Bayshire San Dimas Post-Acute: Missed Dialysis - CA
The resident, identified in inspection records only as Resident 2, last received dialysis on July 23, 2025. The first missed session came because of an insurance issue. The second because of a transportation problem. Then the days kept accumulating.
On July 28, a nurse documented that Resident 2 had missed dialysis due to transportation issues and that her physician had been informed. The doctor's response was an order to monitor her for fluid overload, fatigue, muscle cramps, loss of appetite, and mental changes. That monitoring order became the facility's primary response for the next two weeks.
Nursing notes from August 7, 8, 9, 10, 12, and 13 all read the same way: Resident 2 was being monitored for fluid retention due to missing dialysis. Monitored. Not transported. Not dialyzed. Monitored.
On August 11, a laboratory called the facility with results that should have ended the waiting. Resident 2's blood urea nitrogen level was 79 milligrams per deciliter. Her creatinine was 8.4. A normal BUN tops out around 24. A normal creatinine for a woman sits below 1.1. Hers was more than seven times that ceiling.
The physician who had been receiving updates throughout was asked about those numbers during the inspection. He said a BUN of 79 and a creatinine of 8.4 indicated Resident 2 needed dialysis. Then he added that he was not sure whether he had actually recommended dialysis when he received those results.
He had not. His response on August 11 was to order a nephrology consultation.
Two more days of monitoring notes followed. On the evening of August 13, three weeks after her last treatment, Resident 2 was loaded into an ambulance and transferred to an acute care hospital.
Hospital records from August 14 documented what the nursing home's weeks of observation had produced: left-sided flank pain, nausea lasting a week, and a metabolic crisis attributed directly to missed hemodialysis.
The facility's Director of Nursing told inspectors that when Resident 2 was admitted, the nursing home assumed responsibility for her care, including responsibility for her transportation to dialysis. That acknowledgment sits at the center of what the inspection report describes as a failure to provide necessary care and services.
The transportation and insurance problems that triggered the first missed sessions are referenced in the inspection records but not resolved into a clear timeline of what the facility did, or didn't do, to fix them. What the records show is the result: a resident dependent on dialysis to filter waste her kidneys could not process on their own, going without it from July 23 to August 13, while her BUN climbed to more than three times the upper limit of normal and her creatinine to more than seven times.
Dialysis for kidney failure patients is not a treatment that can be deferred for weeks without consequence. When kidneys fail, the body has no other mechanism to clear urea and creatinine from the blood. Those compounds accumulate. Fluid accumulates. The symptoms Resident 2's doctor ordered staff to watch for, the fatigue, the mental changes, the fluid retention, are the symptoms of that accumulation progressing.
The inspection was triggered by a complaint. The report classified the level of harm as minimal harm or potential for actual harm, a designation that applies to the regulatory category of the violation, not necessarily to what happened to the resident herself.
Resident 2 spent August 13 in an ambulance with flank pain she had been living with for a week.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 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, identified in inspection records only as Resident 2, last received dialysis on July 23, 2025.
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.