Inspection visit

Health inspectionJanuary 26, 2024

BAYSHIRE YORBA LINDA POST-ACUTECMS #55576830 citations on this visit

30 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 30 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of 13 final sampled residents (Resident 330) was informed in advance of the proposed treatment regarding the use of psychotropic medications (medications affecting brain activity). Residents Affected - Few * The facility failed to ensure the informed consent was obtained from Resident 330's responsible party before administering sertraline (antidepressant medication) to Resident 330. This failure had the potential to compromise the right of the resident or her responsible party (person designated to make decisions on behalf of the resident) to be fully informed regarding the medication and its potential side effects. Findings: Medical record review for Resident 330 was initiated on 1/23/24. Resident 330 was readmitted to the facility on [DATE]. Review of Resident 330's History and Physical examination dated 1/15/24, showed Resident 330 had no capacity to understand and make decisions. Review of the Order Summary Report showed a physician's order dated 1/16/24, to administer sertraline 50 mg one tablet a day for depression manifested by verbalization of sadness. Review of the Consent Form for Psychoactive Med Therapy dated 1/12/24, did not show the sertraline medication ordered. Review of the Informed Consent Form - Skilled Nursing (CA Only) dated 1/16/24, did not show the sertraline medication ordered. Further review of Resident 330's medical record did not show documented evidence of informed consent for the sertraline medication was obtained from Resident 330's responsible party. On 1/26/24 at 1008 hours, an interview and concurrent medical record review for Resident 330 was conducted with the DON. The DON verified the above findings. The DON verified the informed consent forms did not show the sertraline medication ordered for Resident 330. The DON acknowledged the informed consent forms were incomplete. 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 74 Event ID: 555768 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 01/26/2024 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 reasonable accommodation to meet the needs of one of 13 final sampled residents (Resident 8). Residents Affected - Few * The facility failed to ensure the call light for Residents 8 was within the resident's reach. This had the potential for the resident to not be able to call for assisstance when needed. Finding: Review of the facility's P&P titled Answering Call Light revised September 2022 showed the facility should ensure the call light is accessible to the resident when in bed, from the toilet, from the shower, from the shower or bathing facility & from the floor. During the initial tour of the facility on 1/23/24 at 1047 hours, Resident 8 was observed lying in her bed, awake, with the call light hanging on a metal rod on the right side of the head of bed. Medical record review for Resident 8 was initiated on 1/23/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's History and Physical examination dated 10/13/23, showed Resident 8 had no capacity to understand and make her own decisions. On 1/23/24 at 1055 hours, an observation and concurrent interview was conducted with CNA 1. CNA 1 verified Resident 8's call light was not within reach. CNA 1 stated Resident 8's call light should have been within the resident's reach. CNA 1 also stated the call light should always be within the reach of all the residents while they were in bed whether they were alert and oriented or confused. On 1/25/24 at 0855 hours, an interview was conducted with the DON. The DON stated the expectation was for the call light to be placed within reach of the residents even if the residents were confused. The DON stated their call light system was very sensitive also for the movements. If the resident was restless, constantly moving or trying to get out of bed, the call light helped to alert the staff to check on the resident. The DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 2 of 74 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 01/26/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident 25 was initiated on 1/24/24. Resident 25 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 25's History and Physical examination dated 12/29/23, showed Resident 25 did not have the capacity to understand, and make decisions. Review of Resident 25's Generations Care Conference dated 12/28/23, showed Resident 25 was admitted to the facility with an advanced directives. Review of Resident 25's POLST dated 12/28/23, under Section D-Information and Signatures, showed Resident 25 did not have an advance directive. Review of Resident 25's medical record failed to show documented evidence a copy of Resident 25's advance directive was obtained or a follow-up was made to obtain a copy of Resident 25's advance directive as per the facility's P&P. On 1/24/24 at 1445 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified the medical record did not contain a copy of Resident 25's advance directive. On 1/24/24 at 1615 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and verified the above findings. Based on interview, medical record review, and facility P&P review, the facility failed to ensure the residents' advance directives were part of their medical records for three of 13 final sampled residents (Residents 19, 25, and 429). This failure had the potential for the residents' wishes for provisions of health care not being followed. Findings: Review of the facility's P&P titled ADM- Advanced Directives dated 9/1/22, showed upon admission, the facility will ask the resident or the resident's representative if they have an Advance Directive, and copies are obtained and maintained in the residents' medical record. 1. Medical record review for Resident 429 was initiated on 1/23/24. Resident 429 was admitted to the facility on [DATE]. Further review of Resident 429's medical record failed to show a POLST and if the resident had an advance directive. Review of Resident 429's Generations Care Conference -V3 dated 1/17/23, the section for advance directive was incomplete. On 1/24/24, at 1009 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 stated they were the admitting nurse for Resident 429, and the LVN filled out a POLST for the resident. LVN 4 stated Resident 429's family member provided him a copy of the resident's advance directive on admission and they should both (POLST and advance directive) be in the binder at the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 3 of 74 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 01/26/2024 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 0578 Level of Harm - Minimal harm or potential for actual harm station. Review of the binder labeled Facesheets, POLSTS, Inventory Records with LVN 4, LVN 4 verified Resident 429's POLST and advanced directive were not located in the binder. On 1/24/24, an interview was conducted with the SSD. The SSD stated Resident 429 informed her that he believed he had an advance directive and to ask Family Member 1. Residents Affected - Few On 1/24/24 at 1132 hours, an interview was conducted with Family Member 1. Family Member 1 stated they provided a copy of Resident 429's advance directive to the nurse on admission, and the facility should have a copy of it. 2. Medical record review for Resident 19 was initiated on 1/23/24. Resident 19 was initially admitted to the facility on [DATE]. Review of the Resident - POLST dated 12/11/23, showed the resident did not have an advance directive. Review of Resident 19's admission MDS dated [DATE], showed the resident was cognitively intact. On 1/23/24 at 1211 hours, an interview was conducted with Resident 19. Resident 19 stated they had an advance directive and stated the facility was provided a copy of it. Review of Resident 19's medical record failed to show a copy of Resident 19's advance directive. Review of Resident 19's Generations Care Conference -V3 dated 12/10/23, showed the resident did not have an advance directive. Review of Resident 19's Physician Orders for Life-sustaining Treatment (POLST) dated 12/11/23, showed the resident did not have an advance directive. On 1/24/24 at 1012 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 reviewed Resident 19's POLST and stated it showed the resident did not have an advance directive. LVN 4 reviewed Resident 19's medical record and verified there was no advance directive. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 4 of 74 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 01/26/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **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 the timely notification of changes for one of 13 final sampled residents (Resident 16). * The facility failed to notify the physician, RD, and resident responsible party for the resident's weight changes. This failure had the potential for a delay of the interventions to prevent further weight loss/gain. Findings: Review of the facility's P&P Weight Assessment and Intervention dated 12/1/22, showed the following: - A weight change of 5% or more since prior weight assessment will be rechecked the next day, and if verified, nursing will immediately notify the dietitian. - Unless notified of a significant weight change (5% weight loss in a one month period; greater than 5% is severe weight loss.) Review of the facility's P&P Change in a Resident's Condition or Status revised 2/2021 showed the facility promptly notifies the resident's physician and responsible party of changes in the resident's medical status, including for significant changes in the resident's physical condition. The nurse will record the notification in the resident's medical record. Medical record review for Resident 16 was initiated on 1/23/24. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's admission Record showed Resident 16's primary emergency contact was Family Member 2. Review of Resident 16's Weight and Vitals Summary in the resident's electronic medical record dated 1/24/24, showed the following weights: - 148.2 lbs, on 12/4/23, - 142.6 lbs, on 12/19/23, - 150 lbs, on 12/26/23 (5.2% and 7.4 lbs. increase from 12/19/24's weight), - 134.8 lbs, on 1/2/24 (10.1% and 15.2 lbs. decrease from 12/26/23's weight), and - 139.2 lbs, on 1/9/24. Review of Resident 16's Weight Record showed the following weights: -148.2 lbs, on 12/4/23, -142.6 lbs, on 12/19/23, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 5 of 74 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 01/26/2024 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 0580 -134.8 lbs, on 1/2/24, and Level of Harm - Minimal harm or potential for actual harm -139.2 lbs, on 1/9/24, with written notes of weight gain dated 1/10/24, and positive edema (swelling caused by too much fluid trapped in the body's tissues) Residents Affected - Few The weight record did not show the resident's weight obtained on 12/26/23. Review of Resident 16's Order Audit Report dated 1/26/24, showed on 1/4/24 at 2121 hours, a physician's order was obtained to refer to the RD for recent weight loss, 142.6 lbs on 12/19/23, and 134.8 on 1/2/24. The order was obtained two days after the most recent weight was obtained. On 1/25/24 at 1414 hours, an interview and concurrent record review were conducted with CNA 1. CNA 1 stated they weighted all the residents weekly and wrote it down on the Weekly Weights log, then recorded the weights in the resident's weight record and electronic medical record. CNA 1 stated they then gave the weight record to the resident's nurse if there were changes, so the nurse could do a change of condition. CNA 1 stated the nurse usually had their initials on the weight record to show they had reviewed it. When asked why Resident 16's weight on 12/26/23, was not recorded on their weekly weight record, CNA 1 stated they must have forgotten. Review of Resident 16's eINTERACT Change in Condition Evaluation - V 5.1 dated 1/3/24, showed an incomplete assessment for a weight loss. The sections for reviewing the findings with the physician showed the physician's recommendation and responsible party notification sections were blank. Review of Resident 16's progress notes failed to show the physician was notified of Resident 16's weight gain on 12/26/23, and was notified timely of Resident 16's weight loss on 1/2/24. The progress notes also failed to show the RD and Resident 16's responsible party were notified of the weight changes. On 1/25/24 at 1434 hours, an interview and concurrent medical record review were conducted with LVN 4. LVN 4 stated for the notification of changes, to notify the physician and the resident's responsible party immediately; and if needed, the physician would order an RD consult. LVN 4 reviewed Resident 16's Weight and Vitals Summary and verified Resident 16's weight gain on 12/26/23, and weight loss on 1/2/24. LVN 1 was unable to find documentation to show the physician, RD, and resident's representative were notified of the resident's weight gain. LVN 1 was unable to find documentation showing the 1/2/24 weight loss with timely notification to the physician and that the RD and resident's responsible party were notified. On 1/26/24 at 1112 hours, a telephone interview was conducted with Family Member 2. Family Member 2 stated they were Resident 16's primary emergency contact. Family Member 2 stated they were not notified by the facility of any weight gain or losses. On 1/26/24 at 1238 hours, a telephone interview was conducted with Resident 16's physician, Physician 1. Physician 1 stated he was notified of a weight gain and reviewed the resident's weight log. When asked if it was the weight on 1/9/24, with the note for positive edema, the physician stated yes, and that they wrote the note about edema. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 6 of 74 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 01/26/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **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 the baseline care plans related to the fall risk was developed for one of 13 final sampled residents (Resident 379). This failure had the potential for the resident to not receive the necessary care and services in accordance with their care needs. Findings: Review of the facility's P&P titled Baseline Care Plans for New Residents dated 6/22 showed the baseline care plans should be completed upon admission based on the resident's individual needs. Medical record review for Resident 379 was initiated on 1/24/24. Resident 379 was admitted to the facility on [DATE]. Review of Resident 379's Order Summary Report for January 2024 showed a physician's order dated 1/22/24, to place the bilateral floor mats to prevent and/or minimize further injury from fall, and another physician's order for Joerns deluxe assist handle (a assistive device attached to the resident's bedframe to assist with mobility) times two for better positioning and transfers. Review of the Generations Post-Acute admission Data Collection dated 1/22/24, under the section Interim Care Plan on Falls, showed no information if Resident 379 was at risk for falls. Review of the Morse Fall Risk assessment dated [DATE], showed Resident 379 was assessed as a low risk for falling. Review of the baseline plan of care formulated upon admission of Resident 379 showed the specific care plans addressing the basic care needs of the resident. However, further review of the plan of care showed no documented evidence a baseline care plan was developed to address the fall risk, use of side rails, and bilateral floor mats. On 1/24/24 at 1400 hours, an interview for Resident 379 was conducted with CNA 4. CNA 4 verified Resident 379 had side rails installed on their bed. CNA 4 stated Resident 379 was not able to use the side rails in bed. On 1/25/24 at 1012 hours, an interview and concurrent medical record review for Resident 379 was conducted with LVN 4. LVN 4 verified there was a physician's order for Resident 379's use of side rails in bed and the floor mat on both side of the bed. LVN 4 stated Resident 379 was not able to move in bed due to pain. LVN 4 verified Resident 379 was assessed for a low risk for fall and the least restrictive intervention included a floor mat. LVN 4 verified there was no baseline care plan addressing the risk for fall with the use of side rail and floor mats. On 1/25/24 at 1019 hours, an interview and concurrent medical record review for Resident 379 was conducted with RN 1. RN 1 verified there was a physician's order for the use of the side rail. RN 1 verified there was no baseline care plan for fall and the use of the side rails in bed. On 1/25/24 at 1606 hours, an interview for Resident 379 was conducted with the DON. The DON was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 7 of 74 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 01/26/2024 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 0655 informed and verified the above findings. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 8 of 74 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 01/26/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 330 was initiated on 1/23/24. Resident 330 was readmitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 1/16/24, to administer sertraline 50 mg one tablet a day for depression manifested by verbalization of sadness. Review of Resident 330's plan of care failed to show a care plan problem was developed to address Resident 330's use of the sertraline medication. On 2/11/22 at 0825 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 stated the residents' care plans were initiated on admission and revised when there were any changes to the resident's condition and treatment plan. LVN 4 reviewed Resident 330's care plan and verified the above findings. On 1/24/24 at 1542 hours, an interview and concurrent medical record review for Resident 330 was conducted with RN 1. RN 1 verified the above findings. RN 1 stated the nurse who placed the physician's order for the sertraline medication should have initiated the care plan for the medication. Based on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive care plans to reflect the individual care needs for three of 13 final sampled residents (Resident 25, 330, and 679) when: * The facility failed to develop a comprehensive care plan for Resident 25's use of Risperdal (a medication used to treat a number of mental health disorders including psychosis.) and sertraline hcl (a medication used to treat certain mood disorders such as depression.) * The facility failed to develop a care plan problem to address Resident 330's use of sertraline hcl. * The facility failed to develop a care plan problem to address the PVR monitoring for Resident 679. These failures posed the risk of not providing the appropriate, consistent, and individualized care to the residents. Findings: 1. Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised March 2022 showed the comprehensive, person-care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 9 of 74 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 01/26/2024 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 0656 b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; Level of Harm - Minimal harm or potential for actual harm c. includes the resident's stated goals upon admission and desired outcomes; Residents Affected - Few d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. Medical record review for Resident 25 was initiated on 1/24/24. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's Order Summary Report for December 2023 showed a physician's order dated 12/28/23, to administer Risperdal oral tablet 0.5 mg by mouth two times a day for paranoid delusions manifested by false accusation that someone taking her money and sertraline hcl oral tablet 25 mg by mouth one time a day for depression manifested by sadness. Review of the Order Summary Report for January 2024 showed the order for Risperdal 0.5 mg was changed on 1/4/24, to be administered one time a day for paranoid delusions manifested by false accusation that someone taking her money. Review of Resident 25's care plan dated 12/28/23, showed the resident used Risperdal medication. However, the care plan failed to show the interventions to monitor for the false accusation behavior and provide non-pharmacological interventions. In addition Resident 25's care plan failed to show the care plan problem to address the use of sertraline hcl medication for depression manifested by verbalization of crying, monitoring for its effect and any adverse drug reactions and non-pharmacological interventions. On 1/24/24 at 1515 hours, an interview and concurrent record review was conducted with LVN 5. LVN 5 verified the comprehensive care plan for Resident 25 did not include the monitoring of behavior manifestations related to Resident 25's use of Risperdal, and no care plan problem to address the resident's depression and use of sertraline hcl. On 1/24/24 at 1600 hours, an interview and concurrent record review was conducted with the MDS/RAI Coordinator. The MDS/RAI Coordinator verified Resident 25's comprehensive care plan failed to show the behavior manifestations related to Resident 25's use of Risperdal and a care plan problem to address for the resident's depression and use of sertraline hcl. On 1/25/24 at 1407 hours, an interview was conducted with the DON. The DON stated the comprehensive care plan should have been developed for Resident 25's use of Risperdal and sertraline hcl. The DON was informed and acknowledged the above findings. 3. Medical record review for Resident 679 was initiated on 1/23/24. Resident 679 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 679's Order Summary Report showed a physician's order dated 1/18/24, to check PVR Q six hours, perform IN and OUT catheterization (a method of emptying the bladder) Q six Hours PRN if PVR more than 125 ml or equal, insert Foley catheter on the 3rd check every six hours for bladder training outcome for two days and notify MD of Outcome. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 10 of 74 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 01/26/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of Resident 679's Plan of Care failed to show a care plan problem was developed to address the PVR monitoring as ordered by the physician. On 1/25/24 at 0755 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 acknowledged Resident 679's Plan of Care did not have a care plan problem to address the physician's order to check for PVR. Event ID: Facility ID: 555768 If continuation sheet Page 11 of 74 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 01/26/2024 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 0657 Level of Harm - Potential for minimal harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on interview and medical record review, the facility failed to ensure the comprehensive plans of care for one of 13 final sampled residents (Resident 25) were revised to reflect the residents' current care needs and interventions. * The facility failed to revise the comprehensive plan of care for Resident 25's diagnosis of dementia (a memory impairment and disruption of thought process that impacts a person's ability to perform daily activities). This posed the risk of not providing the resident with individualized and person-centered care. Findings: Medical record review for Resident 25 was initiated on 1/24/24. Resident 25 was admitted tot the facility on 12/28/23, with a diagnosis of dementia. Review of Resident 25's History and Physical examination dated 12/29/23, showed Resident 25 was admitted to the facility for dementia and had no capacity to understand and make decisions. Review of Resident 25's Order Summary Report dated 1/24/24, showed a physician's order dated 12/28/23, to administer donepezil Hcl (medication used to treat dementia) 5 mg one tablet by mouth at bedtime for dementia. Review of Resident 25's plan of care showed a care plan problem dated 12/28/23, to address Resident 25's cognitive function and thought process. However, the interventions did not show specific interventions including non-pharmacological approaches to support the resident and lessen their distress and the use of the medication for dementia. On 1/25/24 at 1036 hours, an interview and concurrent medical record review for Resident 25 was conducted with RN 1. RN 1 verified Resident 25 had a diagnosis of dementia and on the medication. RN 1 was asked about Resident 25's plan of care for the diagnosis of dementia, RN 1 verified there was a plan of care for dementia and the interventions did not include the non-pharmacological approaches to lessen the resident distress and pharmacological interventions used for dementia. On 1/25/24 at 1613 hours, an interview and concurrent medical record review for Resident 25 was conducted with the DON. The DON was informed and verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 12 of 74 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 01/26/2024 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 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 provide the services to attain or maintain the highest practicable well-being for three of 13 final sampled residents (Residents 8, 9, and 679). Residents Affected - Few * Resident 9 was administered olmesartan medoxomil (medication to treat high blood pressure) and metoprolol (medication to treat high blood pressure) when Resident 9's systolic blood pressure was below the parameter prescribed by the physician. * The facility failed to continue to monitor and document assessment every shift for 72 hours after the change in condition identified for Resident 8. * The facility failed to ensure the physician's orders were followed related to monitoring of Resident 679's urinary output and PVR. These failures had the potential to negartively affect the residents' health condition and well-being. Findings: 1. Medical record review for Resident 9 was initiated on 1/23/24. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's Order Summary Report showed the following physician's orders: - On 10/4/23, to administer metoprolol tartrate 25 mg one tablet by mouth two times a day for hypertension (high blood pressure. Hold medication if systolic blood pressure less than 130 mmHg, or heart rate less than 60 beats per minute; and - On 10/25/23, to administer olmesartan medoxomil 40 mg one tablet by mouth every 48 hours for hypertension. Hold if systolic blood pressure less than 130 mmHg, or heart rate less than 60 beats per minute a. Review of Resident 9's MAR for November 2023 showed Resident 9 was administered the metoprolol medication when the resident's systolic blood pressure was below 130 mmHg as follows: - On 11/3/23 at 1700 hours, a blood pressure of 115/54 mmHg; - On 11/4/23 at 0900 hours, a blood pressure of 119/87 mmHg; - On 11/6/23 at 1700 hours, a blood pressure of 128/87 mmHg; - On 11/15/23 at 1700 hours, a blood pressure of 117/67 mmHg; - On 11/18/23 at 1700 hours, a blood pressure of 128/88 mmHg; - On 11/19/23 at 0900 hours, a blood pressure of 121/66 mmHg; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 13 of 74 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 01/26/2024 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 0684 - On 11/25/23 at 1700 hours, a blood pressure of 118/66 mmHg; and Level of Harm - Minimal harm or potential for actual harm - On 11/26/23 at 0900 hours, a blood pressure of 122/66 mmHg. Residents Affected - Few Review of Resident 9's MAR for December 2023 showed Resident 9 was administered the metoprolol medication when the resident's systolic blood pressure was below 130 mmHg as follows: - On 12/15/23 at 1700 hours, a blood pressure of 126/69 mmHg; - On 12/18/23 at 1700 hours, a blood pressure of 126/66 mmHg; - On 12/19/23 at 1700 hours, a blood pressure of 114/68 mmHg; - On 12/27/23 at 1700 hours, a blood pressure of 128/75 mmHg; and - On 12/30/23 at 1700 hours, a blood pressure of 118/62 mmHg. b. Review of Resident 9's MAR for January 2024 showed Resident 9 was administered the olmesartan medoximil medication when the resident's systolic blood pressure was below 130 mmHg as follows: 121/66 mmHg on 1/4/24, and 102/69 mmHg on 1/13/24. On 1/26/24 at 1026 hours, an interview and concurrent medical record review for Resident 9 was conducted with the DON. The DON verified the metoprolol and olmesartan medoximil medications were administered to Resident 9 when the resident's systolic was below the parameter prescribed by the physician. The DON stated the nurses should have held the metoprolol and olmesartan medoximil medications when Resident 9's systolic blood pressure was below 130 mmHg. 2. Medical record review for Resident 8 was initiated on 1/24/23. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 10/13/23, showed Resident 8 did not have the capacity to understand and make her own decisions. a. Review of Resident 8's eInteract SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 12/28/23, showed upon body assessment, Resident 8 was noted to have yellow discharge from the G-tube site with no odor, afebrile, and non-tachycardic; and the dressing was changed. Review of Resident 8's Plan of Care dated 12/29/23, showed a care plan problem for infection of the G-tube site. The care plan interventions included to monitor/document/report to MD for changes in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness, agitation, and altered sleep. b. Review of Resident 8's eInteract SBAR Communication form dated 1/16/24, showed Resident 8 had a body temperature of 100 degrees Fahrenheit. Review of Resident 8's Plan of Care updated on 1/17/24, showed a care plan problem for UTI. The care plan interventions included to monitor/document/report to MD as needed for signs and symptoms of UTI: frequency, urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 14 of 74 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 01/26/2024 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 0684 behavioral changes. Level of Harm - Minimal harm or potential for actual harm However, review of Resident 8's Change in Condition notes showed documentation of assessment only for the following dates: Residents Affected - Few - 12/29/23, for 7-3 shift - 12/29/23, for 11-7 shift - 12/30/23, for 3-11 shift - 12/31/23, for 3-11 shift - 1/17/24, for 7-3 shift - 1/17/24, for 3-11 shift On 1/24/24 at 1029 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated the abnormal vital signs and drainage from the G-tube site were considered a change in a resident's condition or status. RN 1 stated for a change in condition, the licensed nurse had to initiate a change in condition note documenting the assessment monitoring every shift for 72 hours. RN 1 verified there was no documentation of change in condition assessment monitoring for 72 hours for Resident 8's two change of conditions identified on 12/28/23 and 1/16/24. On 1/25/24 at 0855 hours, an interview was conducted with the DON. The DON stated when the licensed nurse identified a change in condition for a resident, the Change in Condition assessment monitoring had to be initiated every shift for 72 hours. The DON was notified of the missing documentation for the Change in Condition assessment monitoring for Resident 8. The DON acknowledged the above findings. 3. Review of the facility's P&P titled Fluid Intake and Output Monitoring dated 1/2021 showed the facility shall record output for the residents with indwelling urinary catheter. Medical Record Review for Resident 679 was initiated on 1/23/24. Resident 679 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Resident's 679 Order Summary Report showed a physician's order dated 1/17/24, to monitor the resident's total urinary output in cc every shift. Review of Resident's 679's MAR for January 2024 showed the following recorded output: - On 1/20/24, for the day shift, 400 cc, - On 1/20/24, for the evening shift, 400 cc, - On 1/20/24, for the night shift, 680 cc, - On 1/21/24, for the day shift, none was recorded, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 15 of 74 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 01/26/2024 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 0684 - On 1/21/24, for the evening shift, 680 cc, Level of Harm - Minimal harm or potential for actual harm - On 1/21/24, for the night shift, none was recorded, - On 1/22/24, for the day shift, 600 cc, Residents Affected - Few - On 1/22/24, for the evening shift, 400 cc, and - On 1/22/24, for the night shift, 600 cc. On 1/25/24 at 0755 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 acknowledged there were missing output documented for the day and on evening shifts on 1/21/24. b. Review of the Order Summary Report showed a physician's order dated 1/18/24, with start date 1/24/24, and end date 1/26/24, to check PVR every six hours and perform IN and OUT catheterization every six hours PRN if PVR more than 125 ml or equal. However, further review of medical record showed no documented evidence the PVR was monitored as ordered. On 1/25/24 at 0755 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 acknowledged there was no record for PVR monitoring as ordered by physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 16 of 74 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 01/26/2024 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 0692 Provide enough food/fluids to maintain a resident's health. 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 follow the physician's order for the RD consult for one of 13 final sampled residents (Resident 16). Residents Affected - Few * The RD did not review the resident's enteral feeding formula for more concentrated formula as ordered by the physician on 12/25/23, and failed to conduct the RD consultation for weight loss timely as ordered on 1/4/24, for Resident 16. This failure had the potential for a delay or dietary interventions putting the resident at risk of further undesirable outcomes. Findings: Medical record review for Resident 16 was initiated on 1/23/24. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's History and Physical examination dated 12/4/23, showed the resident was unable to eat food by mouth and received nourishment through their G-tube. a. Review of Resident 16's MAR for December 2023 showed starting 12/7/23, Resident 16 received Glucerna 1.2 (an enteral feeding formula) via G-tube to run at 70 ml/hr for 20 hours. The record also showed to flush Resident 16's G-tube every six hours with 200 ml of water starting 12/6/23, and was discontinued on 12/25/23. Review of Resident 16's Physician's Progress Note dated 12/22/23, showed Resident 16 had hyponatremia (low sodium level in the blood) and the physician would monitor and consider a more dilute G-tube feedings and fluid restriction. a. Review of Resident 16's Order Summary Report showed a physician's order dated 12/25/23, for the RD to review if the resident's enteral formula could be changed to a more concentrated formula. A Physician's Order Note dated 12/25/23 at 1027 hours, showed RN 1 notified Physician 1 of Resident 16's laboratory results and received a physician's order to decrease the resident's water flushes and for the RD to see if Resident 16's enteral formula of Glucerna 1.2 could be changed to a more concentrated formula. A Physician's Order Note dated 12/25/23 at 1051 hours, showed RN 1 notified the RD of the new order for the RD to review Resident 16's enteral formula to see if it could be changed to a more concentrated formula, and of the order to decrease the resident's routine water flushes. * Further review of the medical record showed no documented evidence the RD had review the resident's formula for more concentrated formula as ordered by the physician. On 1/26/24 at 1014 hours, an interview and concurrent record review were conducted with RN 1. RN 1 reviewed Resident 16's medical record and was unable to find where the RD reviewed Resident 16's enteral formula to see if it could be changed to a more concentrated formula. On 1/26/24 at 1114 hours, a telephone interview was conducted with RD 2. RD 2 stated she was the owner of the facility's contracted dietetic consultant service. RD 2 stated when there was a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 17 of 74 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 01/26/2024 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 0692 physician's order for a RD consult, the standard of practice was to review the resident within 72 hours. Level of Harm - Minimal harm or potential for actual harm On 1/26/24 at 1238 hours, a telephone interview was conducted with Physician 1. Physician 1 stated on 12/25/23, due to Resident 16's hyponatremia and laboratory results, he ordered for the water flushes to be decreased and for the RD to review if the resident could be changed to a more concentrated enteral formula. Physician 1 stated the purpose was to decrease Resident 16's fluid intake without decreasing their calorie intake. Physician 1 stated he had not received an update on it the RD reviewed if a more concentrated formula could be use. Residents Affected - Few On 1/26/24 at 1335 hours, a telephone interview was conducted with RD 1. RD 1 stated Glucerna 1.5 was more concentrated than Glucerna 1.2. b. Review of Resident 16's Order Summary Report showed a physician's order dated 1/4/24, for RD consult for recent weight loss, for a weight of 142.6 lbs on 12/19/23, and 134.8 lbs on 1/2/24 (a 7.8 pounds weight loss in two weeks). Another physician's order dated 1/8/24, showed to refer to the RD to change enteral formula to bolus (to consolidate feedings and administer a larger quantity via a syringe or pump). Review of Resident 16's Nutrition Progress Note dated 1/10/24, showed the RD reviewed Resident 16's weight loss and recommended Glucerna 1.2, to give two cans (237 ml per can) bolus feeding TID (three times a day). The record failed to show the RD reviewed Resident 16's weight loss timely for the consult ordered on 1/4/24. On 1/26/24 at 1014 hours, an interview and concurrent record review were conducted with RN 1. RN 1 reviewed Resident 16's medical record and verified an order for a RD consult on 1/4/24. RN 1 stated the record showed the RD reviewed Resident 16 on 1/10/24, and changed the enteral feeding to bolus feedings. On 1/26/24 at 1114 hours, a telephone interview was conducted with RD 2. RD 2 stated when there was a physician's order for a RD consult, the standard of practice was to review the resident within 72 hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 18 of 74 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 01/26/2024 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 0693 Level of Harm - Minimal harm or potential for actual harm Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 16 was initiated on 1/23/24. Resident 16 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 16's MAR for January 2023, showed a physician's order effective 1/11/24, for an enteral feeding (formula administered directly to the stomach through a tube) of Glucerna 1.2, to give two cans TID (three times a day). On 1/23/24 at 0833 hours, Resident 16 was observed lying in bed. Resident 16's bedside table was observed to have an opened Glucerna 1.2 ready-to-hang bottle. The bottle was labeled 1500 ml and had markings on the side from 300 to 1500 ml, in 100 increments. The amount of the formula in the bottle was at the line marked 500 ml. Review of the manufacturer's guidance for Glucerna 1.2 showed the following: - for the 237 ml container, to refrigerate after opening. - for the ready-to-hang container, the instruction showed failure to follow the instructions for use, increase the potential for microbial contamination. Administer the formula with a feeding set and avoid touching any part of the container that comes into contact with the formula. On 1/23/24 at 1121 hours, an observation of Resident 16 was conducted. The opened Glucerna 1.2 enteral feeding ready-to-hang bottle was still on the resident's bedside table. On 1/23/24 at 1123 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 16 had a bolus enteral feeding. LVN 1 stated the facility did not currently have cans of the Glucerna 1.2 to administer to Resident 16, so the LVN was using the ready-to-hang bottle. The LVN stated they discarded the bottle daily. When asked if the bottle was safe at room temperature once opened and left at bedside, the LVN replied they believed it was because when they administered it with a feeding set, it was good for 24 hours. LVN 1 verified they were not using a closed feeding set to administer the formula, and punctured the bottle top where the feeding set would be inserted so they could pour it into a cup at each scheduled feeding. On 1/25/24 at 1125 hours, a telephone interview was conducted with the RD. The RD stated she was unable to find information to show Glucerna 1.2 in the ready-to-hang bottle was safe at room temperature when administered as a bolus, and not with a feeding set. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary enteral tube care and services for two of 13 final samples residents (Residents 16 and 629). * The facility failed to ensure Resident 629's J-tube placement was verified prior to the administration of medications. * Resident 16's enteral formula bottle was left at bedside after being opened. These failures posed the risk for developing complications related to enteral feeding. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 19 of 74 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 01/26/2024 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 0693 Findings: Level of Harm - Minimal harm or potential for actual harm Review of the facility's P&P titled Administering Medications through an Enteral Tube revised 11/2018 showed steps in the procedure to verify placement of feeding tube prior to the administration of medication through enteral tube. Residents Affected - Few On 1/23/24 at 1045 hours, an observation of medication administration was conducted with LVN 1. LVN 1 was observed to have instilled 15-20 cc of air through Resident 629's J-tube, without use a stethoscope . LVN 1 did not verify the placement of the J-tube prior to the administration of medication through the J-tube. Medical record review for Resident 629 was initiated on 1/23/24. Resident 629 was admitted to the facility on [DATE]. Review of Resident 629's Order Summary dated 1/24/24 showed a physician's order dated 1/13/24, to check placement of the J-tube before beginning a feeding and before administering medications. On 1/23/24 at 1456 hours, an interview was conducted with LVN 1. LVN 1 confirmed she failed to use a stethoscope to listen to verify J-tube placement. On 1/25/23 at 1520 hours, an interview was conducted with the DON. The DON stated the tube placement must be verified prior to the administration of medications. The DON was informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 20 of 74 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 01/26/2024 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 0694 Provide for the safe, appropriate administration of IV fluids 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 ensure one of 13 final sampled residents (Residents 429) received the appropriate care for peripheral intravenous catheter. Residents Affected - Few * The facility failed to ensure Residents 429's IV site was assessed and monitored as per the facility's P&P. This failure posed the risk for a delay in identify and provide necessary care if the resident developed complications such as catheter-related infections. Findings: Review of the facility's P&P titled Administering Medications by IV Push revised 3/2022 showed assessment, inspect intravenous catheter site and system for signs of complications. On 01/23/24 at 0833 hours, an IV medication administration observation with RN 1 was conducted. RN 1 was observed cleansing Resident 429's IV port with alcohol wipes then proceeded with administering ceftriaxone (an antibiotic) 1 gm via IV pump. Medical record review for Resident 429 was initiated on 1/23/24. Resident was admitted to the facility on [DATE]. Review of Resident 429's Order Summary dated 1/17-1/24/23, showed a physician's order dated 1/17/24, to administer ceftriaxone 1 gm intravenously every 24 hours until 1/24/24. However, further review of the medical record failed to show documented evidence the resident's IV site was assessed and monitored for signs of complication as per the facility's P&P. On 1/25/24 at 1503 hours, an interview was conducted with the DON. The DON acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 21 of 74 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 01/26/2024 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 ensure the respiratory services were provided as ordered for three of 13 final sampled residents (Residents 330, 429, and 629). Residents Affected - Few * The facility failed to ensure Resident 330 received continuous oxygen via nasal cannula as per the physician's order. * Resident 429's physician's order for oxygen failed to show if the order was continuous or PRN. * Resident 629's nasal cannula was found in the floor and physician's order for oxygen failed to show if the order was continuous or as needed. These failures had the potential for these residents to not receive appropriate respiratory care and increase risks of infection. Findings: Review of the facility's P&P titled Oxygen Administration revised dated 10/2010 showed to verify there is a physician's order for this procedure and review the physician's orders of facility protocol for oxygen administration. 1. On 1/24/24 at 1044 hours, 1/25/24 at 0945 hours, and 1/26/24 at 0935 hours, Resident 330 was observed sitting in the wheelchair in her room. There was no oxygen provided via nasal cannula to Resident 330. Medical record review for Resident 330 was initiated on 1/23/24. Resident 330 was readmitted to the facility on [DATE]. Review of Resident 330's Order Summary Report showed a physician's order dated 1/12/24, for continuous oxygen at one to two liters per nasal cannula, and may titrate to maintain oxygen saturation level above 90% every shift. On 1/26/24 at 0938 hours, an observation of Resident 330 and concurrent interview was conducted with CNA 4. Resident 330 was observed sitting in the wheelchair in her room. There was no oxygen provided via nasal cannula to Resident 330. CNA 4 verified Resident 330 did not have any oxygen provided via nasal cannula. On 1/26/24 at 0958 hours, an observation of Resident 330 and concurrent interview and medical record review for Resident 330 was conducted with LVN 6. LVN 6 verified Resident 300 had a physician's order for continuous oxygen at one to two liters per minute via nasal cannula. LVN 6 verified Resident 330 was not provided with oxygen via nasal cannula as ordered. On 1/26/24 at 1008 hours, an interview and concurrent medical record review for Resident 330 was conducted with the DON. The DON verified the above findings. 2. Review of the facility's P&P titled Oxygen Administration dated 1/1/21, showed to verify if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 22 of 74 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 01/26/2024 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 there is a physician's order for supplemental oxygen Level of Harm - Minimal harm or potential for actual harm Medical record review for Resident 429 was initiated on 1/23/24. Resident 429 was admitted to the facility on [DATE]. Residents Affected - Few Review of Resident 429's Order Audit Report dated 1/24/23, showed an order for oxygen at 2 lpm via nasal canula. The order failed to show if it was a continuous or PRN order. On 1/23/23 at 0831 hours, Resident 429 was observed lying in bed, on room air (without the use of supplemental oxygen). On 1/23/23 at 1223 hours, an interview was conducted with LVN 1 and Resident 429's bedside. LVN 1 verified the resident was on room air. LVN 1 was then pulled up Resident 429's physician's orders for oxygen and stated the order did not show if it was to be continuous or if it was PRN and the order needed to be clarified from the physician. 3. Review of the facility's P&P titled Oxygen Administration revised 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. During the initial tour on 1/23/24 at 0858 hours, Resident 629 was observed in bed, sleeping. Resident 629's family member was in the room. Resident 629 had an oxygen concentrator machine. Resident 629's nasal cannula was observed on the floor. Resident 629's family member stated Resident 629 was using the nasal cannula on and off. Medical record review for Resident 629 was initiated on 1/23/24. Resident 629 was admitted on [DATE], and readmitted on [DATE]. Review of Resident 629's Order Summary Report showed a physician's order dated 1/12/24, for administering oxygen at 2-4 liters per minute via nasal cannula to keep oxygen saturation level above 90%. However the physician's order did not show if the oxygen administration was ordered for continuous or as needed. On 1/23/24 at 0915 hours, an observation and concurrent interview and medical record review was conducted with RN 1 and LVN 1. RN 1 and LVN 1 verified Resident 629's nasal cannula was in the floor. RN 1 checked Resident 629's oxygen saturation level and noted at 91%. LVN 1 stated when she assessed Resident 629 at 0800 hours, the oxygen saturation level was 93% on room air. RN 1 checked the order for Resident 629's oxygen and verified the order did not show whether to give the oxygen continuous or as needed. RN 1 stated the nurses had to verify with the physician if the oxygen administration was continuous or as needed. On 1/24/24 at 1015 hours, an interview was conducted with the IP. The IP stated the nasal cannula had to be in a bag labeled with the resident's name and date when not in use. The IP stated if the nasal cannula was found on the floor, it had been contaminated and had the potential to cause infection when used by the resident. On 1/25/24 at 0855 hours, an interview was conducted with the DON. The DON stated the licensed nurses were expected to verify the order for oxygen administration with indication to administer continuously or as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 23 of 74 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 01/26/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/23/24 at 0924 hours, 1/24/24 at 1044 hours, and 1/25/24 at 0945 hours, bilateral assist rails were observed on Resident 330's bed. On 1/25/24 at 0932 hours, an interview for Resident 330 was conducted with CNA 5. When asked about Resident 330's use of the assist rails, CNA 5 stated Resident 330 used the assist rails during turning and repositioning. On 1/25/24 at 0945 hours, Resident 330 was observed sitting in the wheelchair in her room. Bilateral assist rails were observed elevated. When asked about the bilateral assist rails, Resident 330 stated she used the assist rails for turning and repositioning while in bed. Medical record review for Resident 330 was initiated on 1/23/24. Resident 330 was admitted to the facility on [DATE]. Review of Resident 330's History and Physical examination dated 1/15/24, showed Resident 330 did not have the capacity to understand and make decisions. Review of Resident 330's Generations Initial Assistive Device Data Collection dated 1/12/24, did not show any entrapment assessment was conducted related to the use of the assist rails. Further review of the medical record showed no documented evidence a physician's order was obtained and a care plan problem was initiated related to the use of side rails for Resident 330. On 1/25/24 at 0950 hours, an interview and concurrent medical record review for Resident 330 was conducted with RN 1. When asked about the assist rails, RN 1 verified there was no physician's order obtained, care plan was not initiated and no entrapment assessment conducted related to the use of assist rails for Resident 330. Cross-reference to F909, example #3. 4. On 1/23/24 at 0959 hours, 1/24/24 at 1338 hours, and 1/25/24 at 0905 hours, bilateral assist rails were observed on Resident 9's bed. On 1/24/24 at 1338 hours, Resident 9 was observed sitting in the wheelchair in her room. Bilateral assist rails were observed elevated. When asked about the bilateral assist rails, Resident 9 stated she used the assist rails when she gets out of bed. Medical record review for Resident 9 was initiated on 1/23/24. Resident 9 was readmitted to the facility on [DATE]. Review of Resident 9's MDS dated [DATE], showed Resident 9 had moderate cognitive impairment and required partial/moderate assistance for bed mobility. Review of Resident 9's Order Summary Report showed a physician's order dated 10/2/23, for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 24 of 74 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 01/26/2024 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 0700 Bilateral Joerns deluxe assist handle rails for better repositioning and transfer while in bed. Level of Harm - Minimal harm or potential for actual harm Review of Resident 9's Generations Initial Assistive Device Data Collection dated 9/27/23, did not show any entrapment assessment was conducted related to the use of the assist rails. Residents Affected - Few Review of Resident 9's plan of care showed a care plan problem dated 9/28/23, to address Resident 9's use of the assist rails bilaterally to aide with bed mobility. The interventions/tasks included to ensure a valid consent on chart prior to initiating the assist rails and evaluate the resident's ongoing appropriateness for use of the assist rails for bed mobility. Further review of the medical record showed no documented evidence an informed consent was obtained prior to initiating the use of side rails for Resident 9. On 1/25/24 at 0931 hours, an interview for Resident 9 was conducted with CNA 5. When asked about Resident 9's use of the assist rails, CNA 5 stated Resident 9 used the assist rails when getting up from bed and during turning and repositioning. On 1/25/24 at 0959 hours, an interview and concurrent medical record review for Resident 9 was conducted with RN 1. When asked about the consent for assist rails, RN 1 verified there were no consent obtained and entrapment assessment conducted prior to the use of the assist rails for Resident 9. Cross reference to F909, example #4. Based on observation, interview, medical record review, and facility P&P review, the facility failed to complete the entrapment assessments, obtain the physician's orders, and an informed consents prior to the use of side rails for five of 13 final sampled residents (Residents 9, 25, 330, 379, and 629). These failures had the potential to put the residents at risk for serious injuries. Findings: Review of the facility's P&P titled Bed Rails, Side Rails dated 4/12/21, showed the resident's assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. The resident assessment must also assess the resident's risk from using bed rails. The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself. Informed consent from the resident or resident representative must be obtained after appropriate alternative have been attempted prior to installation and use of bed rails. 1. On 1/23/24 at 0908 hours, and 1/24/24 at 0858 hours, Resident 25 was observed in bed with the left upper side rails elevated. Medical record review for Resident 25 was initiated on 1/24/24. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's History and Physical examination dated 12/29/23, showed Resident 25 had no capacity to understand and make decisions. Review of Resident 25's MDS dated [DATE], showed Resident 25 required substantial assistance of one staff for bed mobility and transfer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 25 of 74 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 01/26/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 25's Order Summary Report for January 2024, showed a physician's order dated 12/28/23, for Joerns deluxe (a assistive device attached to the resident's bedframe to assist with mobility) assist handle times two for better positioning and transfers. Review of Resident 25's Generations Initial Assistive Device Data Collection dated 12/28/23, showed the use of bilateral side rails for bed mobility and transfer purposes. Further medical record review for Resident 25 did not show documented evidence the informed consent for the use of the side rails were obtained, initiation of care plan for the use of side rails, and entrapment assessment prior to the installation of side rails. On 1/24/24 at 1337 hours, an observation and concurrent interview was conducted with CNA 3. CNA 3 verified Resident 25's bilateral side rails were elevated. CNA 3 stated Resident 25 used the side rails for pulling herself up in bed. On 1/25/24 at 1006 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 25 had a physician's order for the use of side rails. RN 1 verified there were no informed consent obtained, entrapment assessment, and care plan developed prior to installing the side rails. On 1/25/24 at 1609 hours, an interview for Resident 25 was conducted the DON. The DON was informed and verified the findings. Cross reference to F909, example #1. 2. On 1/24/24 at 0836 hours and 1/25/24 at 0846 hours, an observation and concurrent interview was conducted with Resident 379. Resident 379 was observed in bed with the upper side rails elevated. Resident 379 stated he was not able to use the side rails because he was in pain when he moved in bed. Medical record review for Resident 379 was initiated on 1/24/24. Resident 25 was admitted to the facility on [DATE]. Review of Resident 379's History and Physical examination dated 1/22/24, showed Resident 379 had the capacity to understand and make decisions. Review of Resident 379's Order Summary Report for January 2024 showed a physician's order dated 1/22/24, for Joerns deluxe (a assistive device attached to the resident's bedframe to assist with mobility) assist handle times two for better positioning and transfers every shift. Review of Resident 379's Generations Initial Assistive Device Data Collection dated 1/22/24, showed the use of bilateral side rail for bed mobility and transfers. Further medical record review for Resident 379 did not show documented evidence the informed consent for side rails were obtained, initiation of care plan for the use of side rails, and entrapment assessment prior to the installation of side rails. On 1/24/24 at 1400 hours, an interview for Resident 379 was conducted with CNA 4. CNA 4 verified Resident 379's use of the side rails. CNA 4 stated Resident 379 was not able to use the side rails in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 26 of 74 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 01/26/2024 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/25/24 at 1012 hours, an interview and concurrent medical record review for Resident 379 was conducted with LVN 4. LVN 4 verified there was a physician's order for Resident 379's use of side rails in bed. LVN 4 stated Resident 379 was not able to move in bed due to pain. On 1/25/24 at 1019 hours, an interview and concurrent medical record review for Resident 379 was conducted with RN 1. RN 1 verified there was a physician's order for the use of the side rails. RN 1 verified there were no informed consent, entrapment assessment, and care plan developed prior to installing the side rails. On 1/25/24 at 1606 hours, an interview for Resident 379 was conducted the DON. The DON was informed and verified the above findings. Cross reference to F909, example #2. 5. On 1/26/24 at 0954 hours, an observation was conducted with Resident 629. Resident 629 was in bed and asleep. Resident 629's bed was observed with bilateral upper side rails elevated. Medical record review for Resident 629 was initiated on 1/26/24. Resident 629 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 629's H&P examination dated 1/14/24, showed Resident 629 had the capacity to understand and make decisions. The examination also indicated Resident 629 had general weakness. Review of Resident 629's Generations Initial Assistive Device Data Collection dated 1/12/24, showed the use of bilateral side rails for bed mobility and transfer purposes. Further review of Resident 629's medical record failed to show the physician's order and informed consent were obtained for the use of bilateral side rails. On 1/26/24 at 1000 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified Resident 629's bilateral side rails were elevated. LVN 2 stated Resident 629 used the side rails for mobility and turning in bed. LVN 2 stated before the use of side rails, the physician's order and consent should have been obtained, and the side rail and entrapments assessment should be completed. On 1/26/24 at 1003 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated when Resident 629 was readmitted to the facility, the new physician's order and consent should have been obtained for the use of side rails. RN 1 verified Resident 629 did not have the physician's order and consent for the use of side rails. On 1/26/24 at 1310 hours, an interview and concurrent medical record reviewed was conducted with the DON. The DON verified Resident 629 did not have the physician's order and consent obtained for the use of bilateral side rails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 27 of 74 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 01/26/2024 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 provide the pharmaceutical services for one of 13 final sampled residents (Resident 629) and one nonsampled resident (Resident 23) to meet the needs of each resident as evidenced by: * The facility failed to ensure the medications were administered as ordered to Resident 629. * The facility failed to ensure the controlled drug, hydrocodone-acetaminophen 10 mg-325 mg tablet,signed out from the controlled drug record were documented as administered on the MAR for Resident 23 * The facility failed to ensure the disposed medications were destructed and mixed with undesirable substance or a medication destroyer chemical. These failures had the potential for poor health outcomes to the residents and controlled medications diversion. Findings: 1. On 1/23/24 at 0903 hours, medication administration observation was conducted with LVN 1. LVN 1 was observed administering one medication via J-Tube to Resident 629. Resident 629 was given 3 ml of oxycodone (a narcotic analgesic) 5 mg/5 ml. On 1/23/24 at 1045 hours, medication administration observation was conducted with LVN 1. LVN 1 was observed administering the following two medications via J-tube to Resident 629: - Gabapentin (works in the brain to prevent seizures and relieve pain for certain conditions in the nervous system) 600 mg one tablet. - iron (a mineral the body needs for growth and development) 65 mg one tablet. Medical record review for Resident 629 was initiated on 1/23/24. Resident 629 was admitted to the facility on [DATE]. Review of Resident 629's Order Summary dated for January 2024 showed the following physician's orders: - on 1/13/24, calcium carbonate antacid oral tablet chewable 500 mg one tablet via J-tube one time a day for supplement. - on 1/13/24, Coenzyme Q10-Vitamin E oral tablet chewable 100-300 mg- unit one tablet via J-tube one time a day for supplement - on 1/15/24, ferrous sulfate oral tablet 325 (65 mg) one tablet via J-tube one time a day for supplement (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 28 of 74 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 01/26/2024 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 - on 1/12/24, multivitamin with minerals oral liquid 5 ml via J-tube one time a day for supplement Level of Harm - Minimal harm or potential for actual harm - on 1/15/24, nebivolol hcl oral tablet 10 mg 0.5 tablet via J-tube one time a day for hypertension hold if systolic blood pressure less than 105 mmHg or heart rate less than 60 bpm Residents Affected - Few - on 1/15/24, potassium chloride oral solution 20 meq/15 ml (10%) 7.5 ml via J-tube one time a day for supplement with four to eight ounces of water to prevent gastric irritation - on 1/13/24, PreserVision Areds two capsules via J-tube for supplement - on 1/13/24, calcium-cholecalciferol oral tablet 500-5 mg-mcg one tablet via J-tube two times a day for supplement - on 1/15/24, docusate sodium oral tablet 100 mg one tablet via J-tube two times a day for bowel management - on 1/15/24, dorzolamide hcl ophthalmic solution 2% instill one drop in both eyes two times a day for eye maintenance wait five minutes between each drop to prevent wash out of previous eye drop - on 1/15/24, Timolol Maleate Ophthalmic Solution 0.5 % instill one drop in both eyes two times a day for eye maintenance wait for five minutes between each drop to prevent wash out of previous eye drop - not given - lunch time - on 1/13/24, gabapentin oral tablet 600 mg one tablet via J-tube three times a day for pain management - on 1/22/24, oxycodone hcl oral solution 5 mg/5 ml 3 ml via J-tube every four hours for pain moderate to severe pain. Give 3 ml via J- tube every four hours as needed for moderate to serve pain - on 1/15/24, benazepril hcl oral tablet 10 mg four tablets via J-tube one time a day for hypertension. Hold if systolic blood pressure less than 105 mmHg or heart rate less than 60 bpm On 1/23/24 at 1456 hours, an interview and concurrent record review was conducted with LVN 1. LVN 1 stated she had given some of Resident 629's medication at 0730 hours, prior to the observation of medication administration at 1045 hours, because the resident did not want to take all medications at the same time. LVN 1 was asked to show the medications given at 0730 hours. LVN 1 showed the medication supply and stated the medications given to Resident 629 were as follows: - calcium carbonate oral tablet gave ultra strength 1000 mg - Coenzyme Q10-Vitamin E 10 ml - multivitamin with mineral one tablet - PreserVision AREDS two chewable tablets - potassium chloride oral solution 20 meq/15 ml - calcium 600 mg tablet (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 29 of 74 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 01/26/2024 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 - vitamin D 25 mcg (1000 unit) one tablet Level of Harm - Minimal harm or potential for actual harm - docusate sodium oral 100 mg one tablet - dorzolamide hcl ophthalmic solution 2 % one drop in both eyes was given before lunch time Residents Affected - Few - timolol maleate ophthalmic solution 0.5 % instill one drop in both eyes given before lunch time - benazepril hcl oral tablet 10 mg four tablets (was not given due to blood pressure reading was 104/65 mmHg) - nebivolol hcl Oral Tablet 10 mg (Nebivolol HCl) 0.5 tablet (was not given due to blood pressure reading was 104/65 mmHg) LVN 1 verified Resident 629 were given the following medications via J-tube which were not according to the physician's orders: - calcium carbonate oral tablet gave ultra strength 1000 mg was given instead of 500 mg - multivitamin with minerals tablet was given instead of liquid form - calcium 600 mg was given instead of 500 mg - Coenzyme Q10-Vitamin E 10 ml liquid instead of oral chewable tablet form - PreserVision AREDS capsule was given instead of chewable tablets On 1/25/24 at 1503 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings. 2. On 1/24/24 at 1050 hours, review of Resident 23's hydrocodone-acetaminophen 10 mg-325 mg tablet Controlled or Antibiotic Drug Record showed one tablet was taken on the following dates and times: - 1/4/24 at 1430 hours; - 1/12/24 at 1800 hours; and - 1/21/24 at 1700 hours However, review of Resident 23's MAR for January 2023 showed the above hydrocodone-acetaminophen 10 mg-325 mg tablet removed from the controlled drug record were not documented as administered. On 1/24/24 at 1050 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified the above findings. On 1/25/24 at 1510 hours, an interview was conducted with the DON. The DON stated the licensed nurses were expected to sign out the narcotic medication and document the administration of the narcotic medication in the MAR after the medication was given to the resident. The DON was informed and acknowledged findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 30 of 74 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 01/26/2024 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 3. Review of facility's P&P titled Discarding and Destroying Medications revised November 2022 showed non controlled and schedule V (nonhazardous) controlled substances are disposed of in accordance with the state regulations and federal guidelines regarding disposition of non-hazardous medications. For unused non-hazardous controlled substances that are not disposed by an authorized collector, the Environmental Protection Agency (EPA) recommends destruction and disposal of the substance with other solid waste following the steps below: a. Take the medication out of the original containers. b. Mix medication, either liquid or solid, with an undesirable substance. Undesirable substances include sand, coffee grounds, kitty litter, or other absorbent materials. Place the mixture in the sealable bag, empty can, or other container to prevent leakage. On 1/24/24 at 0924 hours, a concurrent observation and interview was conducted with the DON. A white bin with about one-third full of medications was observed with whole tablets and capsules accessible inside the medication room. The DON stated these medications were disposed and should have the drug destroyer chemical poured into the bin. The DON poured three half gallon bottles of a drug destroyer chemical and poured some water right away. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 31 of 74 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 01/26/2024 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **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 one of 13 final sampled residents (Resident 25) was provided the management for the use of psychotropic medications (medications that affect the mind, emotions, and behavior). * The facility failed to ensure non-pharmacological approaches to care were provided for Resident 25 while receiving risperidone (Risperdal, a medicine that helps with symptoms of some mental health conditions where someone may see, hear, or feel things that are not there or believe things that are not true or you feel unusually suspicious) and sertraline (Zoloft, a medication used to treat depression). This failure had the potential to cause harm to Resident 25. Findings: Review of facility's P&P titled Use of Psychotropic Medication dated 5/23/23, showed the residents who use psychotropic drugs shall receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. Medical record review for Resident 25 was initiated on 1/24/24. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's Order Summary Report for December 2023 showed a physician's order dated 12/28/23, to administer Risperdal oral tablet 0.5 mg by mouth two times a day for paranoid delusions manifested by false accusation that someone taking her money and sertraline hcl oral tablet 25 mg by mouth one time a day for depression manifested by sadness. Review of the Order Summary Report for January 2024 showed the order for Risperdal was changed on 1/4/24, to Risperdal oral tablet 0.5 mg by mouth one time a day for paranoid delusions manifested by false accusation that someone taking her money. Review of Resident 25's MAR for December 2023 and January 2024 showed Resident 25 had received Risperdal and sertraline hcl daily since admission. There was no documented evidence of non-pharmacological interventions provided for the resident. Further review of Resident 25's care plan problem addressing the use of Risperdal and sertaline hcl medications failed to show documentation of interventions for non-pharmacological implementation for the use of the above medications. On 1/24/24 at 1458 hours, a concurrent observation and interview with Resident 25 was conducted. Resident 25 was lying in bed. Resident 25 denied sadness and stated she felt fearful at times. On 1/25/24 at 0922 hours, a concurrent interview and medical record review was conducted with the DON. The DON stated the residents on psychotropic medications should be provided with non-pharmacologic interventions and should be documented in the MAR. Further review of Resident 25's MAR failed to show non-pharmacologic interventions provided for the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 32 of 74 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 01/26/2024 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 0758 use of Risperdal and sertraline hcl. Level of Harm - Minimal harm or potential for actual harm On 1/25/24 at 1407 hours, an interview conducted with the DON. The DON was informed and acknowledged above findings. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 33 of 74 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 01/26/2024 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 0759 Ensure medication error rates are not 5 percent or greater. 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 document review, the facility failed to ensure the medication error rate was below 5%. The facility's medication rate was 18.52%. Two of two licensed nurses (LVNs 1 and 3) observed administering the medications was found to have errors while administering the medications to four nonsampled residents (Resident 14, 17, 23, and 630). Residents Affected - Few * The facility failed to ensure Resident 17 received the prescribed eye drops in accordance with the facility's P&P. * The facility failed to ensure Resident 14's inhalation medication was administered in accordance with the facility's P&P. *The facility failed to ensure Resident 25's hydroxychloroquine (a medication used to treat discoid lupus erythematosus (a chronic inflammatory condition of the skin) was given with food or meal. * The facility failed to ensure Resident 630's blood pressure was obtained just before giving the medications to control the blood pressure. * The facility failed to ensure Resident 630's Peridex (oral rinse for use between dental visits as part of a professional program for the treatment of gingivitis- inflammation of the gums) mouth or throat solution was given as prescribed by the physician. These failures had the potential for the residents developing complications and ineffective therapeutic effects of the medications. Findings: 1. Review of the facility's P&P titled Instillation of Eye Drops dated 1/2014 showed steps in the procedure to gently pull the lower eyelid down, instruct resident to look up. Drop the medication into the mid lower eyelid. (Note do not touch the eye or eyelid with the dropper). Recap the medication bottle. Instruct the resident to slowly close his/her eyelids to allow for even distribution of the drops. Medical record review for Resident 17 was initiated on 1/23/24. Resident 17 was admitted to the facility on [DATE]. On 01/23/24 at 0930 hours, a medication administration observation was conducted with LVN 3. LVN 3 administered one drop of dorzolamide hcl and timolol malate (eye drops used to treat increased pressure in the eye caused by glaucoma) ophthalmic solution directly on Resident 17's both eyes. LVN 3 did not pull down the resident's lower eyelid as per the facility's P&P. Review or Resident 17's Order Summary Report for 1/2024 showed a physician's order dated 12/28/23, for dorzolamide hcl and timolol malate ophthalmic solution 0.5%, instill 1 drop in both eyes two times a day for increased eye pressure. On 1/23/24 at 1513 hours, an interview was conducted with LVN 3. LVN 3 stated she instilled one drop of dorzolamide hcl and timolol malate ophthalmic solution 0.5% to Resident 17's both eyes; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 34 of 74 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 01/26/2024 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 0759 however, failed to pull down the lower eyelids. Level of Harm - Minimal harm or potential for actual harm On 01/25/23 at 1503 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Residents Affected - Few 2. Review of the facility's P&P titled Administering Medication through a Metered Dose Inhaler revised 10/2010, showed steps in the procedure ask the resident to inhale and exhale deeply for few breath cycles. On the last cycle, instruct the resident to exhale deeply then place the mouthpiece in the mouth and instruct the resident to close his or her lips to form a seal around the mouthpiece. Firmly depress the mouthpiece against the medication canister to administer medication. Instruct the resident to inhale deeply and hold for several seconds. Remove the mouthpiece from the mouth and instruct the resident to exhale slowly though pursed lips. Repeat the inhalation, if ordered. Allow at least one minute between inhalations of the same medications and at least two minutes between inhalations of different medications. Medical record review for Resident 14 was initiated on 1/23/24. Resident was admitted to the facility on [DATE]. Review or Resident 14's Order Summary Report for 1/2024 showed a physician's order dated12/28/23, for Breztri Aerosphere Inhalation Aerosol (a medication used long term to treat people with COPD. It improves symptoms of COPD for better breathing and to reduce the number of flare-ups) 160 mg - 9 mcg - 4.8 per inhalation, give 2 inhalations orally two times a day for COPD, and to rinse mouth with water after use. On 01/23/24 at 0933 hours, a medication observation was conducted with LVN 3. LVN 3 administered two inhalations of Breztri Aerosphere Inhalation Aerosol 160 mg - 9 mcg - 4.8 per inhalation to Resident 14. Upon administration of the Breztri Aerosphere Inhalation, LVN 3 placed the mouthpiece of the medication to Resident 14's mouth. LVN 3 counted one to three then administered the first inhalation to Resident 14. Resident 14 was not observed to take breaths and to inhale deeply upon administration of the medication. LVN 3 removed the Breztri Aerosphere Inhalation from Resident 14's mouth. LVN 3 then proceeded to place the Breztri Aerosphere Inhalation mouthpiece back to Resident 14's mouth again for the second inhalation. LVN 3 counted one to three. Resident 14 was not observed to take cycle of breaths and did not inhale deeply as medication was being administered. Right after the Breztri Aerosphere Inhalation mouthpiece was removed from the Resident 14's mouth, the resident started talking. LVN 3 failed to provide instructions to the resident to inhale and exhale deeply for few breath cycles prior to the administration of the medication. Resident 14 was not observed to hold breaths and exhale slowly with pursed lips after receiving the inhalation. Resident 14 talked right after the mouthpiece was removed from Resident 14's mouth. LVN 3 did not allow at least one minute in between inhalations of the medication. On 01/23/24 at 1513 hours, an interview was conducted with LVN 3. LVN 3 stated she was not able to give instructions to Resident 14 to take deep breaths. LVN 3 stated she usually gave time prior to the administration of the second inhalation. However, LVN 3 was not able to wait during the medication administration. LVN 3 verified Resident 14 talked right after the second inhalation was administered. On 01/25/23 at 1503, an interview with the DON was conducted. The DON was informed and acknowledged the above findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 35 of 74 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 01/26/2024 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 0759 Level of Harm - Minimal harm or potential for actual harm 3. According to Lexicomp by Wolters and Kluwer, provides evidence-based drug information for clinicians and patients with complex conditions, hydroxychloroquine or systemic lupus erythematosus (an autoimmune disease in which the immune system attacks healthy parts of the body such as joints, skin, blood vessels, and organs) and rheumatoid arthritis.) must be administered with food or milk. Do not crush or divide film-coated tablets per the manufacturer. Residents Affected - Few Medical record review for Resident 23 was initiated on 1/23/24. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's Order Summary Report for 1/2024 showed a physician's order dated 1/22/24, to administer hydroxychloroquine 200 mg one tablet by mouth two times a day. On 1/23/24 at 0956 hours, a medication administration observation was conducted with LVN 3. LVN 3 was observed administering hydroxychloroquine 200 mg one tablet to Resident 23. Resident 23 did not have food or meal upon administration of the medication. On 1/23/24 at 1513 hours, an interview was conducted with LVN 3. LVN 3 stated Resident 23 had breakfast at 0800 hours. LVN 3 acknowledged the hydroxychloroquine 200 mg one tablet was not administered with food or meal in accordance to the medication label. On 01/25/23 at 1503 hours, an interview was conducted with the DON. The DON was informed and acknowledged above findings. 4. Medical record review for Resident 630 was initiated on 1/23/24. Resident was admitted to the facility on [DATE]. Review of Resident 630's Order Summary dated for 1/2024 showed the following physician's orders dated: - 1/20/24, for amlodipine besylate (a medication used for treatment of hypertension) oral tablet 10 mg, give one tablet by mouth one time a day. Hold for SBP less than 105 mmHg. -1/20/24, for hydralazine hcl (a medication used for treatment of hypertension.) oral tablet 25 mg, give one tablet by mouth three time a day. Hold for SBP less than 105 mmHg. On 1/23/24 at 1019 hours, a medication administration observation and concurrent interview was conducted with LVN 1. LVN 1 was observed administering amlodipine besylate 10 mg one tablet and hydralazine hcl oral tablet 25 mg to Resident 630. LVN 1 stated Resident 630's BP was 116/88 mmHg at 0730 hours. LVN 1 further stated she usually took the residents' vital signs in the morning before she started passing medications. Further review of Resident 630's MAR showed a blood pressure of 116/88 mmHg was documented on 1/23/24 at 0900. On 01/25/23 at 1503, an interview with the DON was conducted. The DON was asked regarding procedure of taking blood pressure for medications with the prescribed parameters for blood pressure. The DON stated the blood pressure and heart rate should be taken just before giving the prescribed medication. The DON was informed and acknowledged above findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 36 of 74 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 01/26/2024 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 5. Medical record review for Resident 630 was initiated on 1/23/24. Resident 630 was admitted to the facility on [DATE]. On 1/23/24 at 1019 hours, a medication administration observation was conducted with LVN 1. LVN 1 verified Resident 630 would be given 12 tablets/capsules of 10 different medications. LVN 1 was observed to have given the following medications: - Aspirin Enteric Coated 81 mg one tablet - Ubiquinol 100 mg one soft gel - docusate sodium 100 mg one soft gel - levetiracetam 500 mg two tablets - amlodipine besylate 10 mg one tablet - Vitamin D 25 mg (1000 IU) one tablet - allopurinol 100 mg one tablet - acetaminophen 325 mg two tablets - rosuvastatin calcium 20 mg one tablet - hydralazine hcl 25 mg one tablet A medication reconciliation review, post medication administration observation, was conducted for Resident 630. Resident 630 had a physician's order dated 1/20/24, for Peridex mouth/throat solution 0.12 % give 15 ml by mouth every 12 hours for oral care swish and spit out. The Peridex was not administered during the medication administration observation with LVN 1. On 1/23/24 at 1456 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified she did not administer the Peridex mouth or throat solution as ordered by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 37 of 74 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 01/26/2024 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 medications were properly stored and labeled. * The facility failed to ensure the discontinued medication was locked and not left unattended on top of the medication cart. * The facility failed to monitor the temperature of the resident's refrigerator in the medication room. * The facility failed to appropriately label multiple ointments with open date, dispose of the prescription ointments such as triamcinolone and mupirocin, dispose of the expired solutions, and maintain cleanliness of the treatment cart. * The facility failed to dispose opened sterile packages for IV therapy such as IV holder or lock and transparent dressing from the IV cart. * The facility failed to appropriately label the bottle of the iron tablets (supplement) and eye medication drops with open date. * The facility failed to dispose of the insulin pen beyond the used by date. * The facility failed to store the external and internal medications separately. These failures had the potential to negatively impact the residents' well-being. Findings: On 1/23/24 at 1044 hours, a concurrent medication administration observation and interview was conducted with LVN 1. LVN 1 was observed leaving Resident 29's Baclofen (a muscle relaxant) in a medication bubble pack card on top of the medication cart unattended and unsecured while passing medication to another resident. LVN 1 stated the medication was discontinued and was not supposed to be left on top of the medication cart. On 1/24/24 at 0808 hours, an inspection of the medication storage and labeling in the medication room and concurrent interview was conducted with the IP/DSD. The temperature for the freezer for the resident's food was not being monitored. The IP/DSD stated the freezer temperature should have been monitored. On 1/24/24 at 0829 hours, an inspection of the medication storage and labeling of the treatment cart was conducted with LVN 4 with the following findings verified with LVN 4: - one opened tube calmoseptine cream with no open date - two opened bottles of Nu gauze packing strip with open date - house supply - 15 days (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 38 of 74 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 01/26/2024 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 - one Dyna wound cleanser spray with no open date and resident name Level of Harm - Minimal harm or potential for actual harm - one opened tube Remedy clinical protect no open date and resident name - two opened tube Remedy clinical moisturizer with no open date Residents Affected - Few - one opened Triad hydophilic wound dressing with no open date and resident name - one opened tub Aquaphor Healing ointment no open date - one opened tube cream barrier no open date - one opened solosite wound gel - two opened tube antifungal greaseless cream - three opened tubes of triamcinolone acetate 0.1% with prescription label peeled off - one opened tube mupirocin 2% with no label - one opened tube hydrocortisone cream with no open date - Dakins solution 16 oz had expired on 6/23. - Hydrogen peroxide 16 oz 3% had expired on 6/23. - Aerosol foam sanitizer had expired on 10/22 - scattered powder in a bin in the 3rd drawer of the treatment cart On 1/24/24 at 0859 hours, an inspection of the medication storage and IV cart was conducted with RN 1 with the following findings verified with RN 1: - one IV holder/lock was opened. - one opened transparent dressing small in the 3rd IV drawer. - one opened transparent dressing medium in the 3rd IV drawer. - one pack of good wipes, 60 wipes, had expired on 4/2023. On 1/24/24 at 1050 hours, an inspection of the medication storage and Medication Cart 2 was conducted with LVN 3 with the following findings verified with LVN 3: - An opened bottle of iron 65 mg tablets (supplement) with no open date. - An open brimonidine tartrate eye drops (used to treat open-angle glaucoma or high fluid pressure in the eye) with no open date. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 39 of 74 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 01/26/2024 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 - An Insulin Lispro injection 100 units (used for diabetic) labeled with the open date of 12/22/23, past 28 days from the open date - Liothyroxone (used for hypothyroidism) and progesterone capsules (hormone supplement) were stored with topical estradiol (use to treat changes in and around the vagina caused by low estrogen levels or menopause) in a zip lock bag. On 1/25/23 at 1510 hours, an interview was conducted with the DON. The DON stated the medications such as ointments, creams, and tablets should have been labeled with an open date. The DON verified the opened sterile items must not be stored in the IV medication cart. The DON verified the insulin pen was good only for 28 days after the open date. The DON verified the external and internal medications should be stored in different areas. The DON was informed and acknowledge the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 40 of 74 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 01/26/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and the facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operation of the Food and Nutrition Services Department. * Dietary Aides 1 and 2 were unable to demonstrate the thermometer calibration procedure. * Dietary Aide 1 used the wrong strip to test the chemical concentration measured in parts per million of quaternary sanitizing solution used to sanitize food contact surfaces, and to test the chlorine concentration of the dish machine. * Dietary Aide 2 was unable to correctly describe how to manually wash dishes. These failures had the potential to lead to foodborne illnesses in a highly susceptible population of residents who received food prepared in the kitchen. Findings: Review of the facility's Diet Type Report dated 1/24/24, showed 30 of the 34 residents residing in the facility received foods prepared in the kitchen. Review of the facility's P&P titled Operation and Sanitation revised date 8/31/18, showed to document the training of al meployees in the use of kitchen equipment using the Competency Checklists (Forms 711-715 or other designated form) and Dietary Employee Orientation Guide (Form 717 or other designated form). 1. According to the USDA Food Code 2022, 4-502.11(B), Good Repair and Calibration, showed food temperature measuring devices shall be calibrated in accordance with the manufacturer's specifications as necessary to ensure their accuracy. Review of the facility's P&P titled How to Calibrate Thermometers: Bi-metallic Stem and Digital revised 12/12/19, showed the procedure on how to calibrate either a bi-metallic stem or a digital thermometer and to understand the importance of calibration because it resets the thermometer to read accurately. Review of the [NAME] Waterproof Digital Thermometer Instruction Manual (undated) showed the digital thermometers that have a bead type thermistor (a resistance thermometer, or a resistor whose resistance is dependent on temperature) sensor seldom require a calibration or testing. Nevertheless, it is desirable to calibrate to a specific temperature. On 1/24/24 at 1124 hours, during the trayline observation, the dietary staff were asked to perform a thermometer calibration with the CDM and the Culinary Director present. When asked to do a thermometer calibration, Dietary Aide 1 did not perform a thermometer calibration but checked the food temperature with a digital thermometer. Dietary Aide 2 was then asked to perform a thermometer calibration, Dietary Aide 2 answered yes but continued to check the food temperature with a digital thermometer. When asked about the thermometer calibration, the CDM stated they did not perform calibration of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 41 of 74 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 01/26/2024 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 0802 the digital thermometers. Level of Harm - Minimal harm or potential for actual harm 2. According to the USDA Food Code 2022, 4-501.116, Warewashing Equipment, Determining Chemical Sanitizer Concentration, showed the concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. Residents Affected - Few According to the USDA Food Code 2017, 4-301.12, Manual Ware washing, sink compartment requirements, alternative manual ware washing equipment must provide accomplishment of the application of cleaners and the removal of soil, removal of any abrasive and removal or dilution of cleaning chemicals and sanitation. On 1/24/24 at 1403 hours, an observation and interview were conducted with Dietary Aide 1 and the CDM. The following was observed: a. Dietary Aide 1 was asked to demonstrate how to check the sanitizing solution of the dishwasher. Dietary Aide 1 was observed using a pH strip and dipped the strip into the dish surface on the final rinse. b. Dietary Aide 1 was then asked to demonstrate how to check the sanitizing solution in the sanitation bucket. Dietary Aide 1 was observed using the chlorine test strips and dipped the strip into a red bucket filled with sanitizer. The testing strip color did not change. Dietary Aide 1 repeated the steps and the strip color still did not change. The CDM verified Dietary Aide 1 used the wrong test strips to check the sanitizing solution in the red bucket and dishwasher. The CDM stated the chlorine test strip should be used to check the sanitizing solution of the dishwasher, and the pH testing strip should be used to check the sanitizing solution in the red bucket. 3. According to the Food Code 2022, 4-301.12, Manual Warewashing, Sink Compartment Requirements, showed the three-compartment requirement allows for proper execution of the three-step manual warewashing procedure. If properly used, the three-compartments reduce the change of contaminating the sanitizing water and therefore diluting the strength and efficacy of the chemical sanitizer that may be used. Review of the facility's P&P titled How to Clean and Sanitize Pots, Pans, Utensils and Dishes revised 1/17/19, showed the following: - Fill appropriate temperature water to fill lines. Add appropriate amount of detergent and sanitizer. Test and record on Pot and Pan Litmus Test Log. Scrape and flush out food particles; - Wash with detergent (110-120 degrees F). Change water every 30 minutes; - Rinse (110-120 degrees F). Change water frequently; - Sanitize. Test with appropriate litmus test paper and leave in sanitizing solution for appropriate contact time; and - Air dry. Do not towel. Inspect and store dry. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 42 of 74 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 01/26/2024 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/24/24 at 1607 hours, an interview was conducted with Dietary Aide 2 and with the CDM present. Dietary Aide 2 was asked the procedure for manual handwashing in the three-compartment sink. Dietary Aide 2 stated they soaked the dishware with soap and water, sanitized by dunking it in for a little bit and then rinsed the dishware with water. When Dietary Aide 2 was asked if he had a training on manually washing the dishware using the three-compartment sink, Dietary Aide 2 answered he was not really trained, but it was based on experience. On 1/24/24 at 1610 hours, an interview was conducted with the CDM. When asked if any trainings were conducted on performing thermometer calibration, checking the sanitizing solution of the dish machine and sanitizing buckets, and performing manual dish washing using the three-compartment sink, the CDM stated these competency skills were part of the dietary staff orientation and competency training. However, the CDM was not able to show documentation of the orientation and competency trainings. On 1/25/24 at 1500 hours, an interview was conducted with the Culinary Director. When asked what trainings were provided to the staff, the Culinary Director stated she conducted the trainings last year in January, however, she had thrown away the training documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 43 of 74 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 01/26/2024 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** 3. On 1/23/24 at 1240 hours, a concurrent meal observation and interview was conducted with Resident 632 in his room. Resident 632 complained his meal tray was missing some of the food he ordered, and he received a food he did not order. Resident 632's meal ticket showed cob salad, cucumbers, fruit x3, and ice cream x3 marked off. Resident 632's meal tray was observed with missing cobb salad, cucumbers, fruit x3, and ice cream x3 and there was a light orange pureed food in a small bowl that was not listed in the meal ticket. The Culinary Director came to the room and verified there were missing food listed in the meal ticket and there was a pureed food which was a butterscotch pudding in the tray that was not listed. Medical record review for Resident 632 was initiated on 1/23/24. Resident 632 was admitted to the facility on [DATE]. Review of Resident 632's H&P examination dated 12/27/23, showed Resident 632 had the capacity to understand and make his own decisions. On 01/25/24 at 0930 hours, an interview was conducted with the Culinary Director who oversaw the resident menu and meals. The Culinary Director stated the meal tickets were based off the menu she created for the month. She stated the CNAs met with the residents daily to obtain their meal preferences and check off the food items on the meal ticket for meals on the following day. If the residents did not want the food items on the meal ticket, they would choose from the menu. The meal ticket was based on what the residents said they wanted for their meal. The Culinary Director 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. The Culinary Director further stated it was necessary to follow the resident's preferences. Based on observation, interview, and facility document review, the facility failed to ensure the menu and recipes were followed. * The recipe for the mixed green salad was not followed when cucumbers were not served with the mixed green salad. * The lunch meal ticket for Resident 30 was not followed when she was not served with apple juice. * Resident 632 was not provided with the food he ordered as listed on the meal ticket, and received a food he did not order. These failures had the potential for the residents not receiving adequate nutrition, and appropriate food texture based on their diet. Findings: 1. Review of the facility's Diet Type Report dated 1/24/24, showed 25 of the 34 residents residing in the facility received regular-textured food prepared in the kitchen. Review of the facility's document titled Daily Spreadsheet dated 1/23/24, showed regular/NAS (no added salt) diet, CCHO/ NAS (consistent carbohydrate) diet and liberal house renal diet included a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 44 of 74 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 01/26/2024 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 serving mixed green salad. Level of Harm - Minimal harm or potential for actual harm Review of the menu list dated 1/23/24, showed mixed green salad with dressing was a combination of fresh salad greens and sliced cucumbers served with dressing. Residents Affected - Few Review of the recipe of the mixed green salad showed cucumbers as one of the ingredients. On 1/23/24 at 1220 hours, during the dining observation, Resident 9 was observed in her room with her lunch tray in front of her. The lunch tray included a bowl of salad; however, there were no slices of cucumbers in the salad. When asked about her salad and if she liked it with cucumbers, Resident 9 asked why she did not get cucumbers in her salad. On 1/23/24 at 1226 hours, an inspection of the satellite kitchen was conducted with the Culinary Director. The Culinary Director verified there were no cucumber slices on the mixed green salad served to the residents. The Culinary Director stated the food served were from the main kitchen, and the kitchen staff might have forgotten to add the cucumber slices. 2. On 1/24/24 at 1124 hours, during the trayline observation, a random inspection was conducted on the lunch trays in the tray cart ready to be served to the residents. Review of the menu ticket for Resident 30 showed to serve apple juice. Inspection of the lunch tray for Resident 30 did not show an apple juice was included. Dietary 1 verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 45 of 74 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 01/26/2024 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the food preferences were honored for one of 13 final sampled residents (Resident 9). * Resident 329's tray card showed the resident preferred chef salad and cranberry juice. However, this was not served to the resident. This had the potential to negatively impact the resident's well-being. Findings: On 1/23/24 at 1230 hours, during the dining observation, Resident 329 was observed with a mixed green salad, ravioli with cream sauce, and steamed spinach on her tray. Resident 329 stated she preferred chef salad and a cranberry juice as per tray card. On 1/23/24 at 1235 hours, Dietary Aide 1 verified Resident 329 was not served chef salad and cranberry juice as per the resident's tray card. Medical record review for Resident 9 was initiated on 1/23/24. Resident 329 was admitted to the facility on [DATE]. Review of Resident 9's Selection Sheet dated 1/25/24, showed Resident 329's preferred cranberry juice and chef salad. Review of Resident 9's [NAME] 101: Dietary Interview Pre-Screen - V2 dated 1/22/24, showed Resident 329's beverage preferences included cranberry juice and meal preferences for lunch included chef salad. On 1/23/24 at 1236 hours, a concurrent interview and medical record review was conducted with the Culinary Director. The Culinary Director stated the dietary staff should have followed the resident's preferences as stated in the tray card. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 46 of 74 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 01/26/2024 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 sanitary requirements were met in the kitchen as evidenced by: Residents Affected - Some * The facility failed to ensure proper hand hygiene were practiced by the dietary staff in the satellite kitchen. * The facility failed to ensure hair and beard restraint were worn by a non-dietary personnel inside the main kitchen. * The facility failed to ensure the meat thawing in the refrigerator in the main kitchen was labeled with the use-by date, and the date when the meat was pulled from the freezer. * The facility failed to ensure the proper labeling and dating of the food items in the main kitchen and satellite kitchen. * The facility failed to ensure the proper labeling and dating of the foods in refrigerator was in placed for the residents' food brought in by visitors. In addition, the facility failed to ensure the food items were discarded after a resident has been discharged . * The facility failed to ensure the expired food items in the main kitchen were discarded. * The facility failed to ensure the plates, storage bins for bowls and plates, and heated plate dispenser were clean. * The facility failed to ensure the employee personal belongings were not stored in the main kitchen food preparation area. * The facility failed to air dry the plate bases before using in the trayline service. * The facility failed to ensure the quaternary sanitizing strips to check the sanitizing solution for the manual ware washing and sanitization buckets were not expired. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen. Findings: Review of the facility's Diet Type Report dated 1/24/24, showed 30 of the 34 residents residing in the facility received foods prepared in the kitchen. 1. According to the USDA Food Code 2022, 2-301, When to Wash, showed food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment, and utensils, and unwrapped single-service and single use articles; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 47 of 74 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 01/26/2024 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 activities that contaminate the hands. Level of Harm - Minimal harm or potential for actual harm Review of the facility's P&P titled Personal Hygiene/ Safety/ Food Handling/ Infection Control revised 5/18/23, under Clean Hand, Fingernails and Gloves section, showed hands must always be washed prior to beginning work. Residents Affected - Some On 1/23/24 at 0810 hours, during the initial inspection of the satellite kitchen, the kitchen sink was observed not working. A brown stain was observed from the controls to the basin of the kitchen sink. Two dietary staff in the satellite kitchen were observed wearing disposable food prep gloves and preparing breakfast trays. Dietary Aide 1 verified the kitchen sink in the satellite kitchen was not working. Dietary Aide 1 stated the kitchen sink was not working in the morning so they had to use a hand sanitizer and then wear the disposable food prep gloves. Cross reference to F908, example # 2. 2. According to the USDA Food Code 2022 Section 2-402.11 Hair Restraints, Effectiveness, showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens. Review of the facility's P&P titled Personal Hygiene/ Safety/Food Handling/ Infection Control revised 5/18/23, under Head Covering Worn section, showed the following: -Wear a clean hat or other hair restraint. Hair must be appropriately restrained or completely covered; -Head covering must be clean; -Beards, mustaches or any body hair that maybe exposed must be covered. On 1/24/24 at 1120 hours, a technician was observed in the main kitchen. The technician was not wearing a hair and beard restraints. The Culinary Director verified the findings. 3. According to Food Code 2022, 3-501.13, Thawing, showed freezing prevents microbial growth in foods, but usually does not destroy all microorganisms. Improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/ or produce toxins. Review of the facility's P&P titled Refrigerated Storage Chart, under the Meat, Fish, and Poultry - Fresh section revised 12/28/20, showed the recommended time was at 35 to 41 degrees F or less for beef, lamb, pork, and veal chops, steaks or roasts is two to four days, while ground meat or stew meat is one to two days. On 1/24/24 at 0832 hours, four packs of ground beef with a received date of 1/19/24, and four packs with a received date of 1/12/24, were observed in the walk-in refrigerator in the main kitchen. There was no date when the meats were pulled from the freezer. The Culinary Director verified the above findings. 4. Review of the facility's P&P titled Food Receiving and Storage dated 1/1/20, showed the foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 48 of 74 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 01/26/2024 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 a. On 1/23/24 at 0810 hours, an initial satellite kitchen tour and concurrent interview was conducted with Dietary Aide 1. * The following food items were observed in Refrigerator 1: - Seven clear bowls of cut-up watermelon, cantaloupe and melon, and two Styrofoam bowls of cut-up peaches were observed on a tray. The bowls of fruits and/or the tray were not labeled with the use-by dates; - Three cups of orange juice, seven cups of apple juice, and fruit cups were observed on a tray. The cups and/ or the tray were not labeled with the use-by dates; and - A container of cut-up peaches was not labeled with the use-by date. * The following food items were observed in Refrigerator 2: -One opened gallon milk was not labeled with the opened date and use-by date; -One opened container of butterscotch pudding was not labeled with the opened date and use-by date; -One pitcher of iced tea was not labeled with the opened date and use-by date; -One opened container of salsa was not labeled with the opened date and use-by date; and -One opened container of prune juice concentrate not labeled with the opened date and use-by date; Dietary Aide 1 verified the above findings. Dietary Aide 1 stated she forgot to label the food items with the opened date. b. On 1/24/24 at 0832 hours, an inspection of the main kitchen and concurrent interview was conducted with the Culinary Director. The following food items were observed in the dry storage area without the label of opened date and use-by-date: - An opened bag of polenta - An opened bag of egg noodles - Two opened bags of spaghetti - An opened bag of tricolor rotini - Two opened bags of macaroni pasta - An opened bag of penne rigate pasta - An opened box of lasagna pasta - An opened bag of marshmallow (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 49 of 74 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 01/26/2024 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 - An opened bag of powdered sugar Level of Harm - Minimal harm or potential for actual harm The Culinary Director verified the above findings. Residents Affected - Some 5. Review of the facility's P&P titled Food Brought in by Family dated 8/27/21, showed the food brought by the family/ visitors for individual residents may not be shared with or distributed to other residents. The food brought by the family/ visitors that left for the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. On 1/23/24 at 0834 hours, an inspection of the refrigerator used for residents' food brought in from visitors, and concurrent interview was conducted with the IP/DSD. The following food items were observed: - A fruit bowl was not labeled with resident name, room and date received. - An ice pop was labeled with resident name and room number. The IP/DSD stated the resident had already been discharged . - A can of green tea was not labeled with the resident name, room number, and date received. - A container of vanilla honey yogurt was not labeled with the resident name, room and date received. The IP/DSD verified the above findings. The IP/DSD stated the food items were supposed to be labeled with the resident name, room number and date when the food items were received. The IP/DSD stated if the food item was from the restaurant and/or from home, they were only supposed to keep the food for three days; but if the food items were store-bought, they could keep the food until consumed or expired, or give the food back or discard when the resident discharged . Cross reference to F813. 6. On 1/24/24 at 0832 hours, an inspection of the dry storage in the main kitchen, and concurrent interview was conducted with the Culinary Director. The following was observed: -A bag of chocolate chips was observed with a use-by date of 4/28/23; -A box of small white beans was observed with a use-by date of 11/15/23; and -A box of small white beans was observed with a use-by date of 4/10/22. The Culinary Director verified the above findings. 7. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2017, 4-602.13, Non-Contact Surfaces, nonfood-contact surfaces of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 50 of 74 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 01/26/2024 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 equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Level of Harm - Minimal harm or potential for actual harm On 1/23/24 at 0818 hours, during the initial tour of the satellite kitchen and concurrent interview was conducted with Dietary Aide 1. The following was observed: Residents Affected - Some -The heated plate dispenser was observed with plates inside. The heated plate dispenser was observed with a brownish stain on the inner panel; -Five plates on the heated plate dispenser were observed with food debris; -The storage bin for plates and bowls were observed with food debris; and -The lids of the storage bins for condiments, and cereals were dirty and dusty. Dietary Aide 1 verified the above findings. 8. Review of the facility's P&P titled Personal Hygiene/ Safety/ Food Handling/ Infection Control revised date 5/18/23, under the Designated Area for Employee Personal Belongings section showed the following: - An area in the Director of Food and Nutrition office or dry storage area may be designated as a separate employee personal belonging area with signage; and - Personal belongings, beverages and/ or food may be stored in the designated area. Review of facility's P&P titled Personal Cell Phones dated 9/2020 showed the employees may carry cell phones on their person while at work, unless explicitly mandated otherwise for any reason by their supervisor. Cell phone may be used by employees while on scheduled break areas only. a. On 1/24/24 at 0832 hours, an inspection of the main kitchen and concurrent interview was conducted with the Culinary Director. The following was observed: - A cellphone was observed on top of the sink inside the main kitchen; and - A pen was observed inside the storage bin for flour. The Culinary Director verified the above findings. b. On 1/24/24 at 1101 hours, during a follow-up inspection of the main kitchen, a cellphone and a phone charger were observed in the cereal food preparation area. Dietary Aide 3 verified the above findings. 9. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air- Drying Required, showed items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganism can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms. On 1/24/24 at 1120 hours, during the trayline observation, four insulated plate bases were observed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 51 of 74 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 01/26/2024 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 stacked togethe, and ready to be used during the trayline service. The Culinary and CDM verified the above findings. 10. According to the USDA Food Code 2022, 4-301.12, Manual Ware Washing, the three- compartment requirement allows for the proper execution of the three-step manual ware washing procedure. If properly used, the three compartments reduce the chances of contaminating the sanitizing water and therefore diluting the strength and efficacy of the chemical sanitizer that may be used. Alternative manual ware washing equipment, allowed under certain circumstances and conditions, must provide for accomplishment of the same three steps: application of cleaners and the removal of soil, removal of any abrasive and removal or dilution of cleaning chemicals, and sanitization. Review of the manufacturer's Safety Information on pH Test Papers (undated) showed the pH test papers are marked with an expiration date and will perform as designed until that date as long as stored in a dry area, protected from sunlight. On 1/24/24 at 1403 hours, an observation and concurrent interview was conducted with Dietary Aide 1. When asked to check the sanitizer solution of the quaternary sanitizer bucket (red sanitizing bucket), Dietary Aide 1 was observed checking the concentration of the sanitizer using a piece of quaternary sanitizer strip. The quaternary sanitizer strip container had an expiration date of 2/1/22. Dietary Aide 1 verified the quaternary sanitizer strip container had expired. Cross reference to F908, example #1. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 52 of 74 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 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility P&P review, the facility failed to follow their policy to ensure foods brought into the facility for residents by visitors were properly stored and safely consumed. Residents Affected - Few * The facility failed to ensure the nursing staff were trained on properly labeling the food items brought in by the visitors for the residents. This failure had the potential for unsafe food handling. Findings: Review of the facility's P&P titled Food Brought in by Family dated 8/27/21, showed the following: - Family members and visitors are requested to inform nursing staff of their desire to bring food into the facility; - Nursing staff will provide family/ visitors who wish to bring foods to the facility with a copy of this policy. Residents will also be provided a copy in a language and format they can understand; and - All personnel involved in preparing, handling, serving or assisting the resident with meals or snacks will be trained in safe food handling practices. On 1/23/24 at 0834 hours, an inspection of the refrigerator used for the residents' food brought in from the visitors, and concurrent interview was conducted with the IP/DSD. Several food items were observed not labeled with the resident's name, room and date received. The IP/DSD verified the findings. On 1/25/24 at 1415 hours, an interview was conducted with the IP/DSD. When asked if the nursing staff had been educated or trained on the safe storage and handling of resident foods brought in by the visitors, the IP/DSD stated she had not provided any staff training regarding safe storage and handling of the foods brought in for the residents by the visitors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 53 of 74 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 01/26/2024 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, interview, and facility P&P review, the facility failed to dispose and store trash in a sanitary manner. Residents Affected - Some * The facility's two of four trash dumpsters' lids were not fully closed. One dumpster lid was fully open and another dumpster was observed overflowing with garbage, which prevented the dumpster lid to be fully closed. This failure had the potential to harbor pests. Findings: According to the US Food Code 2022 5-501.113, Covering Receptacles, showed receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered with tight-fitting lids. Review of the facility's P&P titled Food-Related Garbage and Refuse Disposal revised 10/2017 showed the outside dumpsters provided by the garbage pickup services will be kept closed and free of surrounding litter. On 1/24/24 at 1348 hours, an observation of trash disposal and concurrent interview with the Plant Operations Director. The lids of the two of four dumpsters were observed opened. One dumpster lid was fully open and another dumpster was observed overflowing with garbage, which prevented the dumpster lid to be fully closed. The Plant Operations Director verified the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 54 of 74 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 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10. On 1/23/24 at 0924 hours, during the initial tour of the facility, an interview was conducted with Resident 330. Resident 330 stated she wanted to ask the social worker about her discharge planning. Medical record review for Resident 330 was initiated on 1/23/24. Resident 330 was readmitted to the facility on [DATE]. Review of Resident 330's History and Physical examination dated 1/15/24, showed Resident 330 did not have the capacity to understand and make decisions. Review of Resident 330's Generations Care Conference - V3 dated 1/13/24, showed the admission care conference was conducted on 1/16/24 at 1100 hours. Review of the care conference form showed the sections for medication/ assistive devices, nursing, and social services were blank. Further review of the care conference form showed only the dietary and vitality personnel were signed, and there were no signatures from the nursing, therapy, social services, resident, and her responsible party. On 1/24/24 at 0953 hours, an interview and concurrent medical record review for Resident 330 was conducted with the SSD. When asked about Resident 330's discharge planning, the SSD stated the discharge planning was discussed during the care conference conducted with the resident, her responsible party, and the department heads. The SSD stated the care conference was usually conducted within five days upon admission, unless the resident or responsible party asked to do it after that. The SSD verified the care conference form for Resident 330 was incomplete and should have been completed within that timeframe. Based on interview, record review and facility P&P, the facility failed to ensure the complete and accurate medical records for six of 13 final sampled residents (Residents 16, 19, 24, 25, 330, and 430) and one nonsampled resident (Resident 24). *Resident 24's insulin was documented incorrectly as being administered in their axilla for 13 instances. *Resident 16's insulin was documented incorrectly as being administered in their axilla for seven instances. In addition, Resident 16's Care Conference assessment was not completed timely. *Resident 25's insulin was documented incorrectly as being administered in their axilla for three instances. *Resident 19's insulin was documented incorrectly as being administered in their axilla for two instances. In addition, Resident 19's Care Conference assessment was not completed timely. *Resident 330's insulin was documented incorrectly as being administered in their axilla for one instance. *Resident 429's and 430's Care Conference assessments were incomplete. * Resident 330's Care Conference assessment was not completed timely. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 55 of 74 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 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 These failures had the potential for inaccurate and incomplete medical records. Level of Harm - Minimal harm or potential for actual harm Findings: Residents Affected - Few 1. Medical record review for Resident 24 was initiated on 1/25/24. Resident 24 was admitted to the facility on [DATE]. Review of Resident 24's MAR for January 2024 showed the following injections of Humalog KwikPen insulin were administered subcutaneously: -On 1/1/24 at 1630 hours, 10 units of insulin. -On 1/1/24 at 2100 hours, 10 units of insulin. -On 1/2/24 at 1630 hours, 10 units of insulin. -On 1/2/24 at 2100 hours, 10 units of insulin. -On 1/3/24 at 2100 hours, 6 units of insulin. -On 1/5/24 at 1130 hours, 10 units of insulin. -On 1/5/24 at 1630 hours, 8 units of insulin. -On 1/6/24 at 1630 hours, 15 units of insulin. -On 1/6/24 at 2100 hours, 6 units of insulin. -On 1/12/24 at 1630 hours, 8 units of insulin. -On 1/14/24 at 1630 hours, 10 units of insulin. -On 1/15/24 at 0630 hours, 6 units of insulin. -On 1/18/24 at 1630 hours, 6 units of insulin. Review of Resident 24's Location of Administration Report for January 2024 showed the above 13 doses were administered to the resident's axilla. On 1/25/24 at 1059 hours, an interview was conducted with Resident 24. Resident 24 stated they never received their insulin in their axilla. The resident stated the nursing staff always injected their insulin into the back of their upper arms or abdomen. On 1/25/24 at 1320 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated subcutaneous injections were to be administered into the fatty posterior of the arm, abdomen, or legs, and not the axilla. RN 1 reviewed Resident 24's Medication Administration Record and Location of Administration Report for January 2024 and verified the insulin was incorrectly documented as administered to the resident's axilla for 13 doses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 56 of 74 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 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 2. Medical record review for Resident 16 was initiated on 1/23/24. Resident 16 was admitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident 16's Medication Administration Record for January 2024, showed the following Residents Affected - Few injections of Humulin R insulin were administered subcutaneously: -On 1/1/24 at 2100 hours, 6 units of insulin. -On 1/3/24 at 2100 hours, 6 units of insulin. -On 1/14/24 at 0630 hours, 6 units of insulin. -On 1/14/24 at 1630 hours, 6 units of insulin. -On 1/14/24 at 2100 hours, 6 units of insulin. -On 1/15/24 at 0630 hours, 6 units of insulin. -On 1/18/24 at 1630 hours, 6 units of insulin. Review of Resident 16's Location of Administration Report for January 2024, showed the above seven doses were administered to the resident's axilla. On 1/25/24 at 1320 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated subcutaneous injections were to be administered into the fatty posterior of the arm, abdomen, or legs, and not the axilla. RN 1 reviewed Resident 16's Medication Administration Record and Location of Administration Report for January 2024, and verified the insulin was incorrectly documented as administered to the resident's axilla for seven doses. 3. Medical record review for Resident 25 was initiated on 1/25/24. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's Medication Administration Record for January 2024, showed on 1/12/24 at 2100 hours, Insulin Glargine 20 units subcutaneously was administered. Review of Resident 25's Medication Administration Record for January 2024, showed the following injections of Humulin R insulin were administered subcutaneously: -On 1/7/24 at 2100 hours, 6 units of insulin. -On 1/15/24 at 2100 hours, 6 units of insulin. Review of Resident 25's Location of Administration Report for January 2024, showed the above three insulin doses were administered to the resident's axilla. On 1/25/24 at 1320 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated subcutaneous injections were to be administered into the fatty posterior of the arm, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 57 of 74 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 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few abdomen, or legs, and not the axilla. RN 1 reviewed Resident 25's Medication Administration Record and Location of Administration Report for January 2024, and verified the insulin was incorrectly documented as administered to the resident's axilla for three instances. 4. Medical record review for Resident 19 was initiated on 1/23/24. Resident 19 was initially admitted to the facility on [DATE]. Review of Resident 19's Medication Administration Record for January 2024, showed the following injections of Insulin Regular Human were administered subcutaneously: -On 1/3/24 at 1630 hours, 8 units. -On 1/5 /24 at 1630 hours, 6 units. Review of Resident 19's Location of Administration Report for January 2024, showed the above two doses were administered to the resident's axilla. On 1/25/24 at 1320 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated subcutaneous injections were to be administered into the fatty posterior of the arm, abdomen, or legs, and not the axilla. RN 1 reviewed Resident 19's Medication Administration Record and Location of Administration Report for January 2024 and verified the insulin was incorrectly documented as administered to the resident's axilla for two doses. 5. Medical record review for Resident 330 was initiated on 1/25/24. Resident 330 was readmitted to the facility on [DATE]. Review of Resident 330's Medication Administration Record for January 2024, showed on 1/15/24 at 1630 hours, 6 units of Humalog KwikPen insulin were administered subcutaneously. Review of Resident 330's Location of Administration Report for January 2024, showed the above dose was administered to the resident's axilla. On 1/25/24 at 1320 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated subcutaneous injections were to be administered into the fatty posterior of the arm, abdomen, or legs, and not the axilla. RN 1 reviewed Resident 330's Medication Administration Record and Location of Administration Report for January 2024 and verified the insulin was incorrectly documented as administered to the resident's axilla for one dose. 6. Medical record review for Resident 19 was initiated on 1/23/24. Resident 19 was initially admitted to the facility on [DATE]. Review of Resident 19's Generations Care Conference - V 3 dated 12/10/23, showed Section A was completed on 1/18/24, and Sections B, C and D were incomplete. On 1/24/24 at 1015 hours, an interview and concurrent medical record review were conducted with the SSD. The SSD reviewed Resident 19's Generations Care Conference - V 3 dated 12/10/23, and verified it was incomplete. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 58 of 74 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 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/24/24 at 1420 hours, an interview and concurrent medical record review were conducted with the DON. The DON stated the Care Conference assessments were available for staff to document in once the assessment document was created, and the care conference was held within 72 hours after admission. Review of the assessment screen showed Sections B, C and D were completed on 1/24/24. The DON reviewed Resident 19's Generations Care Conference - V 3 dated 12/10/23, and verified she had just competed Sections B, C, and D that day, and they were not completed timely. 7. Medical record review for Resident 16 was initiated on 1/23/24. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's Generations Care Conference - V 3 dated 12/4/23, showed Sections A, B, C, and D were incomplete. On 1/24/24 at 1420 hours, an interview and concurrent medical record review were conducted with the DON. The DON stated the Care Conference assessments were available for staff to document in once the assessment document was created, and the care conference was held within 72 hours after admission. Review of the assessment screen showed Sections A, B, C and D were completed on 1/24/24. The DON reviewed Resident 16's Generations Care Conference - V 3 dated 12/4/23, and verified she had just competed the sections that day, and they were not completed timely. 8. Medical record review for Resident 429 was initiated on 1/23/24. Resident 429 was admitted to the facility on [DATE]. Review of Resident 429's Generations Care Conference - V 3 dated 1/17/24, showed Sections A, B, C and D were incomplete. On 1/24/24 at 1420 hours, an interview and concurrent medical record review were conducted with the DON. The DON stated the Care Conference assessments were available for staff to document in once the assessment document was created, and the care conference was held within 72 hours after admission. The DON reviewed Resident 429's Generations Care Conference - V 3 dated 1/17/24, and verified the documentation was not completed timely. 9. Medical record review for Resident 430 was initiated on 1/23/24. Resident 430 was admitted to the facility on [DATE]. Review of Resident 430's Generations Care Conference - V 3 dated 1/17/24, showed Sections A, B, C and D were incomplete. On 1/24/24 at 1420 hours, an interview and concurrent medical record review were conducted with the DON. The DON stated the Care Conference assessments were available for staff to document in once the assessment document was created, and the care conference was held within 72 hours after admission. The DON reviewed Resident 430's Generations Care Conference - V 3 dated 1/17/24, and verified the documentation was not completed timely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 59 of 74 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 01/26/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and facility document review, the facility failed to implement their POC dated 2/6/23. There was no documentation to show the facility was monitoring the results of audits to the QAPI committee meetings to identify if they had achieved compliance threshold of 100% for repeated deficient practice cited at F695 in accordance with their POC for recertification survey dated 2/6/23. This failure had the potential to affect the quality of care for all the residents in the facility. Findings: On 1/26/24 at 1304 hours, an interview and concurrent facility document review was conducted with the Administrator and DON. Review of the POC submitted by the facility to the CDPH, L&C Program for the recertification survey completed on 2/6/23, showed the deficient practice cited at F695 related to oxygen order not indicating whether the oxygen should be continuous or as needed. The POC included the following: * Medical Records, RN Supervisor, the DON and/or designee will monitor daily all oxygen administration orders. * Findings will be discussed and reviewed daily during stand-up meeting and at the facility's monthly QAPI meeting. * Compliance will be monitored and discussed during daily clinical meeting and at the QAPI meetings with an expected compliance threshold of 100%. The Administrator verified the above findings and stated every three months, the QAPI meetings were conducted to address the POC compliance. The Administrator could not provide documentation on how the missing reports on the audits for the deficient practice cited at F695 was addressed. The Administrator stated the facility was not in 100% compliance so they would still be addressing this issue in their quarterly QAPI meetings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 60 of 74 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 01/26/2024 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Review of facility's P&P titled Laundry Bedding dated 9/1/22, showed the clean linen is protected from dust/ soiling during transport and storage to ensure cleanliness. Residents Affected - Few Review of the facility's P&P titled Personal Cell Phones dated 9/2020 showed employees may carry cell phones on their person while at work, unless explicitly mandated otherwise for any reason by their supervisor. Cell phone may be used by employees while on a scheduled break areas only. On 1/26/24 at 0827 hours, an observation of the laundry area and concurrent interview was conducted with the Laundry Aide and Plant Operations Director. The following was observed: a. A cellphone, a container of petroleum jelly, a bag, a purple sweater, a face mask, a faceshield, and binders were observed on the folding table in the clean area. The binders were observed touching the resident towels. b. The laundry P&P were not posted or available in the laundry area. The Laundry Aide and the Plant Operations Director verified the findings. The Laundry Aide acknowledged she placed her personal items on the clean folding area. The Laundry Aide stated she was not informed she could not store her personal items on the clean folding area. When asked about the laundry P&P, the Laundry Aide and the Plant Ops Director could not locate the P&P, and the Plant Ops Director stated he would have to print it out. Based on interview, observation, facility document review, and facility P&P, the facility failed to ensure an appropriate infection control practices for one of 13 final sampled residents (Resident 429), two nonsampled residents (Residents 630 and 633) and in the facility laundry service area. * The facility failed to follow appropriate transmission-based precautions for Resident 429. * The facility failed to ensure the staff implemented handwashing with soap and water after caring for Resident 429 who was on contact isolation for C. Difficile to care for another resident. * The facility failed to ensure equipment used for Resident 429 who was infected with C. Difficle were appropriately disinfected. * The bedpans and basins for Residents 630 and 633 in a double bed room were not labelled. * The facility failed to ensure Resident 679's urinary drainage bag was kept off the floor. * The facility failed to ensure the employee's personal belongings were not in the clean linen folding area. These failures had the potential for spread of infections. Findings: 1. Review of the facility's P&P titled Management of C. Difficile Infections dated 6/25/23, showed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 61 of 74 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 01/26/2024 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 Level of Harm - Minimal harm or potential for actual harm Clostridioides difficile (C. diff) is a bacterium that causes diarrhea and colitis (inflammation of the colon). It is spread by direct contact with contaminated objects or the hands of persons who have touched a contaminated object. The P&P also showed contact precautions shall be implemented, in addition to the following: Residents Affected - Few -All staff are to wear gowns and gloves upon entry into the resident's room and while providing cares. -Hand hygiene shall be performed by handwashing with soap and water. -Thoroughly clean and disinfect reusable equipment with sporicidal disinfectant (agent that destroys bacterial and fungal spores). Review of the CDC's, Clean Hands Count for Healthcare Providers Factsheet undated, showed C. diff spores are not killed by alcohol-based hand sanitizer and to wash your hands with soap and water after removing gloves. Review of the CDC's, Prevent the Spread of C. diff, reviewed 7/20/21, showed C. diff spores have a protective coating allowing them to live for months or sometimes years on surfaces. Medical record review for resident 429 was initiated on 1/23/24. Resident 429 was admitted to the facility on [DATE]. Review of Resident 429's Order Summary Report dated 1/24/24, showed a physician's order dated 1/17/24, for contact isolation for C. diff. a. On 1/23/24 at 0831 hours, Resident 429 was observed in bed. Outside the resident's doorway, isolation signage was posted next to the door above the plastic drawers. On top of the cart, one container of alcohol based Super Sani-Cloth wipes, one container of Sani-Cloth Bleach wipes, and one pump bottle of alcohol-based hand sanitizer were observed. Isolation gowns were in the bottom drawer. On 1/23/24 at 0910 hours, the MDS/RAI Coordinator was observed in Resident 429's wearing a procedure mask and gloves. No isolation gown was observed in use. The MDS/RAI Coordinator was observed touching Resident 429's bed controls on the foot of their bed. The MDS/RAI Coordinator removed her gloves and used alcohol-based hand rub for hand hygiene. The MDS/RAI Coordinator proceeded to the nurses' station, picked up papers off the copy machine, and walked down another hallway to go speak to a nurse. On 1/23/24 at 0913 hours, an interview was conducted with the MDS/RAI Coordinator. The MDS/RAI Coordinator stated she was doing her routine daily rounds, and greeted Resident 429 and used the resident's bed controls to adjust their bed. The MDS/RAI Coordinator stated they saw the isolation signage at the resident's doorway, and that's why they were wearing a procedure mask and gloves. The MDS/RAI Coordinator verified they used alcohol-based hand rub (ABHR) for hand hygiene and was not wearing an isolation gown while in the resident's room. When asked what Resident 429 was in isolation for, the MDS/RAI Coordinator stated she would have to check. When asked what isolation precautions were needed for C. diff, the MDS/RAI Coordinator stated a gown was also required. When asked if she washed her hands when leaving the resident's room, the MDS/RAI Coordinator stated they did not have to because they used ABHR, and was not aware handwashing with soap and water were required for C. diff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 62 of 74 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 01/26/2024 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 isolation precautions. Level of Harm - Minimal harm or potential for actual harm On 1/23/24 at 0917 hours, an interview was conducted with the IP/DSD. The IP/DSD stated for C. diff, the staff must wear a gown and gloves while in the room. The IP/DSD was not aware the ABHR were not effective for use with C. diff. Residents Affected - Few On 1/23/24 at 0922 hours, and interview was conducted with the Administrator. The Administrator stated for C. diff, the staff must perform hand washing as ABHR was not effective against C. diff spores. b. On 1/23/24 at 1144 hours Resident 429's call light indicator was observed being on above the door. CNA 1 donned a gown, gloves, and procedure mask and entered Resident 429's room. The indicator light above the resident's doorway was turned off. CNA 1 was heard talking briefly to the resident and was observed removing the gown and gloves, used ABHR, and left the room. CNA 1 stated they knew they were supposed to wash their hands for C. diff, but they did not touch the resident and just turned off the call light. c. On 1/23/24 at 1216 hours, the Activity Director was observed in Resident 429's room wearing an isolation gown, gloves, and procedure mask while talking to the resident. The Activity Director removed the PPE, and used ABHR, and left the resident's room. The Activity Director verified they used ABHR and did not wash their hands when leaving the room. The Activity Director stated they brought the resident the Daily Chronicle (a single sheet paper printout) and turned on the resident's TV. The Activity Director stated they usually brought the resident crossword puzzles and magazine to read. Sometimes, they would discard the items when the resident was done with them, or she would wipe down the magazines with the alcohol-based wipes. d. On 1/24/24 at 1115 hours, Family Member 1 was observed in Resident 429's room. Family Member 1 was wearing a procedure mask, but was not wearing an isolation gown or gloves. Family Member 1 moved the resident's bedside tray table, removed a blanket from Resident 429's bed, and placed a blanket just brought in over the resident. On 1/24/24 at 1132 hours, LVN 1 was observed in Resident 429's doorway and asked Family Member 1 to please wear the gown and gloves and to wash their hands when they left. Family Member 1 went to the doorway and put on an isolation gown and gloves. On 1/24/24 at 1342 hours, an interview was conducted with Family Member 1. Family Member 1 stated they were aware Resident 429 was in isolation at the hospital, but today was the first time anyone at the facility asked them to wear a gown and gloves. Family Member 1 stated they visited Resident 429 daily since their admission. 5. Review of the facility's P&P titled Clostridium Difficile revised 10/2018 showed steps toward prevention and early intervention include frequent hand washing with soap and water by staff and residents. When caring for resident with Clostridioides Difficile Infection (CDI), staff is to maintain vigilant hand hygiene. Hand washing with soap and water is superior to alcohol based hand rub (ABHR) for mechanical removal of the clostridium difficile spores. On 1/23/24 at 0833 hours, an IV medication administration observation was conducted with RN 1. RN 1 used required PPE prior entering Resident 429's room who was on contact isolation. RN 1 programmed the IV pump in resident's room, cleansed Resident 429's access site, and administered the IV (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 63 of 74 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 01/26/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication. RN 1 removed PPE after administration of medication by the Resident 429's doorway and cleansed her hands with alcohol sanitizer. RN 1 then proceeded to prepare IV medication for another resident (Resident 630). On 1/23/24 at 1530 hours, an interview was conducted with RN 1. RN 1 stated she did not wash her hands with soap and water; however, used an alcohol-based sanitizer to clean her hands prior to the preparation of Resident 630's medications. On 1/25/24 at 1503 hours, an interview was conducted with the DON. The DON stated the staff were expected to wash hands with soap and water after caring for a resident who was infected with C. Difficile. 6. Review of the facility's P&P titled Clostridium Difficile revised 10/2018, showed environmental cleaning in the rooms of resident with Clostridioides Difficile Infection (CDI) is done with a disinfecting agent recommended for Clostridium Difficile (household bleach and water solution or an Environmental Protection Agency (EPA) registered germicidal agent effective against Clostridium Difficile spores. On 1/24/24 at 0859 hours, RN 1 was observed cleaning the IV pole with alcohol sani-wipes from Resident 429 who was on contact isolation for c. difficile because the IV medication was discontinued. RN 1 put plastic over the IV pole, then stated this was ready for the next resident to use. On 01/24/24 at 0903 hours, an interview was conducted with RN 1. RN 1 stated she was not aware the alcohol sani wipes was not sufficient to clean the euipment. On 1/25/23 at 1503 hours, an interview was conducted with the DON. The DON stated the staff were expected to know the equipment from a resident infected with CDI should be cleaned with bleach. The DON was made aware of the above findings and acknowledged the findings. 7. During initial tour of the facility on 1/23/24 at 1159 hours, an observation and concurrent interview was done with LVN 1 and CNA 2. The bedpans and basins used by Residents 630 and 633 were observed in the residents' bathroom without a label. LVN 1 and CNA 2 verified the bedpans and basins were not labeled for Residents 630 and 633. LVN 1 and CNA 2 stated for rooms with two residents, the bedpans and basins used by residents in the room should have been labeled with their names. When asked who was responsible to label the equipment, LVN 1 stated either the licensed nurse or the CNA was to label the equipment during admission. Medical record review for Resident 630 was initiated on 1/23/24. Resident 630 was admitted to the facility on [DATE]. Medical record review for Resident 633 was initiated on 1/23/24. Resident 633 was admitted to the facility on [DATE]. On 1/24/24 at 1015 hours, an interview was conducted with the IP. The IP stated for rooms with two residents, the bedpans and basins used by the residents should have been labeled with the residents' names to prevent cross-contamination between the residents. The IP stated the expectation was for either the licensed nurse or CNA to label the bedpans and basins during the residents' admissions. The IP was informed and acknowledged the above findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 64 of 74 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 01/26/2024 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 9. Review of the facility's P&P titled Catheter Care, Urinary revised 8/2022 showed the facility shall ensure prevention of urinary catheter associated complications, including urinary tract infections, provide resident's care plan to assess for any special needs of the resident, and ensure the drainage bag are kept off the floor. Medical record review for Resident 679 was initiated on 1/23/24. Resident 679 was admitted to the facility on [DATE], and readmitted on [DATE]. On 1/23/24 at 1238 hours, Resident 679 was observed sitting on his wheelchair, eating his lunch, with the TV on. Resident 679's indwelling urinary drainage bag was observed laying on the floor. On 1/23/24 at 1240 hours, an observation and concurrent interview was conducted with LVN 3. LVN 3 verified the indwelling urinary drainage bag was laying on the floor and should be kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 65 of 74 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 01/26/2024 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 0881 Implement a program that monitors antibiotic use. 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, facility document review, and facility P&P review, the facility failed to monitor and address the use of antibiotic to identify if the resident's condition did or did not meet the McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for four of 12 nonsampled residents (Residents 11, 13, 634, and 635). The facility failed to complete the criteria for indication of antibiotic use for Residents 11, 13, 634, and 635. In addtion, Resident 13's antibiotic order was not clarified with the physician regarding the stop date. These failures had the potential to negatively impact the residents' well-being. Residents Affected - Few Findings: Review of the facility's P&P titled Infection Control 10-Antibiotic Stewardship dated 7/28/23, showed Infection Preventionist to utilize expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotics starts, monitoring adherence to evidence-based published criteria during evaluation and management of treated infections, and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms. Facility uses CDC's NHSN Surveillance Definitions, updated McGreer criteria, or other surveillance tool to define infections. Loeb Minimum Criteria may be used to determine whether to treat infection with antibiotics. All prescriptions for antibiotics shall specify dose, duration, and indication for use. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. Antibiotic orders from consulting, specialty, or emergency providers should be reviewed for appropriateness. New or changed orders based on antibiotic timeout recommendations will be obtained from the practitioner. Review of the facility's P&P titled Infection Control 12-Antibiotic Stewardship Surveillance dated 11/15/22, showed identifying an Infection Preventionist who would review antibiotic utilization as part of the antibiotic stewardship program identifying specific situations not consistent with appropriate use of antibiotics. At review conclusion, provider will be notified of review findings as needed. Review of the facility document was initiated on 1/25/24. The Infection Control Binder containing Surveillance Data Collection-Infection Control (Urinary Tract Infections for Resident without Indwelling Catheter) failed to show the criteria to determine for true UTI was completed for Residents 11, 13, 634, and 635. Resident 13's antibiotic order did not show a stop date. 1. Medical record review for Resident 11 was initiated on 1/25/24. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's Order Summary Report showed a physician's order dated 12/19/23, for Zosyn Intravenous Solution 3.375 mg intravenously every eight hours for UTI until 12/25/23 at 2359 hours. Review of Resident's 11 Surveillance Data Collection-Infection Control (Urinary Tract Infections for Resident without Indwelling Catheter) dated 12/20/23, showed the criteria checklist to determine if the resident had a true UTI was not completed. 2. Medical record review for Resident 13 was initiated on 1/25/24. Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 66 of 74 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 01/26/2024 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 0881 Review of Resident 13's Order Summary Report showed the following: Level of Harm - Minimal harm or potential for actual harm a. A physician's order dated 12/18/23, for Cefpodoxime Proxetil oral tablet (antibiotic) give one tablet by mouth every 12 hours for UTI until 12/23/23 at 2359 hours. Residents Affected - Few b. A physician's order dated 12/18/23, for Methenamine Hippurate oral tablet (used to prevent or control returning urinary tract infections caused by certain bacteria) 1 gm one tablet by mouth one time a day for UTI prophylaxis. Review of Resident 13's Surveillance Data Collection-Infection Control (Urinary Tract Infections for Resident without Indwelling Catheter) dated 12/18/23, showed the criteria checklist to determine if the resident's infection was true infection or true UTI was not completed. 3. Medical record review for Resident 634 was initiated on 1/25/24. Resident 634 was admitted to the facility on [DATE]. Review of Resident 634's Order Summary Report showed a physician's order dated 12/13/23, for Bactrim DS oral tablet 800-160 mg one tablet by mouth one time a day for sepsis until 12/15/23 at 2359 hours. Review of Resident 634's Surveillance Data Collection-Infection Control (Urinary Tract Infections for Resident without Indwelling Catheter) dated 12/12/23, showed the criteria checlist to determine if the resident's infection was true infection or true UTI was not completed. 4. Medical record review for Resident 635 was initiated on 1/25/24. Resident 635 was admitted to the facility on [DATE]. Review of Resident 635's Order Summary Report showed a physician's order dated 12/1823, for macrobid Oral Capsule (antibiotic) 100 mg one capsule by mouth two times a day for UTI until 12/18/23 at 2359 hours, and was discontinued on 12/19/23. Review of Resident 634's Surveillance Data Collection-Infection Control (Urinary Tract Infections for Resident without Indwelling Catheter) dated 12/12/23, showed the criteria checklist to determine if the resident's infection was a true infection or true UTI was not completed. On 1/25/24 at 1321 hours, an interview and concurrent medical record review was conducted with the IP. The IP stated the criteria to determine for true UTI or true infection should have been completed for the indication of antibiotics use and the antibiotic order should have a stop date. The IP further stated the criteria findings should have been communicated with the physician, however, it was not completed. The IP verified the above findings. 2. Review of the facility's P&P titled Infection Control 12-Antibiotic Stewardship Surveillance dated 11/15/22 showed that all resident antibiotic regimens will be documented via the facility approved antibiotic surveillance tracking method. Information will include: a) resident name; b) unit number; c) date symptoms appeared; d) name of antibiotic e)start date of anitibiotic; f) pathogen identified g) site of infection h) date of culture i) stop date; j) total days of therapy; k) outcome; and l) adverse events. Medical record review for Resident 13 was initiated on 1/24/24 at 0834 hours. Resident 13 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 67 of 74 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 01/26/2024 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 0881 Level of Harm - Minimal harm or potential for actual harm admitted to the facility on [DATE], and readmitted on [DATE]. Resident 13 with diagnosis including UTI, not specified. Review of the Order Summary Report showed a physician's order dated 12/24/23, for Methenamine Hippurate oral tablet 1 gm one tablet by mouth one time a day for UTI prophylaxis. Residents Affected - Few On 01/24/24 at 1114 hours conducted interview and concurrent record review with RN 1. RN 1 verified there was no clarification made with the phycian by the licensed nurses regarding the stop date of the Methenamine Hippurate ordered on 12/24/23, for UTI prophylaxis for Resident 13. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 68 of 74 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 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility document review, the facility failed to maintain the essential kitchen equipment in safe operating condition. Residents Affected - Some * The facility failed to ensure the dish machine in the satellite kitchen was working. * The facility failed to ensure the sink in the main kitchen was not leaking. * The facility failed to ensure there was no ice buildup and brownish stain in the freezer of the refrigerator used to store residents' food brought in by the visitors. These failures had the potential for the equipment to not function in the way it was intended, which could cause food borne illnesses for the residents. Findings: Review of the facility's Diet Type Report dated 1/24/24, showed 30 of the 34 residents residing in the facility received foods prepared in the kitchen. According to USDA Food Code 2022, Section 4-501.11, Good Repair and Proper Adjustment, showed the proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. Review of the Dish Machine Temperature Log - Low Temp for January 2024, showed the instruction as follows: the dish machine temperatures and chemical levels must be monitored and recorded every meal period. Wash cycle must be between 110 to 120 degrees F. Chlorine levels must be between 50 to 100 ppm (parts per million), and quaternary levels must be between 180 to 200 ppm. Furthe review of the Dish Machine Temperature Log showed the wash temperatures were recorded as 121/124 for breakfast, lunch, and dinner every day from 1/1 to 1/23/24. 1. On 1/24/24 at 1403 hours, an observation of the dish machine and concurrent interview were conducted with Dietary Aide 1, with the CDM and the Plant Operations Director present. When asked to check the dish machine water temperature during the wash cycle, Dietary Aide 1 was observed checking the thermometer gauge which showed 100 degrees F. When asked to demonstrate how to check the sanitizing solution of the dishwasher, Dietary Aide 1 was initially observed using a pH strip and dipped the strip into the dish surface on the final rinse. The CDM stated Dietary Aide 1 used the wrong strip and should use the chlorine strip instead. Dietary Aide 1 was observed using the chlorine test strips and dipped the strip into the dish surface on the final rinse. The testing strip color did not change. Dietary Aide 1 repeated the steps, and the strip color still did not change, and the strip only read 10 ppm. The Plant Operations Director and CDM were observed checking the hoses connected to the bottles of detergent and sanitizer. The Plant Operations Director and CDM verified the dish machine was not properly dispensing sanitizer. On 1/24/24 at 1602 hours, a follow-up observation of the dish machine and concurrent interview was conducted with the CDM. The CDM was observed running the dish machine twice, and the water temperature was still at 100 degrees F during the wash cycle. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 69 of 74 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 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 1/25/24 at 1050 hours, a follow-up observation of the dish machine and concurrent interview was conducted Dietary Aide 1. Dietary Aide 1 stated the dish machine was checked by an outside repair vendor and they had to replace some of the parts of the dish machine. On 1/25/24 at 1115 hours, an interview was conducted with the Plant Operations Director. The Plant Operations Director stated he was informed of the outside repair vendor checking the dish machine, to which he showed the invoice from the outside repair vendor. Review of the invoice for the dish machine dated 1/25/24, showed, booster heater not reaching temperature. Unable to get booster heater to reach temperature due to bad heating elements. 2. On 1/24/24 at 0832 hours, an inspection of the main kitchen and concurrent interview was conducted with the Culinary Director. The sink in the main kitchen was observed continuously leaking from the faucet. The Culinary Director verified the findings. On 1/24/24 at 1350 hours, an interview was conducted with the Plant Operations Director. When the Plant Operations Director was informed of the leaking sink in the main kitchen, the Plant Operations Director called the Maintenance Assistant to inform him of the leaking sink in the main kitchen. The Maintenance Assistant stated he already checked and fixed the sink in the main kitchen. A follow-up inspection of the main kitchen and concurrent interview was conducted with the Plant Operations Director and Maintenance Assistant. The sink in the main kitchen was still observed leaking from the faucet lever. The Plant Operations Director and Maintenance Assistant verified the findings. 3. On 1/23/24 at 0834 hours, an inspection of the refrigerator used for the residents' food brought in by the visitors, and concurrent interview was conducted with the IP/DSD. An ice build-up and a brownish stain was observed in the freezer of the refrigerator used for residents' food brought in from the visitors. The IP/DSD verified the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 70 of 74 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 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/23/24 at 0924 hours, on 1/24/24 at 1044 hours, and 1/25/24 at 0945 hours, bilateral assist rails were observed on Resident 330's bed. On 1/25/24 at 0932 hours, an interview for Resident 330 was conducted with CNA 5. When asked about Resident 330's use of the assist rails, CNA 5 stated Resident 330 used the assist rails during turning and repositioning. On 1/25/24 at 0945 hours, Resident 330 was observed sitting in the wheelchair in her room. Bilateral assist rails were observed elevated. When asked about the bilateral assist rails, Resident 330 stated she used the assist rails when for turning and repositioning while in bed. Medical record review for Resident 330 was initiated on 1/23/24. Resident 330 was admitted to the facility on [DATE]. Review of Resident 330's medical record did not show an entrapment assessment and bed inspection. Cross reference to F700, example #3. 4. On 1/23/24 at 0959 hours, on 1/24/24 at 1338 hours, and 1/25/24 at 0905 hours, bilateral assist rails were observed on Resident 9's bed. On 1/24/24 at 1338 hours, Resident 9 was observed sitting in the wheelchair in her room. Bilateral assist rails were observed elevated. When asked about the bilateral assist rails, Resident 9 stated she used the assist rails when getting out of bed. On 1/25/24 at 0931 hours, an interview for Resident 9 was conducted with CNA 5. When asked about Resident 9's use of the assist rails, CNA 5 stated Resident 9 used the assist rails when getting up from bed, and during turning and repositioning. Medical record review for Resident 9 was initiated on 1/23/24. Resident 9 was readmitted to the facility on [DATE]. Review of Resident 9's medical record did not show an entrapment assessment and bed inspection. On 1/25/24 at 1112 hours, an interview for Residents 9 and 330 was conducted with the Plant Operation Director. The Plant Operation Director stated he was responsible bed inspection including maintaining, inspecting, and installing the assist rails. The Plant Operations stated the bed inspections were done weekly. When asked if he had done the entrapment assessment for the assist rails, the Plant Operations Director stated he did not do any entrapment assessment as the assist rails were enablers and not bed rails. When asked if he has any documentation of the weekly bed inspection, the Plant Operations Director verified there were no record of the weekly bed inspection conducted. Cross reference to F700, example #4. Based on observation, interview, medical record review, facility document review, and facility P&P (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 71 of 74 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 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 Level of Harm - Minimal harm or potential for actual harm review, the facility failed to ensure the residents' bed were inspected, entrapment assessments were completed, and with the record of the bed inspection when identifying areas of possible entrapment with the use of bed rails for four of 13 final sampled residents (Residents 9, 25, 330, and 379). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Residents Affected - Few Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's P&P titled Bed Safety dated 9/23/22, showed the inspection of all beds and related equipment including the frame, mattress, assistive devices, and bed accessories. The assistive devices were properly installed using the manufacturer instructions and other pertinent safety guidance to ensure proper fit. There should be an assessment of the resident using assistive device for bed mobility. If side rails were used, the maintenance staff will inspect the rails monthly and as needed to ensure the rails are in proper working order and placed appropriately in bed. 1. On 1/23/24 at 0908 hours, and 1/24/24 at 0858 hours, Resident 25 was observed in bed with the left upper side rails was elevated. Medical record review for Resident 25 was initiated on 1/24/24. Resident 25 was admitted to the facility on [DATE]. Cross reference to F700, example #1. 2. On 1/24/24 at 0836 hours and 1/25/24 at 0846 hours, an observation and concurrent interview with Resident 379. Resident 379 was observed in bed with the upper side rails elevated. Resident 379 stated he was not able to use the side rail because he was in pain when he moves in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 72 of 74 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 01/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire Yorba Linda Post-Acute 17803 Imperial Highway Yorba Linda, CA 92886 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Medical record review for Resident 379 was initiated on 1/24/24. Resident 379 was admitted to the facility on [DATE]. On 1/25/24 at 1112 hours, an interview for Resident 25 and 379 was conducted with the Plant Operation Director. The Plant Operation Director stated he was responsible for inspecting, fixing, and placing the side rails in bed weekly and as needed. The Plant Operation Director was asked if the entrapment assessment was done for the bed rails. The Plant Operation Director stated the entrapment assessment was not done because the enabler was not considered a bed rails. When asked if there was any record log for the bed inspection, the Plant Operation Director verified there was no record log of bed inspection and entrapment assessment. On 1/24/24 at 1609 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. Cross reference to F700, example #2. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 73 of 74 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 01/26/2024 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the effective pest control program to prevent the presence of gnats in the main kitchen and the satellite kitchen. This failure had the potential to lead to food-borne illnesses (illnesses caused by food contaminated with bacteria, viruses, parasites or toxins) to the residents who eat food prepared in the kitchen. Residents Affected - Few Findings: Review of the facility's Diet Type Report dated 1/24/24, showed 30 of the 34 residents residing in the facility received foods prepared in the kitchen. According to the USDA Food Code 2022, 6-501.111 Controlling Pests, showed insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. Review of the facility's P&P titled Pest Control revised May 2008 showed the facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. On 1/24/24 at 0832 hours, an inspection of the main kitchen and concurrent interview was conducted with the Culinary Director. Gnats were observed in a bag of bread and in the food preparation area in the main kitchen. The Culinary Director verified the findings. The Culinary Director stated they had a fly trap in the main kitchen. On 1/24/24 at 1339 hours, an interview was conducted with the Plant Operations Director. When asked about the gnats in the kitchen, the Plant Operations Director stated the pest prevention company came last month, to which he showed the service information. Review of the service information conducted by the pest control company dated 12/8/23, showed there were no pest activity during the pest control company inspection to the facility. On 1/24/24 at 1602 hours, an inspection of the satellite kitchen and concurrent interview was conducted with the CDM. Gnats were observed in the food preparation area in the main kitchen. The CDM verified the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555768 If continuation sheet Page 74 of 74

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Citations

30 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0552GeneralS&S Dpotential for harm
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.
0558GeneralS&S Dpotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0578GeneralS&S Dpotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0580GeneralS&S Dpotential for harm
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
0655GeneralS&S Dpotential for harm
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0657GeneralS&S Bno actual harm
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0692GeneralS&S Dpotential for harm
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0694GeneralS&S Dpotential for harm
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0700GeneralS&S Dpotential for harm
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
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.
0802GeneralS&S Dpotential for harm
F802 - Staffing
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
0803GeneralS&S Dpotential for harm
F803 - Menus and nutritional adequacy
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.
0806GeneralS&S Dpotential for harm
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
0813GeneralS&S Dpotential for harm
F813 - Food Safety Requirements
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
0814GeneralS&S Bno actual harm
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
0867GeneralS&S Dpotential for harm
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0881GeneralS&S Dpotential for harm
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
0908GeneralS&S Epotential for harm
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
0925GeneralS&S Dpotential for harm
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0909GeneralS&S Dpotential for harm
F909 - Conduct Regular inspection of all bed frames, mattresses, and bed
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.

FAQ · About this visit

Common questions about this visit

What happened during the January 26, 2024 survey of BAYSHIRE YORBA LINDA POST-ACUTE?

This was a inspection survey of BAYSHIRE YORBA LINDA POST-ACUTE on January 26, 2024. The surveyor cited 30 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BAYSHIRE YORBA LINDA POST-ACUTE on January 26, 2024?

Yes, 30 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are fully informed and understand their health status, care and treatments."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·January 26, 2024