SAN DIMAS, CA - Federal inspectors found that Bayshire San Dimas Post-Acute failed to maintain proper emergency response capabilities after discovering that staff lacked current CPR certification and the facility operated with insufficient nursing coverage during overnight shifts.
Staff Unprepared for Medical Emergencies
Federal inspectors identified critical gaps in the facility's emergency response preparedness during a February 2025 inspection. A certified nursing assistant (CNA 5) was found working without valid CPR certification, with facility leadership unable to provide documentation of current Basic Life Support (BLS) training.
The Director of Staff Development acknowledged during the inspection that CNA 5's certification had expired and confirmed the facility could not produce a current BLS/CPR card or any documentation showing the employee had completed the necessary courses for recertification. The tracking system used to monitor staff certifications was found to be incomplete, with columns for CPR issue dates and expiration dates left blank.
This situation represents a significant safety concern, as CPR certification is mandatory for healthcare workers who may need to respond to cardiac emergencies. The facility's own emergency procedures specify that all staff should be prepared to initiate chest compressions at a 30:2 ratio (30 compressions to 2 breaths) when residents become unresponsive.
The Director of Nursing emphasized during the inspection that "every second counted" in emergency situations and stated that all staff should be prepared to perform CPR rather than waiting for assistance. However, the facility was unable to demonstrate that all staff possessed the necessary training to fulfill this critical responsibility.
Knowledge Gaps in Emergency Response Protocols
The inspection revealed concerning gaps in staff knowledge of basic life support procedures. When questioned about CPR protocols, one certified nursing assistant (CNA 6) demonstrated insufficient understanding of the proper compression-to-breath ratio required for effective cardiopulmonary resuscitation.
This knowledge deficit is particularly troubling given that nursing assistants are often the first responders in emergency situations within nursing facilities. Federal regulations require that all nursing home staff maintain current CPR certification through approved providers that include hands-on practice and in-person skills assessment. Online-only certification programs do not meet federal standards for healthcare facilities.
The facility's policy documentation states that CPR and BLS procedures should be initiated in response to sudden cardiac arrest, with all trained rescuers expected to provide chest compressions and ventilations. However, the inspection found that staff lacked both the certification and practical knowledge necessary to implement these lifesaving measures effectively.
Medical experts note that proper CPR technique can double or triple survival rates for cardiac arrest victims. The American Heart Association emphasizes that high-quality chest compressions delivered at the correct depth and rate are crucial for maintaining blood circulation to vital organs until advanced medical care arrives.
Inadequate Overnight Nursing Coverage
The facility was cited for failing to provide sufficient nursing staff during overnight shifts, a violation that directly affected resident care and safety. On multiple dates in February 2025, including February 3, 5, and 6, only two certified nursing assistants were scheduled to work the night shift instead of the facility's standard three-person staffing requirement.
Two residents reported significant delays in receiving assistance during overnight hours. Resident 19, who requires help with basic activities of daily living due to right-side weakness and muscle wasting, reported waiting up to 30 minutes for staff response when using the call light. "I don't know if there was enough staff or they were just too busy," the resident stated.
Resident 27, who needs maximum assistance with personal hygiene and mobility tasks following hip replacement surgery, experienced even longer delays. This resident reported waiting up to 40 minutes for assistance when using the restroom call light and expressed concern that "they send the staff home because they don't want to pay overtime."
These delays pose serious safety risks for residents who may need urgent assistance with mobility, medication administration, or emergency situations. Extended response times can lead to falls, complications from delayed medication, or worsening of medical conditions that require prompt attention.
Industry Standards and Medical Implications
Federal regulations mandate that nursing facilities maintain adequate staffing levels to meet residents' needs around the clock. The facility's own policy requires sufficient numbers of nursing staff with appropriate competencies to provide necessary care and services for all residents.
Proper staffing ratios are particularly critical during overnight hours when fewer supervisory staff are present and medical emergencies may be more likely to occur. Research indicates that inadequate nursing home staffing is associated with increased rates of hospitalizations, infections, and other adverse health outcomes.
The CPR certification violations compound these staffing concerns by potentially leaving the facility unable to respond effectively to cardiac emergencies. Federal guidelines specify that nursing facilities must be able to provide immediate basic life support, including CPR, to any resident requiring such care before emergency medical personnel arrive.
Effective CPR requires specific training in chest compression depth (at least 2 inches for adults), compression rate (100-120 per minute), and proper ventilation techniques. Without current certification and regular skills practice, staff may not maintain the competency needed to perform these procedures correctly under pressure.
Additional Issues Identified
Beyond the major violations, inspectors documented several related concerns about the facility's emergency preparedness and staff training systems. The tracking system for monitoring staff certifications was found to be incomplete and unreliable, making it difficult for supervisors to identify when renewals were needed.
The facility also lacked a specific policy addressing CPR procedures, despite having general emergency response protocols. This gap in policy documentation may contribute to inconsistent training and unclear expectations for staff response during medical emergencies.
The Director of Staff Development acknowledged that complete and accurate tracking of staff certifications was essential for ensuring timely renewals and maintaining emergency response capabilities. The inspection findings suggest systematic issues with how the facility manages and monitors mandatory staff training requirements.
These violations highlight the interconnected nature of nursing home safety systems, where gaps in staffing, training, and oversight can combine to create significant risks for vulnerable residents who depend on skilled nursing care around the clock.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brookdale San Dimas from 2025-02-09 including all violations, facility responses, and corrective action plans.
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