a qualified full-time dietetic services supervisor to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. Review of the facility's general job summary titled Culinary Director dated 6/12/20, showed the Culinary Director is responsible for organizing, developing, and directing the overall operation of the culinary department to ensure that quality nutritional services are provided on a daily basis and the culinary services are maintained in a clean, safe, and sanitary manner, as well as other job duties. Further review of the facility's document showed the Culinary Director's signature dated 9/1/20. On 1/10/23 at 0915 hours, an interview was conducted with the Culinary Director. The Culinary Director stated she was working fulltime for both ALF and SNF. The Culinary Director further stated all food were prepared in the main kitchen and the Registered Dietitian was employed part-time. On 1/11/23 at 1450 hours, an interview was conducted with the Administrator. The Administrator stated the Culinary Director oversaw the whole building, both ALF and SNF. The Administrator further stated the Registered Dietitian visited once a week. On 1/12/23 at 1034 hours, a telephone interview was conducted with the Registered Dietitian. The Registered Dietitian stated she was a consultant for the facility. The Registered Dietician further stated the Culinary Director oversaw both ALF and SNF. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 14 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed and residents' nutritional needs were met when: * Puree recipes were not followed. * Correct portion size was not followed. * Resident 473 was not provided food as listed on his meal ticket. This failure had the potential to cause physical and psychosocial harm to Resident 473. These failures had the potential for the residents receiving food prepared in the kitchen to not meet their nutritional needs which may lead to nutritional related health complications. Findings: 1. Review of the facility's P&P tilted Standard Portions revised 9/1/18, showed to provide proper equipment for portioning out the correct quantity of food for the residents; the recipes and menus should have the appropriate portions noted; and the portion sizes must be accurate on each diet. On 1/11/23 at 1120 hours, an observation of the puree preparation for the lunch meal was conducted with [NAME] 1. [NAME] 1 stated he was pureeing food for two servings. [NAME] 1 was observed placing five pieces of cooked meat, unmeasured, added two four ounces of applesauce and two tablespoon of meat broth, then blended the mixture. The blended mixture of meat and applesauce was put in a steamtable pan, covered, and placed inside the hotbox (a storage and transport of cooked meals). The Culinary Director stated the residents only wanted the meat and veggies. Review of the facility's document titled Recipe undated, showed Applesauce Pork Chops, five servings of four ounces cooked meat portions. However, during the observation of puree preparation, [NAME] 1 was not observed measuring the pork chops. In addition, no measurement of applesauce was stated in the recipe used. On 1/12/23 at 0940 hours, an interview was conducted with the Culinary Director. The Culinary Director stated [NAME] 1 weighed the meat prior to puree preparation. In addition, the Culinary Director stated apple sauce was added to the meat instead of the liquid that was stated in the recipe. The Culinary Director acknowledged the findings and further stated the recipe should be followed. 2. Review of the facility's P&P tilted Standard Portions revised 9/1/18, showed to provide proper equipment for portioning out the correct quantity of food for the residents; the recipes and menus should have the appropriate portions noted; and the portion sizes must be accurate on each diet. Review of the facility's document titled Week at a Glance a weekly menu dated 1/8/23 to 2/11/23, showed for the lunch meal on 1/11/23, Pork Chop with Apples, Red Bliss Potatoes, Brussels Sprouts with cranberries, and Bread or Roll and Butter or Margarine were to be served. On 1/11/23 at 1114 hours, an observation of the lunch meal service was conducted with Dietary Aide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 15 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1. Dietary Aide 1 was observed serving the pureed meat with applesauce mixture using number 10 scoop (three ounces). Review of the facility's document titled Daily Spreadsheet (a document which referenced portion sizes and therapeutic diet extensions) dated 1/8/23 to 2/11/23, showed for puree diets on 1/11/23, # eight scoop (four ounces) of puree meat and #16 scoop (two ounces) of puree apples. On 1/12/23 at 0940 hours, an interview was conducted with the Culinary Director. When asked how to have the correct portions, the Culinary Director stated to round up the mixture and divided by two, which made two of the #12 scoop (2.6 ounces). The Culinary Director further stated [NAME] 1 should have told Dietary Aide 1 on what scoop number to use when serving the puree meat mixture, and Dietary Aide 1 should have followed the spreadsheet for nutritional value purposes. On 1/12/23 at 1034 hours, a telephone interview was conducted with the Registered Dietitian. The Registered Dietitian was informed of the findings and stated the spreadsheet should be followed. 3. Medical record review for Resident 473 was initiated on 01/10/23. Resident 473 was admitted to the facility on [DATE], with the diagnosis of iron deficiency anemia, vitamin B12 deficiency anemia, and severe protein calorie malnutrition. On 01/10/23 at 1220 hours, during concurrent meal observation and interview in the dining room, CNA 2 brought Resident 473 his meal tray. Resident 473's meal ticket had soft and bite sized vegetables marked off. However, upon observation of Resident 473's meal tray, no vegetables were served. When asked if Resident 473 had received all the food ordered, CNA 2 stated Resident 473 did not receive vegetables as marked on the meal ticket. On 01/13/23 at 1040 hours, an interview was conducted with the Culinary Director who oversaw the resident menu and meals. When asked to explain the purpose of meal tickets, the Culinary Director stated the meal tickets were based off the menu she created for the month. She stated the CNAs met with residents daily to obtain their meal preferences and check off the food items on the meal ticket for meals on the following day. The meal ticket was based on what the resident said they wanted for their meal. The Culinary Director further stated all the food or food substitutions listed on a resident's meal ticket should be served to ensure the resident received their necessary caloric intake. On 01/13/23 at 1500 hours, the DON and Administrator were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 16 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the dietary department as evidenced by the following: Residents Affected - Some * The facility failed to ensure the thawing of frozen food in the walk-in refrigerator of the main kitchen was labeled and dated. * The facility failed to ensure the plumbing for the ice machine in the main kitchen had an air gap. * The facility failed to ensure the opened food item in the walk-in refrigerator of the main kitchen was dated. * The facility failed to ensure the proper sanitary condition of kitchen equipment. * The facility failed to ensure the kitchen equipment in the main kitchen was in sanitary condition and with a cleanable surface. * The failed to ensure the safe storage of food items in the reach-in the refrigerator of the SNF satellite kitchen . * The facility failed to ensure the kitchen staff personal belongings were stored away from the kitchen preparation area. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of residents completed by the Health Information Specialist dated 1/10/23, showed 16 of 18 residents residing in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Food Storage revised date 3/9/20, under the Frozen Meat/Poultry and Foods section - thawing, showed to date meat when taken out of the freezer. During the initial tour of the main kitchen with the Culinary Director on 1/10/23 at 0923 hours, an observation in the main kitchen walk-in refrigerator showed two bags of chicken unlabeled and undated on the bottom rack. The Culinary Director verified the findings and further stated it should have been labeled and dated when it was taken out of the box. On 1/12/23 at 1034 hours, a telephone interview was conducted with the Registered Dietitian. The Registered Dietitian stated it should be labeled and dated. 2. According to the USDA Food Code 2017 under section 5-202.13 titled Backflow Prevention, Air Gap, showed an air gap between the water supply inlet (pipe inlet) and the flood level rim of the plumbing fixture or equipment shall be at least twice the diameter of the water supply inlet and may not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 17 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some be less than one inch. The food code showed if a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the whole system. During the initial tour of the main kitchen with the Culinary Director on 1/10/23 at 0923 hours, two pipes draining water from the ice machine were observed below the flood level of the floor drain. On 1/11/23 at 1039 hours, a concurrent observation and interview was conducted with the Maintenance Assistant. The Maintenance Assistant acknowledged the above findings and further stated he would raise up the drain pipes. 3. Review of the facility's P&P titled Refrigerated Storage Chart revised date 12/28/20, under the dairy products section showed the whipping cream when opened can be stored for one week. During the initial tour of the main kitchen walk-in refrigerator with the Culinary Director on 1/10/23 at 0923 hours, one Richs on Top whipped topping, was observed opened and undated. The Culinary Director verified findings and further stated it should be dated when opened. The Culinary Director was observed discarding the whipped cream in the trash can. On 1/12/23 at 1034 hours, a telephone interview was conducted with the Registered Dietitian. The Registered Dietitian stated it should be labeled and dated. 4. According to the FDA Food Code 2017, Section 4-601.11 Equipment, Food-Contact Surfaces, Non-Food Contact Surfaces, and Utensils. (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch. (B) the Food-Contact Surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulation. (C) Nonfood Contact Surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. a. During the initial tour of the main kitchen with the Culinary Director on 1/10/23 at 0923 hours, a food slicer was observed to have black and brown unknown dry debris on the back of the blade and other components. The Culinary Director verified and acknowledged findings. The Culinary Director further stated all parts of the food slicer should be cleaned after each use and should be covered. On 1/12/23 at 1034 hours, a telephone interview was conducted with the Registered Dietitian. The Registered Dietitian stated it should be clean. b. During the initial tour of the main kitchen with the Culinary Director on 1/10/23 at 0923 hours, two large frying pans with black discoloration and scratches inside of the pan, one small frying pan with black discoloration inside of the pan, and one small nonstick frying pan with scratches inside of the pan were observed. The Culinary Director verified the findings and further stated the two large and one small frying pans were stainless steel pans. The Culinary Director was observed discarding all four frying pans in the trash can. c. During the initial tour of the satellite kitchen in the SNF with the Culinary Director on 1/10/23 at 0923 hours, a food blender machine was observed on top of the shelf with wet yellow debris on the cap. The Culinary Director verified findings and further stated it could cause cross contamination. 5. During the initial tour of the satellite kitchen in the SNF with the Culinary Director on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 18 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm 1/10/23 at 0923 hours, one red spatula was observed with melted edges. The Culinary Director verified the findings and further stated it could cause a contamination to the food. 6. Review of the facility's P&P titled Refrigerated Storage Chart revised 12/28/20, under the dairy products section showed shakes or supplements should be stored per manufacturers guidelines. Residents Affected - Some On 1/11/23 at 0908 hours, a concurrent observation and interview was conducted with Dietary Aide 1. Multiple boxes of health shakes in the reach-in refrigerator of the satellite kitchen were observed undated. Dietary Aide 1 stated the health shakes was taken out of the freezer on 1/9/23. On 1/11/23 at 0919 hours, a concurrent observation and interview was conducted with the Culinary Director. When asked about how long the health shakes in the reach-in refrigerator should be stored, the Culinary Director stated it should be by the expiration date. Then the Culinary Director proceeded to read the label on the health shake box. The Culinary Director showed the health shakes box was labeled use thawed product within 14 days. The Culinary Director acknowledged the findings and further stated it should have a used by date sticker. 7. According to the USDA Food Code 2017, 6-501.110, personal belongings can contaminate, food, food equipment and food contact surfaces. Review of the facility's P&P titled Personal Hygiene - Safety - Food Handling revised dated 11/30/22, under Designated Area for Employee Personal Belongings section showed personal belongings, beverages, and/or food may be stored in the designated area. On 1/10/23 at 1015 hours, an observation of the food preparation area was conducted during the initial tour of the main kitchen with the Culinary Director. The rolled plaid clothing and white-water bottle were observed on the top shelf of the food preparation area in the three-compartment sink. The Culinary Director and Dishwasher 1 verified the findings. The Culinary Director further stated the personal belongings should be in the locker room. On 1/12/23 at 1034 hours, a telephone interview was conducted with the Registered Dietitian. The Registered Dietitian stated it should be not in the kitchen area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 19 of 20 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555768 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility P&P review, the facility failed to ensure proper infection control practices during the medication administration observation. LVN 2 missed multiple opportunities for hand hygiene when preparing and administering Resident 426's medications. This failure put the residents at risk for infection. Residents Affected - Few Findings: Review of the facility's P&P titled Handwashing/Hand Hygiene revised date 8/19 showed the facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively soap and water for the following situations: - before and after direct contact with residents - before preparing or handling medications - after removing gloves On 1/11/23 at 0839 hours, a medication administration observation and concurrent interview was conducted with LVN 2. LVN 2 prepared the medications to administer to Resident 426. LVN 2 put each medication into a medicine cup. LVN 2 then donned gloves without performing hand hygiene and administered the medications to Resident 426. LVN 2 then prepared medications to administer to Resident 472, including a patch and breathing treatment. LVN 2 put the medications into a medicine cup, and then donned gloves without performing hand hygiene. LVN 2 then administered the medications to Resident 472. First, LVN 2 assisted Resident 472 with the oral (by mouth) medications, then administered the breathing treatment. After administering the breathing treatment, LVN 2 removed her gloves and donned a new pair gloves without performing hand hygiene. LVN 2 then assisted Resident 472 by picking up a used tissue from the floor and placing it in the trash receptacle. LVN 2 then removed her gloves and donned a new pair without performing hand hygiene. LVN 2 was asked when hand hygiene should be performed. LVN 2 stated hand hygiene should be performed between glove changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 20 of 20