Deficiency Records for Bayshire Yorba Linda Post-Acute
Updated as of May 01, 2024
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Deficiency Records for Bayshire Yorba Linda Post-Acute
A list of the most recent deficiencies for Bayshire Yorba Linda Post-Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Bayshire Yorba Linda Post-Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-01-26 | 2024-02-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-26 | 2024-02-23 | N |
| 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. | Health | 2024-01-26 | 2024-02-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-26 | 2024-02-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-26 | 2024-02-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-26 | 2024-02-23 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-01-26 | 2024-02-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-26 | 2024-02-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-26 | 2024-02-23 | N |
| 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. | Health | 2024-01-26 | 2024-02-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-26 | 2024-02-23 | N |
| 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. | Health | 2024-01-26 | 2024-02-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-26 | 2024-02-23 | N |
| 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. | Health | 2024-01-26 | 2024-02-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-26 | 2024-02-23 | N |
| 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. | Health | 2024-01-26 | 2024-02-23 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-01-26 | 2024-02-23 | N |
| 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. | Health | 2024-01-26 | 2024-02-23 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-01-26 | 2024-02-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-26 | 2024-02-23 | N |
| Dispose of garbage and refuse properly. | Health | 2024-01-26 | 2024-02-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-26 | 2024-02-23 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-26 | 2024-02-23 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-01-26 | 2024-02-23 | N |
| 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. | Health | 2024-01-26 | 2024-02-23 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-01-26 | 2024-02-23 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-01-26 | 2024-02-22 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-01-26 | 2024-02-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-26 | 2024-02-22 | N |
| Keep all essential equipment working safely. | Health | 2024-01-26 | 2024-02-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-01-30 | 2024-02-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-01-30 | 2024-02-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-30 | 2024-02-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-01-30 | 2024-02-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-30 | 2024-02-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-30 | 2024-02-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-30 | 2024-02-21 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-01-19 | 2023-02-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-01-19 | 2023-02-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-19 | 2023-02-08 | N |
| Use approved construction type or materials. | Fire Safety | 2023-01-19 | 2023-02-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-19 | 2023-02-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-19 | 2023-02-08 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-01-19 | 2023-02-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-19 | 2023-02-08 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-01-19 | 2023-02-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-19 | 2023-02-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-19 | 2023-02-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-19 | 2023-02-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-19 | 2023-02-08 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-01-13 | 2023-01-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-13 | 2023-01-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-13 | 2023-01-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-01-13 | 2023-01-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-13 | 2023-01-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-01-13 | 2023-01-24 | N |
| 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. | Health | 2023-01-13 | 2023-01-24 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-01-13 | 2023-01-24 | N |
| 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. | Health | 2023-01-13 | 2023-01-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-13 | 2023-01-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-13 | 2023-01-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-15 | 2022-03-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-22 | 2021-10-22 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-06-25 | 2019-09-11 | N |
| 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. | Health | 2019-06-25 | 2019-09-11 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-06-25 | 2019-09-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-25 | 2019-09-11 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-06-25 | 2019-08-13 | N |
| 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. | Health | 2019-06-25 | 2019-08-13 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-06-25 | 2019-08-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-25 | 2019-08-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-06-25 | 2019-08-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-25 | 2019-08-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-06-25 | 2019-08-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-25 | 2019-08-13 | N |
| Dispose of garbage and refuse properly. | Health | 2019-06-25 | 2019-08-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-06-25 | 2019-08-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-06-25 | 2019-08-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-06-25 | 2019-08-13 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-07-11 | 2019-08-05 | N |
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