Bayshire San Dimas Post-acute
BAYSHIRE SAN DIMAS POST-ACUTE in SAN DIMAS, CA — inspection on July 18, 2024.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 7/18/2024 at 12:30 PM with Registered Nurse (RN) 1, RN 1 stated RN 1 discharged Resident 2 on 7/9/2024. RN 1 stated RN 1 did not assess Resident 2's caregiver/support availability at home, equipment needed at home, or verified home health arrangements before and during discharge, because RN 1 assumed the SSD or case manager spoke to Resident 2 or R2R about these concerns.
During an interview on 7/18/2024 at 2:42 PM with the Director of Nursing (DON), the DON stated discharge planning must begin on the first day of a resident's (in general) admission to the facility.
The DON stated on 7/9/2024 (discharge date ), R2R came to the facility and verbalized that Resident 2 was not ready for discharge to home.
The DON stated the facility needed to question the rushed discharge date from Resident 2's health insurance company due to the need for more caregiver training and assistive device at home.
The DON stated the facility needed to send out referrals to home health agencies timely and confirm home health services with visits from an RN, OT, and PT prior to discharging Resident 2 from the facility.
The DON stated improper discharge planning could lead to an unsafe discharge, Resident 2's injury at home, and Resident 2's possible decline physically and mentally.
During a review of the facility's policy and procedure (P&P) titled, Social Services, dated 10/2010, the P&P indicated, the facility provided medically related social services to assure that each resident attained or maintained his/her highest practicable physical, mental, or psychosocial well-being.
The P&P indicated, the social services department was responsible for making and maintaining appropriate documentation of referrals to agencies as necessary or appropriate, working with individuals or groups in developing supportive services for residents according to their individual needs and interests, and participating in the planning of the resident's return to home and community by assessing the impact of these changes and making arrangements for social and emotional support.
During a review of the facility's P&P titled, Discharge Summary and Plan, dated 12/2016, the P&P indicated, when a resident's discharge was anticipated, a discharge summary and post-discharge plan was developed to assist the resident to adjust to his/her new living environment.
The P&P indicated, as part of the discharge summary, every resident was evaluated for his or her discharge needs and had an individualized post-discharge plan.
The P&P indicated, the facility developed the post-discharge plan and the post-discharge plan included arrangements that had been made for follow-up care and services and the degree of caregiver/support person availability, capacity, and capability to perform required care.
The P&P indicated, the facility reviewed the final post-discharge plan with the resident and family at least 24 hours before the discharge was to take place.
555737 07/18/2024
Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773
During an interview on 7/18/2024 at 9:41 AM with the Rehabilitation Director (Rehab D), the Rehab D stated the Rehab D was very upset how it went down.
The Rehab D stated the facility was not ready to discharge Resident 2 when Resident 2's HIC called the facility on 7/9/2024.
The Rehab D stated on 7/14/2024 (5 days after Resident 2's discharge from the facility), the Rehab D personally came to Resident 2's home to make things right and check on Resident 2, since no home health services were arranged.
The Rehab D stated the Rehab D assessed the layout of Resident 2's home for ADLs and mobility and determined it was not possible for R2R to assist Resident 2 with transfers to and from chair and ambulation due to R2R's difficulty with bending.
The Rehab D stated Resident 2's shower chair did not fit in Resident 2's shower area.
The Rehab D stated Resident 2 needed a Hemi-walker (device that gives support to maintain balance while walking and allows the user to lean on just one side for support), which was steadier when walking and safer assistive device than a cane.
The Rehab D stated when home health services were not arranged as ordered, Resident 2 had a potential to decline and was at an increased risk for deconditioning (decline in physical function of the body because of physical inactivity and disuse).
During a telephone interview on 7/18/2024 at 11:52 AM with the HHA 1's DON (HHA DON), the HHA DON stated HHA 1 did not receive a referral for Resident 2 from the facility.
During a review of the facility's policy and procedure (P&P) titled, Discharge Summary and Plan, dated 12/2016, the P&P indicated, when a resident's discharge was anticipated, a discharge summary and post-discharge plan was developed to assist the resident to adjust to his/her new living environment.
The P&P indicated, as part of the discharge summary, every resident was evaluated for his or her discharge needs and had an individualized post-discharge plan.
The P&P indicated, the facility developed the post-discharge plan and the post-discharge plan included arrangements that had been made for follow-up care and services and the degree of caregiver/support person availability, capacity, and capability to perform required care.
The P&P indicated, the facility reviewed the final post-discharge plan with the resident and family at least 24 hours before the discharge was to take place.
555737 07/18/2024
Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773
During a concurrent interview and record review on [DATE] at 8:42 AM with the Social Services
SSD sent referrals to multiple LTC facilities, which either denied Resident 1's admission or were refused by R1R.
The SSD was unable to provide documented evidence of referrals made to Medicaid-certified LTC facilities for Resident 1.
The SSD stated upon Resident 1's admission, the plan was for Resident 1's responsible party to look for placement.
The SSD stated the SSD referred Resident 1's responsible party to a third-party individual, who worked for hospice care and had a relationship with Senior Homes to help find placement for Resident 1.
During an interview on [DATE] at 9:41 AM with the Director of Rehabilitation (DOR), the DOR stated the facility provided R1R with many options for Medicaid-certified facilities for LTC but had not agreed to sign up Resident 1 to any of the LTC facilities provided to R1R.
During an interview on [DATE] at 2:42 PM with the DON, the DON stated complete, accurate, and timely documentation of the referrals made to Medicaid-certified LTC facilities and any assistance provided by the facility to Resident 1 was important to show that the facility helped Resident 1 and/or R1R as much as possible to ensure a safe discharge from the facility.
During a review of the facility's policy and procedure (P&P) titled, Referrals, Social Services, dated 12/2008, the P&P indicated, social services personnel coordinated most resident referrals with outside agencies, unless emergency or specialized services must be arranged directly by the physician or the nursing staff.
The P&P indicated, social services documented the referral in the resident's medical record.
The P&P indicated, social services and administration maintained a listing of referral agencies that may provide assistance or therapy to residents with special problems and/or needs.
A review of the facility's P&P titled, Social Services, dated 10/2010, the P&P indicated, the facility provided medically related social services to assure that each resident attained or maintained his/her highest practicable physical, mental, or psychosocial well-being.
The P&P indicated, the social services department was responsible for compiling up-to-date information about community health and service agencies available for resident referrals, making referrals to social service agencies as necessary and appropriate, maintaining appropriate documentation of referrals and providing social service data summaries to agencies, maintaining contact with the resident's family members, involving them in the resident's total plan of care, and participating in the planning of the resident's transfer to another facility by assessing the impact of these changes and making arrangements for social and emotional support.
555737 07/18/2024
Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773
(DON), the AR 2 and Resident 2's POA documents were reviewed.
The DON stated the AR 2 needed to
revised 12/2006, the P&P indicated, accurate medical records shall be maintained by the facility.
During a review of Resident 2's History and Physical Examination (H&P 2), dated 5/20/2024, the H&P 2 indicated, Resident 2 was able to make needs known but could not make medical decisions.
During a review of Resident 2's Minimum Data Set (MDS 2- a standardized resident assessment and care-planning tool), dated 5/27/2024, the MDS 2 indicated, Resident 2 had absence of spoken words, had difficulty communicating some words or finishing thoughts but was able to if prompted or given time, and would miss part/intent of the message but would comprehend most of the conversation.
The MDS 2 indicated, Resident 2 had some difficulty making decisions regarding tasks of daily life in new situations only.
The MDS 2 indicated, Resident 2 was dependent on staff for toileting hygiene, bathing, lower body dressing, and putting on/taking off footwear.
The MDS 2 indicated, Resident 2 required substantial/maximal assistance with oral hygiene, upper body dressing, personal hygiene, and mobility.
555737
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555737 B.
Wing 07/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773
During a review of Resident 2's History and Physical Examination (H&P 2), dated 5/20/2024, the H&P 2 indicated, Resident 2 was able to make needs known but could not make medical decisions.
During a review of Resident 2's Minimum Data Set (MDS 2- a standardized resident assessment and care-planning tool), dated 5/27/2024, the MDS 2 indicated, Resident 2 had absence of spoken words, had difficulty communicating some words or finishing thoughts but was able to if prompted or given time, and would miss part/intent of the message but would comprehend most of the conversation.
The MDS 2 indicated, Resident 2 had some difficulty making decisions regarding tasks of daily life in new situations only.
The MDS 2 indicated, Resident 2 was dependent on staff for toileting hygiene, bathing, lower body dressing, and putting on/taking off footwear.
The MDS 2 indicated, Resident 2 required substantial/maximal assistance with oral hygiene, upper body dressing, personal hygiene, and mobility.
During a review of Resident 2's Physician Order (MDO 1), dated 7/9/2024, timed at 6:29 PM, the MDO 1 indicated, an order to discharge Resident 2 to home with Home Health (unspecified) on 7/9/2024.
The MDO 1 indicated, Resident 2 may have home health PT/OT & registered nurse (RN) for safety evaluation to follow.
The MDO 1 indicated, Resident discharged home with family at 5:40 PM.
During a telephone interview on 7/17/2024 at 2 PM with R2R, R2R stated Resident 2's discharge came as a total surprise. R2R stated R2R did not think Resident 2 was ready for discharge from the facility. R2R stated no home health RN, OT, PT visits were arranged. R2R stated R2R tried to call Resident 2's health insurance company (HIC), but the HIC staff would not talk to R2R and release any information, stating the HIC staff would need to speak with Resident 2. R2R stated R2R needed to explain to HIC staff that Resident 2 was nonverbal, and R2R had the Power of Attorney documents on file as she was the legal decisionmaker for Resident 2. R2R stated R2R was frustrated due to the runaround.
555737
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555737 B.
Wing 07/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.