Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bayshire Yorba Linda Post-acute during CMS and state inspections, most recent first.
Kitchen sanitation and food handling deficiencies were identified when surveyors observed a dirty hood over the stove, damaged and worn utensils, multiple food-contact items with residue or watermarks, heavily marred cutting boards, a wet and dirty blender and storage containers stacked before drying, a can opener with crusted residue, and a Dietary Aide serving food with facial hair not covered by a hair restraint. The RD verified the beard restraint issue, and the DON was informed.
Pharmacy Consultant Failed to Identify Levothyroxine and PPI Medication Irregularities: The Consultant Pharmacist’s monthly MRR failed to identify medication irregularities for three residents whose orders and MARs showed levothyroxine scheduled at the same time as PPIs such as pantoprazole and lansoprazole. During med pass observations, an LVN administered the levothyroxine and PPI doses together for each resident, and the pharmacist initially stated there was no concern before later acknowledging levothyroxine should not be given within four hours of a PPI.
Food items were served at improper temperatures during tray line and test tray observations. The RD and DSS verified mashed potatoes and other hot items were below the facility's required hot-food range, while apple juice was above the required cold-beverage range. The DSS also verified roast beef and green peas were not hot and were below the recommended temperatures for a hot meal tray; 41 of 41 residents received food prepared in the kitchen.
The facility failed to keep resident records accurate and complete. For several residents, POLST forms and social services notes did not match regarding advance directives, one resident’s admission social services assessment was not completed, and one resident’s MAR did not reflect observed and reported behaviors during the shift. An SSD and DON were aware of the mismatched and missing documentation, and an LVN acknowledged the behavior charting was incorrect.
An LPN failed to perform hand hygiene during medication administration for multiple residents, did not disinfect the glucometer between uses for several residents, and used an alcohol swab that had been dropped on the floor during a blood glucose check on a resident on EBP isolation. The DON stated hand hygiene should occur before entering and after exiting resident rooms, the glucometer should be disinfected after each use, and the dropped swab should have been discarded.
Failure to Offer Advance Directive Information: A resident with intact cognition and decision-making capacity had no documented offer of advance directive information or assistance in the record. Although a POLST referenced an advance directive, the chart lacked a copy of it, and SSD notes did not show that the resident was offered information about formulating one until later, with no documentation in the earlier social service notes.
A resident's record showed PRN zolpidem tartrate for insomnia was ordered for 14 days, then extended for another 14 days after the physician was notified of the resident's request. However, the chart did not include an appropriate clinical rationale for continuing the psychotropic medication beyond the original order, and an RN verified the missing documentation during record review.
A resident’s care plan did not include the specific targeted behavior monitoring tied to psychotropic medication use. The resident had orders for zolpidem for insomnia and buspirone for anxiety, with monitoring for anxiety, insomnia, and ability to fall asleep, but the care plan did not address those behaviors. The DON verified the omission during interview and record review.
Improper PICC Dressing Care and Unlabeled IV Tubing: A resident receiving IV antibiotics and IV hydration through a PICC line was observed with a PICC dressing dated outside the required change interval and IV tubing that was initially unlabeled. The DON and RN later confirmed the dressing date and tubing labeling issues, and RN stated he added a label without replacing the tubing, which was not consistent with procedure.
Failure to provide humidifiers for continuous oxygen therapy. Two residents were observed receiving O2 at 2 L/min via nasal cannula without a humidifier bottle attached to the concentrator. Their records included orders for continuous oxygen and for staff to monitor the humidifier bottle every shift, and an RN verified that documentation was being completed even though no humidifier was present. The DON stated that residents on continuous oxygen need a humidifier to prevent nasal dryness.
Incomplete Dialysis Access Assessments: A resident with ESRD who required hemodialysis had a left upper extremity AVF that was not consistently assessed before and after treatments. Dialysis communication forms were missing documentation of bruit and thrill checks and other access site observations such as color, warmth, drainage, bleeding, and edema. An LVN confirmed licensed nurses were responsible for the documentation and stated the access site should have been assessed pre- and post-dialysis to ensure the AVF was working.
A resident with leg edema had a Lasix order entered with an incorrect indication for pain during urination instead of a diuretic use. The MAR reflected the wrong indication while the medication was administered by an LVN over several days, and the DON and LVN both confirmed the order should have been clarified before administration.
Medication administration errors resulted in a 20% error rate, with two of four LPNs observed making errors involving levothyroxine and pantoprazole or lansoprazole. An LPN gave levothyroxine together with stomach acid medications instead of separating them by at least four hours, and also crushed pantoprazole delayed release tablets for two residents despite no order to do so. Another LPN administered pantoprazole and levothyroxine together to a resident whose orders were for both medications before breakfast.
Unsafe medication storage was observed when an LPN left an insulin vial and a linaclotide bubble pack unattended on top of a med cart during med pass while staff, residents, and a maintenance vendor were present in the hallway. An inspection of another med cart also found an open foil packet of Sorbalgon Ag wound dressing stored inside, and the LPN verified it should have been discarded.
Menu items were not followed for three residents during lunch service. Two residents did not receive the bread or roll with margarine listed on their meal tickets, and one resident did not receive the scalloped potatoes from the menu or the mashed potatoes she requested as a replacement. The RD verified the missed items during observation.
Improperly Covered Dumpster Lids: The facility failed to keep garbage and refuse properly disposed of in three of seven dumpsters. During observation, three dumpsters were found with lids partially propped open by cardboard boxes and black trash bags, preventing the lids from fully closing. The Plant Operations Director verified the finding and stated the dumpster lids should be completely closed at all times for safety and infection control purposes.
A resident with orthostatic hypotension did not have orthostatic blood pressure and pulse checks completed in lying, sitting, and standing positions as ordered by the physician. Instead, only single readings were documented each day, and staff confirmed the required assessments were not performed or recorded.
Surveyors identified multiple failures in food labeling, dating, and storage, as well as unsanitary conditions of kitchen equipment and utensils. Food items in refrigerators were not properly labeled or dated, expired food was not discarded, and utensils and surfaces were found with stains, rust, and food debris. Additionally, utensils were not air-dried before storage, and a cutting board was heavily marred, all contrary to facility policy and professional standards.
A resident with a recent lumbar fusion and orders for spinal precautions and use of an LSO brace when out of bed did not have these interventions included in their care plan. Therapy staff confirmed the need for these precautions, but the care plan was missing the required details. CNAs demonstrated inconsistent knowledge and implementation of the necessary precautions, and facility leadership acknowledged the deficiency.
The facility did not update care plans for three residents to accurately reflect the use of side rails, instead documenting the same interventions for each and failing to include alternatives like adjustable beds or bedside mats that were considered. This resulted in non-individualized care plans regarding bed mobility and safety devices.
Three residents receiving continuous oxygen therapy did not receive care in accordance with physician orders and facility policy. One resident was given oxygen at a lower rate than prescribed, while two residents lacked required 'No Smoking/Oxygen in Use' signage at their room entrances. These deficiencies were confirmed by nursing staff and the DON during observations and interviews.
A resident did not receive insulin as ordered by the physician when blood sugar levels indicated it was needed, and the medication administration record was incorrectly coded. Additionally, narcotic shift count sheets for a medication cart were found to have multiple missing signatures from both incoming and outgoing licensed nurses over several months, contrary to facility policy and increasing the risk of medication errors and diversion.
A medication error rate exceeding 5% was identified when two nurses administered incorrect medications and dosages to a resident, failed to provide required education about not chewing extended-release medications to two residents, and did not assess for signs of bleeding before giving anticoagulants. Staff interviews confirmed these errors and lapses in protocol.
Medications were found stored on an open shelf in the central supply room, accessible to non-licensed staff, and a medication cart was left unlocked and unattended in a hallway near the nurses' station. The DON and an LVN confirmed these lapses, acknowledging that medications should be secured and carts locked when not in use.
Multiple deficiencies were identified in the facility's medical record documentation, including missing or mismatched signatures on psychotropic medication consent forms, incomplete staff job designations on MARs, and missing or incomplete consents for medication administration. Additionally, some residents' medication administrations and treatments were not properly documented, and advance directives were not always available in the active medical record. The facility also failed to document physician notifications and justifications for antibiotic use when residents did not meet clinical criteria.
Surveyors identified multiple infection control failures, including improper classification of infections in surveillance reports, lack of adherence to neutropenic precautions for a resident post-chemotherapy (such as an open door, presence of fresh flowers, and staff not wearing masks), and failure to follow enhanced barrier precautions for a resident with an indwelling device when a CNA did not wear a gown during a transfer. Additionally, the medication room sink was found dirty and in need of cleaning, contrary to facility policy.
Essential equipment, including a leaking sink faucet in a medication room, an improperly cleaned ice machine with black particle residue, and multiple freezers with significant ice build-up, were not maintained in safe and operable condition. Additionally, a digital thermometer used for food safety checks was not calibrated correctly by dietary staff, as confirmed by the CDM. These deficiencies were verified through direct observation and staff interviews, and were not in accordance with facility policy or manufacturer instructions.
Two residents with bed rails had documented gaps between the mattress and bed components, but maintenance staff did not perform timely or complete entrapment assessments after these risks were identified by nursing staff. Annual inspections were relied upon, and some required measurements were missing or not documented, resulting in unaddressed entrapment risks.
The facility did not make the most recent Recertification Survey's plan of correction easily accessible to residents and the public. Several residents stated they were unaware of where to find the latest survey results or their right to review them. A binder in the lobby contained the CMS 2567 but was missing the Plan of Correction, which the Administrator confirmed was not present.
A bag of dry cereal brought in by family was found on a resident's bedside table without a label or date, contrary to facility policy requiring all such food to be labeled and properly stored. An LVN stated only wet food was labeled, and the DON confirmed the dry cereal should have been labeled and dated.
A facility failed to create a care plan for a resident with severe cognitive impairment who was at risk of falls due to behaviors of getting up from a wheelchair. Despite being identified as a fall risk, the resident's care plan lacked specific interventions, leading to an incident where the resident was found on the floor. Interviews with staff confirmed the absence of a tailored care plan, highlighting a deficiency in care planning.
Kitchen sanitation and food handling deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen during observations by surveyors. During the initial kitchen tour, the hood over the stove was observed with black, dirt residue, and the Cook acknowledged that it was cleaned weekly and also serviced by an outside company. The hood service sticker showed the last service date as 1/16/26. The report also documented that the facility’s kitchen utensils and equipment were not maintained in good repair, with multiple items observed damaged or worn, including spatulas with cracked or melted edges, a frayed basting brush, chipped and cracked rubber spatulas, and a deformed whisk. Surveyors also observed multiple kitchen items that were not clean to sight and touch. A clear plastic container used for storing utensils and kitchenware was dirty with fuzzy films, watermarks, and dry residue inside. Two ketchup pumps, several stainless steel scoops, a serving spoon, slotted spoons, a spoon, a ladle, a black peeler, and a knife with a black handle were all observed with dirt, fuzzy films, watermarks, or dry, crusted residue. The facility’s cutting boards were also observed in poor condition; the white, brown, green, blue, and yellow cutting boards were fuzzy, heavily marred, and had deep grooves, and the Culinary Director stated they should have been replaced. Additional observations showed food preparation equipment and utensils were not being properly air dried or stored in a sanitary manner. A heavy-duty blender was observed dirty, still wet, and with white residue inside and on the lid, and five clear rectangular bucket containers used for marinating meats and storage were wet and stacked on top of each other. The countertop mounted can opener had dry, crusted black and white residue on the blade. During lunch tray line observation, a Dietary Aide was serving food with facial hair not covered by a hair restraint, and the RD verified the finding and stated a beard guard was used. The DON was informed of the findings.
Pharmacy Consultant Failed to Identify Levothyroxine and PPI Medication Irregularities
Penalty
Summary
The facility’s Consultant Pharmacist failed to identify and make recommendations for medication irregularities during the monthly drug regimen review for three residents receiving levothyroxine together with proton pump inhibitor (PPI) medications. The facility’s Medication Regimen Review policy stated the Consultant Pharmacist conducts a monthly review for every resident receiving medications and reviews the medical record to prevent, identify, report, and resolve medication-related problems or other irregularities. For Resident 30, the physician ordered levothyroxine sodium 75 mcg daily before breakfast and pantoprazole sodium delayed release 40 mg daily before breakfast. The April 2026 MAR showed both medications scheduled for 0630, and the Consultant Pharmacist’s monthly MRR on 4/7/26 did not identify the irregularity. During a medication administration observation, an LVN administered the pantoprazole sodium delayed release and levothyroxine sodium at the same time. For Resident 17, the physician ordered levothyroxine sodium 88 mcg in the morning on an empty stomach and lansoprazole 30 mg daily before breakfast, with both medications scheduled for 0630 on the April 2026 MAR. The monthly MRR did not identify the irregularity, and an LVN administered both medications at the same time during observation. For Resident 19, the physician ordered levothyroxine sodium 100 mcg in the morning on an empty stomach and pantoprazole sodium delayed release 40 mg twice daily before breakfast and dinner, with both medications scheduled for 0630 on the April 2026 MAR. The monthly MRR also failed to identify the irregularity, and an LVN administered both medications at the same time during observation. During interview, the Pharmacy Consultant initially stated there was not a concern with levothyroxine being administered with lansoprazole or pantoprazole, then later stated levothyroxine should not be administered within four hours of any PPI and the order should be clarified.
Food Served at Improper Temperatures
Penalty
Summary
The facility failed to ensure food items were served at appetizing temperatures. Review of the facility's policy and procedure titled Trayline Setup and Service showed hot food should be 110-120 degrees Fahrenheit and cold food should be 45-50 degrees Fahrenheit. During a tray line observation with the RD and DSS, the mashed potatoes were checked and verified at 100 degrees Fahrenheit, and the apple juice was checked and verified at 54.8 degrees Fahrenheit. The RD acknowledged the apple juice was above the recommended temperature for a cold beverage and the mashed potatoes were below the recommended temperature for hot food. During a later test tray observation of the regular lunch menu, the DSS and RD checked and verified the roast beef was at 105.8 degrees Fahrenheit and the green peas were at 94 degrees Fahrenheit. The DSS verified both items were not hot and were below the recommended temperatures for a hot meal tray. The facility's Diet Type Report showed 41 of 41 residents consumed the food prepared in the kitchen, and the menu for the lunch meal included mixed green salad with dressing, artichoke chicken, red bliss potatoes, seasoned green peas, bread or roll with margarine, chocolate cake with caramel icing, choice of beverage, and herb roast beef for alternate.
Inaccurate and Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to ensure medical records were accurate and complete for five sampled residents. Facility policies required social services assessments to be initiated upon admission and completed within seven days, advance directives to be maintained in the medical record, and documentation to be complete and accurate. Review of records showed that for Residents 2, 4, and 26, the POLST and social services documentation did not match regarding advance directive status, and in Resident 26’s record there was no copy of the advance directive even though the POLST indicated one existed. For Resident 10, the medical record did not show that the social services assessment was completed upon admission. The SSD stated she would try to complete social services assessments within 72 hours after admission, but verified that Resident 10’s assessment had not been completed after admission. Resident 10’s record therefore lacked the required admission social services assessment documentation. For Resident 15, the MAR documented no behaviors on the night shift, but the LVN who worked that shift stated the resident had multiple screaming episodes during the shift. The LVN later reviewed the MAR and verified it showed no behaviors, stating he had incorrectly documented it. Observations during the early morning hours also documented the resident yelling and screaming out, which was inconsistent with the MAR entry.
Infection Control Failures During Medication Pass and Blood Glucose Monitoring
Penalty
Summary
The facility failed to maintain infection prevention and control practices during medication administration and blood glucose monitoring. During an observed medication pass, LVN 5 did not perform hand hygiene after leaving the medication cart area and returning to begin medication administration, and then administered medications to 12 residents without performing hand hygiene between residents or between medication administration and blood glucose checks. LVN 5 also did not disinfect the glucometer between blood glucose checks for seven residents. During a blood glucose check on Resident 35, who was on EBP isolation, LVN 5 placed supplies on the bedside table, dropped an unopened alcohol swab on the floor, picked it up with gloved hands, and used it during the procedure. After obtaining the blood sample, LVN 5 wiped the first drop of blood with his gloved finger and then used the alcohol swab that had been contaminated by contact with the floor to clean Resident 35's finger. The DON stated hand hygiene should be performed before entering a resident's room, upon exiting, and anytime hands are visibly soiled, that the glucometer should be disinfected after each use, and that the alcohol swab dropped on the floor should have been discarded.
Failure to Offer Advance Directive Information
Penalty
Summary
The facility failed to inform and provide written information about the right to formulate an advance directive for one sampled resident. Resident 26 was admitted and later readmitted to the facility, and the medical record review showed the resident had the capacity to understand and make decisions. The resident’s H&P dated 3/20/26 showed capacity for decision-making, and the admission MDS showed a BIMS score of 15, indicating intact cognition. Review of the record showed a POLST dated 3/18/26 indicating an advance directive in Section D, but the medical record did not contain a copy of the advance directive. The Social Service Evaluation dated 3/20/26 documented that the resident had no advance directive and that information was only provided on the right to formulate one on 4/14/26. Social Services progress notes dated 3/19/26 and 3/23/26 did not document that the information and formulation of an advance directive was offered. During interview and concurrent record review, the SSD verified there was no documentation that an advance directive was offered, and the DON was informed and acknowledged the findings.
Missing Clinical Rationale for Continued PRN Zolpidem
Penalty
Summary
The facility failed to ensure that the prescriber documented an appropriate clinical rationale for the continued use of a psychotropic medication for Resident 15. Resident 15 was reviewed for unnecessary medications, and the record showed an order dated 3/21/26 for zolpidem tartrate 5 mg by mouth at bedtime PRN for insomnia with a 14-day duration. The medical record also showed a second order dated 4/7/26 for zolpidem tartrate 5 mg by mouth at bedtime PRN for insomnia with a 14-day duration. Nursing progress notes dated 4/6/26 at 2350 hours documented that the physician was notified of the resident's request to extend the PRN zolpidem tartrate medication and agreed to extend it for an additional 14 days. However, the record did not show an appropriate clinical rationale for continued use of zolpidem tartrate beyond the original 14-day order, and RN 1 verified this during an interview and concurrent record review.
Incomplete Care Plan for Psychotropic Medication Monitoring
Penalty
Summary
The facility failed to ensure that the person-centered care plan for Resident 15 included the specific targeted behavior monitoring related to the resident’s psychotropic medication use. Resident 15 was admitted to the facility and had physician’s orders for zolpidem tartrate 5 mg by mouth at bedtime as needed for insomnia and buspirone HCl 15 mg by mouth twice a day for anxiety. The medical record also included behavior/side effects monitoring orders to monitor anxiety as manifested by verbalization of feeling anxious every shift for buspirone use, and to monitor insomnia and the ability to fall asleep every evening and night shift for zolpidem use. Review of the Care Plan Report showed that these specific targeted behaviors were not addressed in the resident’s care plan. The facility’s policy stated that a comprehensive person-centered care plan should include measurable objectives and timetables to meet the resident’s physical, psychosocial, and functional needs, and should incorporate identified problem areas with treatment goals, timetables, and measurable outcomes. During interview and concurrent record review, the DON verified that Resident 15’s care plan failed to address the behavior monitoring for the zolpidem tartrate and buspirone HCl medication use.
Improper PICC Dressing Care and Unlabeled IV Tubing
Penalty
Summary
The facility failed to provide proper IV care for one resident receiving IV infusions through a PICC line. The resident was observed with two IV bags at the bedside, including a normal saline bag connected to unlabeled IV tubing and a cefepime-dextrose infusion connected to tubing with a green label. The resident stated he was receiving IV antibiotics and IV hydration through the PICC line. The PICC line dressing was observed with a handwritten date of 4/2/26, and the resident had a physician order for the PICC dressing site care and cap change every seven days and as needed. During follow-up observation and record review, the IV normal saline tubing was later found with a green label dated 4/12 at 0800 hours, while the bag remained dated 4/11. The DON stated the facility process was to date PICC dressings on the day they were changed and that IV lines should be labeled when changed or every 72 hours per facility policy. The DON verified the PICC dressing date was 4/2/26 and stated that if it was dated that day, then it had never been changed. RN 1 later stated he had observed the IV NS tubing was not labeled, added a label dated 4/12, and did not replace the tubing, acknowledging this was not following procedure because incorrectly dating the tubing could allow it to be used past the expiration date.
Failure to Provide Humidifiers for Continuous Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents receiving continuous oxygen therapy. Resident 52 was observed on the initial tour receiving oxygen at 2 liters per minute via nasal cannula, and the oxygen concentrator had no humidifier bottle attached. A follow-up observation the next day again showed no humidifier connected to the concentrator. The resident’s record showed orders for continuous oxygen at 2 liters per minute via nasal cannula/mask and to monitor the oxygen humidifier bottle every shift, changing it when close to empty. The DON stated that residents receiving oxygen continuously would need a humidifier to prevent dryness of the nostrils, regardless of oxygen concentration. Resident 17 was also observed in bed and later sitting in a chair receiving oxygen via nasal cannula at 2 liters per minute, with no humidifier bottle present on either observation. The resident’s record included orders to monitor the oxygen humidifier bottle every shift and to administer oxygen therapy continuously at 2 liters per minute via nasal cannula. During interview, RN 1 verified that Resident 17 did not have a humidifier connected to the continuous oxygen and stated nurses had been documenting the humidifier monitoring as completed even though no humidifier was present. The DON was made aware of these findings and acknowledged them.
Incomplete Dialysis Access Assessments
Penalty
Summary
The facility failed to ensure the necessary care of a resident's dialysis access site was consistently and accurately assessed before and after hemodialysis treatments. Resident 4 had end-stage renal disease and required hemodialysis through a left upper extremity AV fistula. The physician ordered that the AV shunt be checked every shift for the presence of bruit and thrill, with notification to the physician if negative. The resident's care plan also addressed the hemodialysis treatment and access site, including monitoring for redness, poor circulation, swelling, drainage, and changes in bruit and thrill. Review of the dialysis communication forms showed incomplete documentation of the access site assessment. On one treatment date, the access was assessed for bruit and thrill before dialysis, but the form did not show assessment for warmth, edema, drainage, or bleeding. On another treatment date, the access was not assessed for bruit and thrill or for color, warmth, and drainage after dialysis. On a later treatment date, the access was again not assessed for bruit and thrill or for color, warmth, drainage, bleeding, and edema after dialysis. During interview, an LVN confirmed that licensed nurses were responsible for completing the dialysis communication form and stated the dialysis site should have been assessed before and after dialysis to ensure the AVF was working. The DON was informed and acknowledged the findings.
Incorrect Lasix Indication on Medication Order
Penalty
Summary
Facility pharmaceutical services failed for one sampled resident when the Lasix order was not accurately reconciled and the medication indication was documented incorrectly. Resident 55 was admitted with capacity to understand and make decisions, and during an observation and interview on 4/12/26, she stated she was having trouble sleeping due to edema in her legs; her lower legs were observed with edema present. The medical record showed a physician's telephone order dated 4/10/26 for Lasix 20 mg by mouth daily for four days, but the MAR listed the medication as being ordered for pain during urination, including one entry for one-time use and another for one time a day for three days. The MAR showed Lasix was administered on 4/10/26 at 2154 hours and on 4/11, 4/12, and 4/13/26 at 0900 hours by LVN 3. Review of the record showed the telephone order did not have an indication for Lasix use, and the DON stated the medication was intended as a diuretic for excess fluid and was not indicated for urinary pain. The DON verified the indication was incorrect and stated the nurse should have called the physician to clarify the order. LVN 3 also stated Lasix was used as a diuretic and should have been questioned before administration.
Medication Administration Errors Involving Levothyroxine and Pantoprazole
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent; the observed error rate was 20 percent. During medication administration observations, two of four licensed nurses were found to have errors involving levothyroxine and pantoprazole or lansoprazole. The report states these failures created the risk for residents to have potential side effects or complications related to the medications. For one resident with low thyroid hormone and GERD, an LVN administered levothyroxine 88 mcg together with lansoprazole delayed release 30 mg, even though the levothyroxine order was for morning administration on an empty stomach and the stomach medication was ordered before breakfast. For another resident with low thyroid hormone and GERD, the same LVN administered levothyroxine 100 mcg together with pantoprazole 40 mg. The report cites online guidance stating stomach medicines such as lansoprazole and pantoprazole should be taken at least four hours before or after levothyroxine. The report also describes two instances in which pantoprazole delayed release 40 mg was crushed and mixed with applesauce for residents who had orders for pantoprazole delayed release in the morning for GERD. The LVN stated there was no physician order to crush the medication and acknowledged delayed-release medications should not be crushed. In a separate medication pass, another LVN administered pantoprazole sodium delayed release and levothyroxine sodium 75 mcg together to a resident whose orders were for both medications before breakfast. The consultant pharmacist stated levothyroxine should not be administered within four hours of any PPI, including pantoprazole, and the order should be clarified by the physician.
Unsafe Medication and Dressing Storage
Penalty
Summary
Medication storage was not maintained in a safe manner for two residents during medication administration and for one medication cart. During an observation of medication administration for one resident, an LVN prepared insulin and then left the vial on top of the medication cart unattended in the hallway while entering the resident’s room. During a separate observation for another resident, the same LVN prepared linaclotide and left the bubble pack on top of the medication cart unattended while entering the resident’s room. Several staff members, residents, and an outside maintenance vendor were observed in the hallway during this time. The facility’s policy stated the medication cart is to be kept closed and locked when out of sight of the medication nurse or aide, and no medications are to be kept on top of the cart. An inspection of Medication Cart B also found an open foil packet of Sorbalgon Ag wound dressing stored in the cart. The dressing was individually wrapped in foil pouches, but one pouch was open with the dressing inside. The LVN who inspected the cart verified the open pouch and stated the dressing should have been thrown away and not stored in the cart.
Menu Items Not Served as Ordered
Penalty
Summary
The facility failed to ensure the menu was followed for three of 41 residents who consumed foods prepared in the kitchen. During a dining observation, Resident 30 was served mixed green salad with ranch dressing, bacon meatloaf, scalloped potatoes, sauteed broccoli florets, and diet cola, but was not served the bread or roll with margarine listed on the meal ticket. Resident 36 was observed eating lunch and was served mixed green salad, bacon meatloaf, scalloped potatoes, sauteed broccoli florets, water, and tea, but was not served the bread or roll with margarine listed on his meal ticket. Resident 33 was observed eating lunch in her room and was served bacon meatloaf, soft sauteed broccoli florets, and diet cola, but did not receive the scalloped potatoes from the menu or the mashed potatoes she requested as a replacement. The RD verified that Residents 30 and 36 did not receive the bread or roll with margarine and stated it should have been provided, and also verified that Resident 33 requested mashed potatoes and did not receive them.
Improperly Covered Dumpster Lids
Penalty
Summary
The facility failed to ensure garbage and refuse were properly disposed of in three of seven garbage dumpsters. During an observation and concurrent interview with the Plant Operations Director, three dumpsters were seen with lids partially propped open by cardboard boxes and black trash bags, which prevented the lids from fully closing. The facility's policy titled Garbage and Rubbish Disposal stated that outside dumpsters are to be maintained in a clean and sanitary condition, that garbage and rubbish are to be placed in waste containers with tight-fitting lids or covers, and that outdoor trash receptacles are to be kept covered. The Plant Operations Director verified the observation and stated the dumpster lids should be completely closed at all times for safety and infection control purposes.
Failure to Obtain Orthostatic Blood Pressure as Ordered
Penalty
Summary
The facility failed to provide necessary care and services as ordered for a resident diagnosed with orthostatic hypotension. The physician's order required that the resident's orthostatic blood pressure and pulse rate be checked daily in lying, sitting, and standing positions for three days. However, a review of the Medication Administration Record (MAR) for the specified period showed that only single blood pressure and pulse readings were documented each day, without specifying the required positions. Further review of the medical record confirmed that the orthostatic blood pressure measurements in all three positions were not obtained as ordered. During interviews, both the LVN and the DON acknowledged that the required assessments were not completed and verified the absence of documentation for the ordered positions. The failure to follow the physician's order was confirmed through both record review and staff interviews.
Sanitary Deficiencies in Food Storage, Labeling, and Kitchen Equipment
Penalty
Summary
The facility failed to meet sanitary requirements in the kitchen, as evidenced by improper labeling and dating of food items, failure to discard expired food, and lack of adherence to food storage policies. During an inspection, surveyors observed multiple food items in refrigerators that were not labeled or dated, including bags of cheese and containers of thickened juices. Additionally, a container with brown granules was found unlabeled on a kitchen shelf. The facility's own policies required all products to be dated upon receipt and when opened, and to include use-by dates, but these procedures were not followed. Food brought in by visitors for residents was also not consistently labeled with the resident's name, room number, and date received, contrary to posted facility instructions. Further observations revealed that kitchen equipment and utensils were not maintained in a sanitary condition. Inspectors found an ice machine with black particles on the deflector and groove, and several utensils and scoops were either chipped, corroded, stained, or had food debris. The can opener and peeler were rusted, and storage bins for scoops were stained. Cupcake pans and a microwave were also found with discoloration and food debris. These findings were verified by dietary staff and the Director of Maintenance, who confirmed the cleaning responsibilities and schedules. Additional deficiencies included the improper air-drying of utensils, as six scoops were found stored wet inside a storage bin, and a cutting board was observed to be heavily marred with knife marks, making it difficult to clean and sanitize. These failures were observed in areas where food was prepared for nearly all residents in the facility, as indicated by the Diet Type Report. The lack of adherence to professional standards and facility policies for food storage, labeling, and equipment sanitation had the potential to impact the safety of food served to a medically vulnerable population.
Care Plan Lacked Spinal Precautions and LSO Brace Interventions for Post-Lumbar Fusion Resident
Penalty
Summary
The facility failed to develop a care plan that addressed the specific needs of a resident who had undergone a lumbar fusion and required spinal precautions and the use of an LSO (lumbosacral orthosis) brace when out of bed. Medical record review showed that the resident was admitted with diagnoses including spinal stenosis and lumbar fusion, and both the history and physical examination and therapy notes indicated the need for spinal precautions and the LSO brace. A physician's order was also present for the use of the LSO brace when the resident was out of bed. However, the resident's care plan did not include interventions for spinal precautions or the use of the LSO brace. Interviews with OT and PT staff confirmed that the resident required spinal precautions and the LSO brace, and they acknowledged that these interventions were not included in the care plan. Observations and interviews with CNAs revealed inconsistent understanding and implementation of the required precautions, with one CNA stating that no other precautions were needed during transfers or in-bed mobility, and another CNA indicating no special precautions were necessary during transfers. The DON and Administrator were made aware of and acknowledged these findings.
Failure to Revise Care Plans for Side Rail Use
Penalty
Summary
The facility failed to revise the comprehensive care plans for three residents to accurately address the use of side rails. For each of these residents, the care plans documented the use of grab bars and quarter-sized side rails as the least restrictive interventions for bed mobility, turning, positioning, and transfers. However, the medical records and side/bed rail evaluations indicated that other alternatives, such as adjustable beds and bedside mats, were considered or attempted. The care plans did not reflect these alternatives or provide individualized interventions prior to the use of side rails. During interviews and medical record reviews, it was confirmed that the interventions related to the use of grab rails were the same across all three residents, and the care plans did not accurately document the least restrictive devices used. The admitting nurse initiated the care plans, but there was uncertainty regarding why the same interventions were applied to each resident and why the documentation did not align with the alternatives considered. This resulted in care plans that were not individualized to each resident's needs regarding side rail use.
Failure to Provide Safe and Appropriate Respiratory Care and Required Oxygen Safety Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to three residents who required continuous oxygen therapy. One resident did not receive oxygen at the rate ordered by the physician, as observations showed the oxygen was administered at 1.5 liters per minute instead of the prescribed 2 to 5 liters per minute. This discrepancy was confirmed by both a registered nurse and a review of the resident's medical orders, which specified the required oxygen flow rate to maintain adequate oxygen saturation levels. Additionally, two other residents who were on continuous oxygen therapy did not have the required 'No Smoking/Oxygen in Use' signage posted at the entrance to their rooms, as mandated by the facility's own policy and procedure for oxygen administration. Observations and interviews with nursing staff and the Director of Nursing confirmed the absence of these safety signs, despite the residents' ongoing use of oxygen. The lack of proper signage was noted during multiple observations and was acknowledged by facility staff as not being in compliance with established procedures.
Failure to Administer Insulin as Ordered and Incomplete Narcotic Shift Counts
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for one resident by not administering insulin as ordered by the physician. Medical record review showed that the resident had a physician's order for Humulin R insulin to be given subcutaneously before meals based on specific blood sugar levels. On two occasions, the resident's blood sugar was above the threshold requiring insulin, but the medication was not administered, and the medication administration record was incorrectly coded to indicate that no insulin was required. Both the LVN and RN involved acknowledged that insulin should have been given according to the physician's order. Additionally, the facility did not ensure proper accounting and safeguarding of controlled medications. Review of the Narcotic Shift Count sheets for one medication cart revealed multiple instances over several months where the required signatures from incoming and outgoing licensed nurses were missing. This failure to complete the narcotic count documentation was verified by staff and acknowledged as a risk for medication errors and drug diversion. The facility's policies required these counts and signatures to be completed at every shift change, but this was not consistently done.
Medication Administration Errors and Lack of Resident Education
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 22.58%. During medication administration, two licensed nurses were found to have made multiple errors. One nurse administered medications to a resident that did not match the physician's orders, including giving a tablet form of a multivitamin instead of the prescribed packet form due to a supply shortage, and provided the incorrect dosage of calcium. The nurse confirmed these errors during an interview and acknowledged that clarification with the physician should have occurred at the time of admission. Another nurse failed to provide necessary education to two residents regarding the proper administration of extended-release (ER) medications, specifically not instructing them not to chew the ER tablets. One resident was observed making chewing motions while taking ER nifedipine and potassium chloride, and the nurse did not intervene or provide guidance. Additionally, the same nurse did not assess or inquire about signs or symptoms of bleeding or bruising before administering apixaban, an anticoagulant, to both residents, despite physician orders requiring such monitoring. Interviews with staff confirmed the medication errors and lapses in protocol. The central supply process for reordering medications was described, and it was noted that nurses would request needed over-the-counter medications, with the central supply staff responsible for obtaining them. The errors were verified by nursing and administrative staff, who acknowledged that proper procedures were not followed in these instances.
Failure to Secure Medication Storage and Lock Medication Cart
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored securely and in accordance with professional standards. During an observation of the central supply room, a CNA, who was the designated supply room designee, was found to have access to and dispense medications such as Thera Antifungal Body Powder, Hydrocortisone Cream, Zinc Oxide ointment, and Triple Antibiotic Ointments to nurses upon request. These medications were stored on an open metal shelf in the central supply room, accessible to non-licensed staff. The DON confirmed that these medications should not have been accessible to non-licensed staff and should have been stored in a locked cabinet accessible only to licensed nurses. Additionally, Medication Cart 1 was observed unlocked and unattended in a hallway near the entrance lobby and nurses' station, with residents, visitors, and staff passing by. The cart was not being attended to by any staff at the time of observation. An LVN confirmed that the cart was left unlocked because they had to check on a resident and acknowledged that the cart should be locked at all times when not in use.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents, as evidenced by missing or mismatched signatures on informed consent forms for psychotropic medications, incomplete documentation of staff job designations on Medication Administration Records (MARs), and missing or incomplete consents for medication administration. For example, the informed consent for buspirone for one resident did not have signatures that matched the printed names, and the staff who signed the consent had not actually obtained the consent from the resident. Additionally, several MARs lacked the professional titles of staff who administered medications, and some consent forms were missing required physician signatures and dates. Documentation lapses were also found in the administration and monitoring of medications and treatments. One resident's MAR showed multiple instances of missing documentation for medication administration, treatments, and required monitoring, such as pain assessments, intake and output, and infection control measures. In some cases, staff admitted to forgetting to document or save entries after providing care. Another resident's advance directive was not available in the active medical record, and staff could not provide documentation that the advance directive had been offered or discussed upon admission. The facility also failed to properly document physician notifications and justifications for continuing antibiotic treatments for residents who did not meet McGeer's Criteria. The Infection Surveillance Monthly Report indicated that antibiotics were continued per physician direction, but the medical records did not include the name of the physician, the date and time of notification, or the name of the nurse who communicated with the physician. These documentation failures were verified by staff during interviews and were not in accordance with facility policies and accepted professional standards.
Infection Control and Precaution Failures Identified
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as evidenced by several observed deficiencies. The infection preventionist (IP) did not accurately classify residents according to McGeer's Criteria in the infection control surveillance reports for December 2024 and January 2025. This resulted in incomplete tracking of residents who did not meet the criteria for true infections, and the IP was unable to provide alternative documentation for this tracking. Additionally, the facility's antibiotic stewardship policies required review and notification of inappropriate antibiotic use, but the surveillance reports did not reflect this process. For a resident on neutropenic precautions following chemotherapy, the facility did not implement required measures. Despite a physician's order for neutropenic precautions, the resident's door was repeatedly observed open, and fresh flowers were present at the bedside, both of which are prohibited under the facility's policy. The IP was also observed entering the room without a mask, contrary to the stated requirements for staff and visitors to wear masks, keep the door closed, and restrict fresh flowers in the room. Another resident with an indwelling medical device was under enhanced barrier precautions, but a CNA was observed transferring the resident without wearing a gown, despite signage and orders indicating that PPE, including gowns, should be used during such care activities. Additionally, the sink in Medication Room A was found to be dirty, with visible discoloration and debris, and both the RN and DON confirmed that the sink required cleaning and maintenance, contrary to facility policy requiring medication preparation areas to be kept clean and sanitary.
Failure to Maintain and Properly Clean Essential Equipment
Penalty
Summary
The facility failed to maintain essential equipment in a safe and operable condition as required by its policies and federal regulations. In Medication Room A, a leaking sink faucet was observed, with water pooling at the base and visible discoloration on the sink strainer and surrounding area. Both the RN and DON confirmed the ongoing leak and associated staining, and the Director of Maintenance acknowledged that the issue could have been addressed if it had been reported by nursing staff. In the main kitchen, the ice machine was found to have black particles on the deflector and grooves, despite records indicating recent cleaning by both an outside vendor and facility staff. The Director of Maintenance confirmed that dietary staff were not using the manufacturer-recommended cleaning and sanitizing products for the ice machine bin and exterior, contrary to both facility policy and manufacturer instructions. Additionally, significant ice build-up was observed in the walk-in freezer in the main kitchen, the freezer in the satellite kitchen, and the freezer of the refrigerator used for residents' food brought from outside. The Culinary Director and Director of Maintenance attributed the ice build-up in the main kitchen freezer to a faulty door, which was pending replacement, and cleaning logs indicated regular cleaning, though the issue persisted. The facility also failed to ensure that food temperature measuring devices were properly calibrated. During an observation, a Dietary Aide was seen incorrectly calibrating a digital thermometer, and the CDM confirmed the calibration was not performed according to manufacturer instructions. The thermometer was subsequently used to check food temperatures, raising concerns about the accuracy of temperature monitoring. These failures collectively demonstrate lapses in equipment maintenance, cleaning, and calibration protocols as outlined in facility policies and relevant regulatory standards.
Failure to Conduct Timely Bed Safety and Entrapment Assessments
Penalty
Summary
The facility failed to ensure that bed safety inspections and entrapment assessments were properly conducted for residents using bed rails, as required by facility policy and federal guidance. Specifically, for two residents, there were documented gaps between the mattress and the side/bed rail, headboard, and footboard, which were identified during initial nursing evaluations. Despite these findings, there was no evidence that maintenance staff performed follow-up inspections or entrapment assessments in response to these identified risks. For one resident, the initial evaluation noted gaps that could pose entrapment risks, but the Director of Maintenance confirmed that he did not conduct a new inspection or assessment after the resident's admission or after changes in the bed or mattress. The maintenance department relied on annual inspections and only performed additional checks if a low air loss mattress was used or if repairs were requested by nursing staff. Documentation provided by the Director of Maintenance showed that some entrapment zones were not assessed, and certain required measurements were left blank. For another resident, the initial evaluation also indicated gaps between the mattress and bed components, but the Director of Maintenance was unaware of these findings and could not provide documentation of a bed entrapment assessment for this resident. The facility's process did not ensure that entrapment risks identified by nursing staff were communicated to or addressed by maintenance, resulting in a lack of timely and comprehensive bed safety assessments for residents at risk.
Survey Results and Plan of Correction Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the most recent Recertification Survey's plan of correction was readily accessible to residents and the public. During a residents' group meeting, five of nine residents reported they did not know where the latest survey results were located and were unaware of their rights to review these results. Upon review, a white binder containing the CMS 2567 from the last recertification survey was found in the lobby, but it did not include a copy of the Plan of Correction. The Administrator confirmed that the Plan of Correction was missing from the binder and acknowledged that it may have been removed.
Failure to Label and Date Family-Brought Food
Penalty
Summary
The facility failed to implement its policy and procedure regarding the labeling and storage of food brought in by family members for residents. During an observation, an unlabeled and undated resealable plastic bag of dry cereal was found on a resident's bedside table. The facility's policy required all food brought in by family or visitors and left with the resident to be labeled and stored in a manner that distinguishes it from facility-prepared food, with non-perishable foods stored in resealable containers with tightly fitting lids. An LVN stated that only wet food was labeled, not dry food, and the DON confirmed that the dry cereal should have been labeled and dated.
Failure to Develop Care Plan for Resident's Fall Risk
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who exhibited behaviors of getting up from a wheelchair, posing a risk of falls. The resident, who was identified as a fall risk, showed behaviors such as being easily distracted, having altered perception, disorganized thoughts, restlessness, lethargy, and confusion. Despite these observations, the facility did not create a care plan with specific interventions to address the resident's behavior of getting up from the wheelchair, which led to an incident where the resident was found sitting on the floor. The medical records and interviews with facility staff, including an LVN and the DON, confirmed the absence of a care plan addressing the resident's behavior and fall risk. The resident's cognitive assessment indicated severe impairment, with a BIMS score of 3, further emphasizing the need for a tailored care plan. The facility's policy required comprehensive, person-centered care plans with measurable objectives, but this was not implemented for the resident in question, leading to a deficiency in care planning and risk management.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 4,447 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Yorba Linda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kindred Hospital Brea D/p Snf | 4.8 mi | ★★★★★ | 27 | 0 |
| Gordon Lane Care Center | 4.8 mi | ★★★★★ | 29 | 0 |
| Park Vista At Morningside | 5.2 mi | ★★★★★ | 21 | 0 |
| St. Catherine Healthcare | 6 mi | ★★★★★ | 22 | 0 |
| Parkview Healthcare Center | 6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.