Bayshire San Dimas: Dialysis Transport Failures - CA
The resident last received dialysis on July 23. By August 11, their blood urea nitrogen had climbed to 79 milligrams per deciliter — more than three times the normal maximum of 24. Their creatinine level hit 8.4, nearly eight times higher than the normal range for women.
Nobody had acted despite weeks of warning signs.
On July 19, staff documented that the resident missed dialysis and couldn't reschedule due to insurance issues. The primary physician was notified but issued no new orders. Nine days later, the resident missed another session due to transportation problems. This time, the doctor ordered monitoring for fluid overload, fatigue, muscle cramps, loss of appetite and mental changes.
For the next two weeks, nurses dutifully recorded the same observation in progress notes: the resident was being monitored for fluid retention due to missing dialysis. August 7, 11:50 pm. August 8, 7:18 am. August 9, 9:36 am. August 10. Each entry identical, each day more dangerous.
The laboratory call came on August 11. A nurse received results showing the resident's kidney function had deteriorated to critical levels. The primary physician finally ordered a nephrology consultation, but by then the resident had developed severe complications.
Hospital records from August 14 revealed the resident suffered left-sided flank pain and nausea for a full week before transfer. Doctors diagnosed metabolic complications directly caused by missed hemodialysis treatments.
During the inspection, the facility's Director of Nursing acknowledged the nursing home was responsible for arranging the resident's dialysis transportation. "When Resident 2 was admitted to the facility, the facility assumed responsibility for Resident 2's care and was responsible for providing Resident 2's transportation to dialysis," the director told investigators.
The primary physician confirmed the laboratory values indicated urgent need for dialysis but couldn't recall whether he recommended immediate treatment when confronted with the toxic levels. "MD 1 stated MD 1 was not sure if MD 1 recommended for Resident 2 to be dialyzed with a BUN of 79 and a creatinine of 8.4," according to the inspection report.
The case illustrates how administrative failures can cascade into medical emergencies. What began as an insurance authorization problem on July 19 evolved into a transportation issue by July 28, then became a monitoring protocol that stretched for weeks while the resident's condition deteriorated.
Blood urea nitrogen and creatinine are waste products that healthy kidneys filter from blood. When kidneys fail, these toxins accumulate rapidly. Normal BUN levels range from 6 to 24 milligrams per deciliter. Normal creatinine for women ranges from 0.6 to 1.1. The resident's levels of 79 and 8.4 respectively represented severe kidney dysfunction requiring immediate intervention.
Dialysis patients typically require treatment three times weekly to prevent dangerous buildup of waste products and excess fluid. Missing even one session can cause complications. Going nearly three weeks without treatment creates life-threatening conditions including fluid overload, electrolyte imbalances, and metabolic acidosis.
The facility's response consisted entirely of documentation. Staff recorded the same monitoring note repeatedly but took no action to secure alternative transportation or emergency dialysis access. The primary physician received multiple notifications about missed treatments but didn't escalate care until laboratory results showed critical values.
State inspectors found the facility violated federal requirements for providing necessary care and services to maintain each resident's highest practicable level of functioning. The violation carried a designation of minimal harm with potential for actual harm affecting few residents.
The resident was transferred to the hospital by ambulance on August 13, more than two weeks after developing symptoms. By then, what started as a scheduling problem had become a medical emergency requiring acute intervention to prevent further complications from kidney failure.
The inspection occurred August 29 in response to a complaint. Records showed the facility continued monitoring protocols for days after receiving the critical laboratory results, with no apparent urgency despite the resident's deteriorating condition and documented symptoms of pain and nausea.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bayshire San Dimas Post-acute from 2025-08-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
BAYSHIRE SAN DIMAS POST-ACUTE in SAN DIMAS, CA was cited for violations during a health inspection on August 29, 2025.
The resident last received dialysis on July 23.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.