Bayshire San Dimas Post-acute
BAYSHIRE SAN DIMAS POST-ACUTE in SAN DIMAS, CA — inspection on February 9, 2025.
Found 2 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 with CNA 6 on [DATE] at 11:08 AM, CNA 6 stated CNA 6 was trained in CPR and had a BLS card. CNA 6 stated CPR was initiated by performing the following:
1. check for pulse and breathing
2. call for help
3. start CPR by doing compression (CNA 6 placed hands under the sternum [flat bone that forms the center front of the chest wall])
4. compression to breath ratio while performing CPR was 10 compressions immediately followed by 10 breath per cycle.
CNA 6 stated it was important to do proper CPR, because [when performing CPR] staff could save a resident's life.
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 02/09/2025
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 an interview with the Director of Nursing (DON), on [DATE] at 11:36 AM, the DON stated Staff was defined as people that worked here (at the facility).
The DON stated CPR was done for residents who became non-responsive.
The DON stated, I would have all my staff perform CPR.
The DON stated all staff should call for a code blue (emergency code that indicates a patient needs immediate medical attention, usually due to cardiac or respiratory arrest), then start compressions: 30 compressions to 2 breaths ratio.
The DON stated it was not OK not to do anything and stand by to wait for assistance because you are talking about a life.
The DON stated [staff had to] do what is necessary to save a life.
During an interview and concurrent record review with the DSD, on [DATE] at 12:55 PM, the facility's document titled, CNA Tracking, was reviewed, the tracking indicated the column titled CPR Issued Date and CPR Exp. [expiration] Date was left blank.
The DSD stated the CNA tracking log was incomplete.
The DSD stated it was important to ensure completion of tracking to see if CNA BLS/CPR cards were expired and know when it was time for renewal.
The DSD stated the DSD would like all staff to know how to perform CPR because CPR was lifesaving, and every second counted.
During an interview with the DSD on [DATE] at 12:55 PM, the DSD stated the facility did not have a policy specifically for CPR.
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 02/09/2025
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.