BAYSHIRE YORBA LINDA POST-ACUTE
17803 IMPERIAL HIGHWAY, YORBA LINDA, CA, 92886 · 7147779666
Legal business name: SKILLED YORBA LINDA LLC
On the CMS record
- Overall rating (CMS)
- 4 / 5
- Health inspection rating
- 3 / 5
- Staffing rating
- 4 / 5
- Certified beds
- 45
- Ownership type
- For profit - Individual
- Chain
- BAYSHIRE SENIOR COMMUNITIES
Inspection findings on record (65)
Quoted exactly as CMS published them. We do not rewrite findings.
— Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Recorded as corrected on .
— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Recorded as corrected on .
— Resident Rights Deficiencies
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.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Recorded as corrected on .
— Pharmacy Service Deficiencies
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.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
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.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Recorded as corrected on .
— Pharmacy Service Deficiencies
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.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Recorded as corrected on .
— Pharmacy Service Deficiencies
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.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Recorded as corrected on .
— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Recorded as corrected on .
— Environmental Deficiencies
Keep all essential equipment working safely.
Recorded as corrected on .
— Environmental Deficiencies
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.
Recorded as corrected on .
— Resident Rights Deficiencies
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Recorded as corrected on .
— Environmental Deficiencies
Keep all essential equipment working safely.
Recorded as corrected on .
— Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Recorded as corrected on .
— Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Recorded as corrected on .
— Resident Rights Deficiencies
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.
Recorded as corrected on .
— Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
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.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
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.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Recorded as corrected on .
— Pharmacy Service Deficiencies
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.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Recorded as corrected on .
— Pharmacy Service Deficiencies
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.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
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.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Recorded as corrected on .
— Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Recorded as corrected on .
— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Recorded as corrected on .
— Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Recorded as corrected on .
— Environmental Deficiencies
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.
Recorded as corrected on .
— Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
Recorded as corrected on .
Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 555768