Inspection Reports for
Bayshire Yorba Linda
17803 Imperial Hwy., Yorba Linda, CA 92886, United States, CA, 92886
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
17.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
343% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
85% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 25, 2025
Visit Reason
The inspection was conducted based on a complaint investigation regarding the facility's failure to provide necessary care and services to Resident 4, specifically the failure to obtain orthostatic blood pressure measurements as ordered by the physician.
Complaint Details
The complaint investigation found the facility failed to follow physician orders for orthostatic blood pressure checks for Resident 4. The failure was substantiated by medical record review and staff interviews.
Findings
The facility failed to ensure Resident 4's orthostatic blood pressure was obtained in lying, sitting, and standing positions as ordered from 11/18 to 11/20/25. This failure posed a potential risk for falls due to possible drops in blood pressure when changing positions. Interviews with LVN 3 and the Director of Nursing confirmed the findings.
Deficiencies (1)
Failure to obtain Resident 4's orthostatic blood pressure in all three positions (lying, sitting, standing) as ordered.
Report Facts
Dates of blood pressure checks: 3
Blood pressure readings: Specific blood pressure and pulse readings were recorded on 11/18/25, 11/19/25, and 11/20/25 but did not include all three positions as ordered.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 3 | Verified the order and confirmed the failure to obtain orthostatic blood pressure as ordered. | |
| Director of Nursing (DON) | Acknowledged the findings during interview. |
Inspection Report
Follow-Up
Census: 97
Capacity: 114
Deficiencies: 0
Date: Sep 17, 2025
Visit Reason
The visit was an unannounced Case Management follow-up on a death report received from the facility.
Complaint Details
The visit was complaint-related to a death report. Interviews with staff and a witness confirmed the death was due to natural causes with no foul play suspected. The incident was not substantiated as questionable.
Findings
No imminent health or safety concerns were observed during the visit. Based on record review and interviews, the incident was determined not to be a questionable death, and no deficiencies were found.
Report Facts
Facility capacity: 114
Census: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Edward Kim | Licensing Program Analyst | Conducted the inspection and authored the report |
| Austin Morris | Executive Director | Met with the Licensing Program Analyst at the start of the visit |
| Mirian Im | Resident Service Director | Signed on behalf of the facility and received a copy of the report |
Inspection Report
Complaint Investigation
Census: 94
Capacity: 114
Deficiencies: 0
Date: Aug 15, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility does not have hot water.
Complaint Details
The complaint alleged that half of the building was experiencing hot water issues, with intermittent water shutoffs and lack of resolution by a plumber. Interviews showed some staff and one witness confirmed the allegation, while others denied it. Water temperature logs from July 6 to August 13, 2025, showed temperatures never below 105°F or above 120°F. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation included observations, interviews, and record reviews which found water temperatures within acceptable ranges and mixed staff and resident reports. There was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.
Report Facts
Water temperature measurements: 115
Water temperature measurements: 113.5
Water temperature measurements: 117.3
Water temperature measurements: 118
Water temperature measurements: 116.6
Water temperature measurements: 112.6
Water temperature measurements: 114.4
Water temperature measurements: 113.7
Water temperature measurements: 116.2
Water temperature measurements: 115.7
Water temperature measurements: 114.8
Water temperature measurements: 114.4
Water temperature measurements: 109.7
Water temperature log range: 105
Water temperature log range: 120
Staff interviewed: 12
Residents interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Edward Kim | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Austin Morris | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
| Lourdes Montoya | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Plan of Correction
Census: 94
Capacity: 114
Deficiencies: 0
Date: Aug 15, 2025
Visit Reason
The visit was a case management Plan of Correction (POC) visit to clear a deficiency observed during a case management visit on July 10, 2025, and was conducted in conjunction with the investigation of complaint 22-AS-20250703163459.
Complaint Details
Investigation was conducted in conjunction with complaint 22-AS-20250703163459; no substantiation status explicitly stated.
Findings
During the visit, water temperature readings in several resident bathrooms were observed and documented, with temperatures ranging from 113.7 to 117.3 degrees Fahrenheit. A 24-hour water temperature log completed on July 11, 2025, was provided, and a POC letter documenting corrections was given to the facility representative.
Report Facts
Water temperature reading: 117.3
Water temperature reading: 116.6
Water temperature reading: 113.7
Capacity: 114
Census: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Edward Kim | Licensing Program Analyst | Conducted the case management POC visit |
| Austin Morris | Executive Director | Facility representative met during inspection and provided documentation |
Inspection Report
Census: 90
Capacity: 114
Deficiencies: 1
Date: Jul 10, 2025
Visit Reason
A case management visit was conducted to document a deficiency observed during the investigation of complaint 22-AS-20250703163459, unrelated to the allegations investigated.
Findings
The facility did not maintain hot water temperatures between 105 and 120 degrees Fahrenheit in resident rooms 103, 112, and 135, with temperatures measured above 120 degrees, posing an immediate health or safety risk.
Deficiencies (1)
Facility did not maintain hot water temperature between 105 degrees F and 120 degrees F for resident rooms 103, 112, and 135.
Report Facts
Water temperature: 125
Water temperature: 121.4
Deficiency Plan of Correction due date: Jul 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Edward Kim | Licensing Program Analyst | Conducted the case management visit and documented the deficiency |
| Austin Morris | Executive Director | Met with during the inspection and received the report and appeal rights |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 114
Deficiencies: 0
Date: May 5, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to a complaint received on 2025-02-11 regarding staffing sufficiency in the memory care unit, safeguarding of resident property, and adequacy of personal care supplies.
Complaint Details
The complaint included allegations that the facility did not have sufficient staff in the memory care unit, failed to safeguard resident's property, and failed to ensure adequate personal care supplies. The investigation concluded the allegations were unsubstantiated due to lack of sufficient evidence.
Findings
The investigation found no sufficient evidence to substantiate the allegations. Observations, interviews, and record reviews indicated that staffing levels met residents' needs, resident property was appropriately safeguarded, and adequate personal care supplies were available or provided as per admission agreements.
Report Facts
Memory care residents: 22
Staff providing direct care in memory care unit: 4
Facility capacity: 114
Facility census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Edward Kim | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Austin Morris | Executive Director | Facility representative met during the investigation and exit interview |
Inspection Report
Annual Inspection
Census: 84
Capacity: 114
Deficiencies: 2
Date: May 5, 2025
Visit Reason
The inspection was an unannounced required 1-Year annual visit conducted to assess compliance with licensing requirements using the CARE Inspection Tool.
Findings
The facility was found to be generally well-maintained, sanitary, and appropriately furnished with adequate supplies and emergency preparedness. However, deficiencies were cited related to medication administration not following physician's directions for four residents and one staff member lacking a valid TB test.
Deficiencies (2)
Four out of nine residents' medications were not given according to physician's directions, posing a potential health, safety, and/or personal rights risk.
One out of eight staff did not have a valid TB test in their records, posing a potential health, safety, and/or personal rights risk.
Report Facts
Resident files audited: 9
Staff files audited: 8
Resident interviews conducted: 6
Staff interviews conducted: 4
Medication deficiencies: 4
Staff with missing TB test: 1
Plan of Correction Due Date: May 19, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Austin Morris | Executive Director | Participated in the inspection tour and exit interview |
| Miriam Im | Resident Service Director | Met with Licensing Program Analysts during the inspection tour |
| Edward Kim | Licensing Program Analyst | Conducted the inspection and authored the report |
Inspection Report
Routine
Deficiencies: 14
Date: Apr 7, 2025
Visit Reason
The inspection was a routine regulatory survey conducted to assess compliance with healthcare facility regulations, including resident care, medication management, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to ensure accessibility of survey results, incomplete care plans, medication administration errors, inadequate infection control practices, improper medication storage, unsanitary kitchen conditions, incomplete medical records, and failure to properly inspect beds for entrapment risks.
Deficiencies (14)
Failure to ensure the most recent Recertification Survey's plan of correction was readily accessible to residents and public.
Failure to develop and implement a complete care plan reflecting individual care needs for Resident 25's spinal precautions and use of LSO brace.
Failure to revise residents' comprehensive care plans to accurately address use of side rails for Residents 16, 17, and 339.
Failure to provide safe and appropriate respiratory care including oxygen administration as per physician's orders and proper signage for Residents 1, 2, and 19.
Failure to ensure proper pharmaceutical services including medication administration and narcotic count documentation; failure to provide insulin medication as ordered for Resident 25.
Failure to monitor and manage psychotropic medication use appropriately for Residents 4 and 26, including lack of monitoring for adverse effects and incomplete diagnoses.
Medication administration errors including failure to instruct residents on not chewing extended release medications and failure to assess for bleeding symptoms.
Failure to ensure medication cart was locked and medications stored securely; medications accessible to non-licensed staff.
Failure to maintain sanitary conditions in kitchen including unlabeled and expired food, unclean utensils and equipment, improper drying of scoops, and unsanitary cutting boards.
Failure to implement policy for storage of foods brought by family members; unlabeled and undated food items found in resident rooms.
Failure to maintain complete and accurate medical records including incomplete consents, missing documentation of physician notifications, and missing advance directives.
Failure to implement infection prevention and control program including inaccurate infection classification, failure to implement neutropenic and enhanced barrier precautions, and unclean medication room sink.
Failure to maintain essential equipment including leaking sink faucet, unclean ice machine not cleaned per manufacturer specifications, ice build-up in freezers, and improperly calibrated thermometer.
Failure to regularly inspect beds and conduct entrapment assessments for residents using bed rails, with incomplete documentation and lack of follow-up on identified risks.
Report Facts
Medication error rate: 22.58
Missing narcotic shift count signatures: 40
Residents reviewed: 13
Residents affected by specific deficiencies: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Named in medication error findings, consent form issues, and medication administration documentation | |
| LVN 1 | Named in medication errors and narcotic count discrepancies | |
| LVN 2 | Named in medication errors and enhanced barrier precaution failure | |
| LVN 3 | Named in insulin medication administration finding | |
| LVN 4 | Named in medication administration documentation and consent follow-up | |
| DON | Director of Nursing | Acknowledged multiple findings including medication errors, infection control, and medical record deficiencies |
| Administrator | Acknowledged multiple findings including medication errors and infection control | |
| Director of Maintenance | Named in equipment maintenance and bed inspection deficiencies | |
| Dietary Aide | Named in kitchen sanitation and thermometer calibration findings | |
| IP | Infection Preventionist | Named in infection control deficiencies |
| MDS Coordinator | Named in informed consent documentation findings | |
| CNA 2 | Named in failure to follow enhanced barrier precautions | |
| CNA 4 | Named in medication storage and kitchen sanitation findings |
Inspection Report
Follow-Up
Census: 82
Capacity: 114
Deficiencies: 0
Date: Apr 2, 2025
Visit Reason
An unannounced Case Management Visit was conducted to follow-up on incident reports received from the facility.
Findings
During the visit, a health and safety check was conducted with no imminent health or safety concerns observed. No deficiencies were cited during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Edward Kim | Licensing Program Analyst | Conducted the unannounced Case Management Visit and interviews. |
| Austin Morris | Executive Director | Greeted the Licensing Program Analyst and was present during the visit. |
| Chad Coleman | Administrator | Named as facility administrator. |
Inspection Report
Deficiencies: 1
Date: Mar 4, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically to assess whether the facility developed and implemented a complete care plan addressing Resident 1's individual care needs and behaviors related to fall risk.
Findings
The facility failed to develop and implement a care plan with measurable objectives and interventions to address Resident 1's behavior of getting up from the wheelchair, posing a risk of inconsistent and inappropriate care. Interviews and medical record reviews confirmed the absence of a care plan and interventions to prevent further fall incidents for Resident 1.
Deficiencies (1)
Failure to develop and implement a complete care plan addressing Resident 1's behavior of getting up from the wheelchair and preventing further falls.
Report Facts
BIMS score: 3
Times up in wheelchair: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding Resident 1's episodes of trying to get up from the wheelchair |
| DON | Director of Nursing | Interviewed and confirmed absence of care plan and interventions for Resident 1 |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 114
Deficiencies: 0
Date: May 29, 2024
Visit Reason
An unannounced complaint investigation visit was conducted regarding allegations that the Administrator was not present in the facility and not qualified to be an Administrator.
Complaint Details
The complaint was filed on 2024-05-23 alleging the Administrator was not present and not qualified. The investigation determined the allegations to be unfounded.
Findings
The investigation found that the allegations were unfounded. Staff provided evidence that the current Administrator is qualified and holds a valid Administrator's certificate, and the Administrator's presence in the facility varies but is consistent with scheduling fluctuations.
Report Facts
Capacity: 114
Census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted the complaint investigation visit |
| Chad Coleman | Administrator | Named as the current Administrator with a valid certificate |
| Luz Adams | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 114
Deficiencies: 0
Date: May 7, 2024
Visit Reason
An unannounced complaint investigation visit was conducted regarding an allegation that unqualified staff are allowed to work at the facility.
Complaint Details
The complaint alleged that unqualified staff were allowed to work at the facility. Two staff members interviewed denied the allegation. Documentation including a valid Administrator's Certificate was provided for the staff in question. The allegation was deemed unfounded.
Findings
The investigation found the allegation to be unfounded after interviews and document review, confirming that staff were qualified and the complaint was false.
Report Facts
Complaint control number: 22
Complaint control number suffix: 20240502113510
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jerome Haley | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jeff Stewart | Executive Director | Met with during the investigation |
| Chad Coleman | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 114
Deficiencies: 2
Date: Apr 16, 2024
Visit Reason
An unannounced case management visit was conducted to follow up on an incident report sent to the Regional Office dated April 13, 2024, regarding a personal rights violation.
Complaint Details
The visit was complaint-related, following an incident report. A personal rights violation was substantiated based on staff interviews and document review.
Findings
Staff interviews and document review confirmed a personal rights violation involving a resident being restrained improperly, and deficiencies related to criminal record clearance for two staff members were cited.
Deficiencies (2)
Personal Rights of Residents violated by staff restraining a resident by grabbing their arms and confining them to a wheelchair, posing an immediate health and safety risk.
Criminal Record Clearance requirement not met as two staff members were not properly cleared prior to working in the facility, posing an immediate health and safety risk.
Report Facts
Capacity: 114
Census: 79
Deficiencies cited: 2
Plan of Correction Due Date: Apr 17, 2024
Inspection Report
Original Licensing
Census: 82
Capacity: 114
Deficiencies: 0
Date: Mar 26, 2024
Visit Reason
The visit was an announced pre-licensing inspection conducted to evaluate the facility for initial licensing and certification.
Findings
The facility was toured and found to have appropriate safety features including fire extinguishers, smoke and carbon monoxide detectors, locked medication rooms, and emergency call systems. The facility was stocked with necessary supplies and was deemed ready to be licensed.
Report Facts
Bedrooms in Assisted Living: 90
Residents in Assisted Living: 60
Bedrooms in Memory Care: 23
Residents in Memory Care: 22
Hot water temperature range (degrees F): 107.1-119
Fire clearance capacity: 114
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Mendivil | Licensing Program Analyst | Conducted the pre-licensing visit and inspection |
| Marie Stern | Director of Operations | Met with Licensing Program Analyst during the visit and toured the facility |
| Hrag Bekerian | Administrator | Met with Licensing Program Analyst during the visit and toured the facility |
Inspection Report
Original Licensing
Capacity: 114
Deficiencies: 0
Date: Mar 19, 2024
Visit Reason
The visit was conducted as a telephone interview for the Change of Ownership (CHOW) application process, verifying the applicant/administrator's understanding of community care facility licensing laws and readiness for licensing.
Findings
The applicant and administrator confirmed their understanding of licensing laws, facility operation, admission policies, staffing requirements, restrictive health conditions, emergency preparedness, complaints reporting, and pre-licensing readiness. Identification was verified and required documentation was obtained.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chad Coleman | Administrator | Applicant/administrator participating in licensing interview and verification |
| Julia Kim | Licensing Program Manager | Named as Licensing Program Manager overseeing the evaluation |
| Nicole Rouse | Licensing Program Analyst | Named as Licensing Program Analyst conducting the evaluation |
Inspection Report
Routine
Deficiencies: 21
Date: Jan 26, 2024
Visit Reason
Routine inspection of Bayshire Yorba Linda Post-Acute facility to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to obtain informed consent for psychotropic medication, inadequate call light accessibility, incomplete advance directives in medical records, failure to notify timely weight changes, incomplete baseline care plans, incomplete care plans for medication use, failure to provide appropriate treatment and care, medication administration errors, improper enteral feeding care, oxygen administration issues, medication storage and labeling problems, dietary service deficiencies, incomplete medical records, failure to monitor antibiotic use, equipment maintenance issues, infection control lapses, bed safety concerns, and pest control problems.
Deficiencies (21)
Failed to ensure informed consent was obtained for psychotropic medication for Resident 330.
Call light was not within reach for Resident 8.
Failed to ensure advance directives were part of medical records for Residents 19, 25, and 429.
Failed to notify physician, RD, and responsible party timely for Resident 16's weight changes.
Failed to develop baseline care plans related to fall risk for Resident 379.
Failed to develop comprehensive care plans for Residents 25, 330, and 679 related to medication and monitoring.
Failed to provide services to attain or maintain well-being for Residents 8, 9, and 679 including medication administration and monitoring.
Failed to provide necessary enteral tube care and services for Residents 16 and 629.
Failed to ensure proper care and monitoring of peripheral intravenous catheter for Resident 429.
Failed to provide safe and appropriate respiratory care for Residents 330, 429, and 629.
Failed to provide pharmaceutical services meeting residents' needs including medication administration errors and controlled drug documentation.
Failed to ensure dietary staff had appropriate skills for safe food and nutrition service operations.
Failed to ensure menus met nutritional needs and were followed, including food preferences and meal tickets.
Failed to ensure sanitary requirements in the kitchen including hand hygiene, hair/beard restraints, food labeling, cleanliness, and personal belongings storage.
Failed to dispose and store trash in a sanitary manner; dumpsters lids were open or overflowing.
Failed to safeguard resident-identifiable information and maintain complete medical records for multiple residents including inaccurate insulin administration documentation and incomplete care conference assessments.
Failed to implement ongoing quality assessment and assurance program to monitor corrective plans of action.
Failed to maintain essential kitchen equipment in safe operating condition including dish machine, sink, and refrigerator freezer.
Failed to ensure residents' beds were inspected, entrapment assessments completed, and records maintained for bed rails use.
Failed to provide and implement an infection prevention and control program including proper isolation precautions, hand hygiene, equipment disinfection, labeling of bedpans and basins, urinary drainage bag placement, and personal belongings storage.
Failed to implement a program that monitors antibiotic use including completion of criteria for true infection and antibiotic order clarification.
Report Facts
Deficiencies cited: 21
Deficiencies cited: 1
Weight change: 15.2
Weight change: 10.1
Medication doses: 13
Medication doses: 7
Medication doses: 3
Medication doses: 2
Medication doses: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Named in medication administration errors and enteral feeding observations |
| LVN 3 | Licensed Vocational Nurse | Named in medication administration errors and eye drop administration |
| DON | Director of Nursing | Verified multiple findings including informed consent, medication errors, infection control, and quality assurance |
| CNA 1 | Certified Nursing Assistant | Verified call light accessibility and infection control observations |
| CNA 4 | Certified Nursing Assistant | Verified call light accessibility and baseline care plan findings |
| RN 1 | Registered Nurse | Verified medication administration, infection control, and insulin administration documentation |
| IP/DSD | Infection Preventionist/Designee | Verified infection control findings and food storage issues |
| CDM | Certified Dietary Manager | Verified dietary service deficiencies and dish machine issues |
| Culinary Director | Culinary Director | Verified dietary service deficiencies and food service observations |
| Plant Operations Director | Plant Operations Director | Verified bed safety and kitchen equipment maintenance findings |
| Family Member 1 | Interviewed regarding infection control isolation procedures | |
| Physician 1 | Physician | Interviewed regarding dietary and medication orders |
| RD 1 | Registered Dietitian | Interviewed regarding dietary consults and formula |
| RD 2 | Registered Dietitian | Interviewed regarding dietary consults and formula |
Inspection Report
Routine
Deficiencies: 11
Date: Jan 13, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including medication administration, respiratory care, pain management, pharmaceutical services, food and nutrition services, infection control, and other care standards.
Findings
The facility was found deficient in multiple areas including failure to provide written notice of bed hold policy upon resident transfer, failure to follow physician orders for equipment and medication administration, inadequate respiratory care, insufficient pain management documentation, pharmaceutical service deficiencies including medication order and monitoring issues, expired medication storage, inadequate food service supervision and menu adherence, food safety and sanitation violations, and lapses in infection control practices during medication administration.
Deficiencies (11)
Failed to provide written notice of bed hold policy to resident or responsible party upon transfer to acute care facility.
Failed to ensure physician's order for pommel cushion in wheelchair was followed.
Failed to provide necessary respiratory care and services including unclear oxygen order, unlabeled nebulizer tubing, and undocumented CPAP cleaning.
Failed to ensure pain management included non-pharmacological interventions prior to narcotic administration.
Failed to follow physician's orders for medication administration site, failed to monitor anticoagulant side effects, and administered medication without indication.
Failed to ensure pharmacist reported medication irregularities for anticoagulant monitoring and medication indication.
Failed to dispose expired medications in Medication Room.
Failed to employ a full-time qualified dietitian or qualified full-time dietetic services supervisor to oversee food service operations.
Failed to follow puree recipes, correct portion sizes, and provide food as listed on resident meal ticket.
Failed to ensure food safety and sanitary requirements including unlabeled thawing frozen food, lack of air gap on ice machine plumbing, undated opened food items, unsanitary kitchen equipment, unsafe food storage, and improper storage of staff personal belongings.
Failed to ensure proper infection control practices during medication administration; missed multiple hand hygiene opportunities.
Report Facts
Residents receiving food prepared in kitchen: 16
Medication administration dates: 20
Medication order dates: 3
Medication order dates: 2
Medication administration observation date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 2 | Licensed Vocational Nurse | Named in medication administration and infection control deficiencies |
| LVN 3 | Licensed Vocational Nurse | Named in medication administration and pharmaceutical service deficiencies |
| DON | Director of Nursing | Acknowledged multiple findings including medication and infection control issues |
| CNA 1 | Certified Nursing Assistant | Interviewed regarding wheelchair cushion use |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding meal service to Resident 473 |
| Culinary Director | Culinary Director | Interviewed regarding food service supervision, menu adherence, and kitchen sanitation |
| Registered Dietitian | Registered Dietitian | Consultant dietitian interviewed regarding food service and sanitation |
| Consultant Pharmacist 1 | Consultant Pharmacist | Interviewed regarding medication order review and irregularities |
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding respiratory care and anticoagulant monitoring |
| Treatment Nurse | Treatment Nurse | Interviewed regarding wheelchair cushion and respiratory care |
| Maintenance Assistant | Maintenance Assistant | Interviewed regarding ice machine plumbing air gap |
| Dishwasher 1 | Dishwasher | Interviewed regarding personal belongings in kitchen |
Report
November 20, 2025
Report
November 19, 2025
Report
October 20, 2025
Report
July 10, 2025
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April 16, 2024
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