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Health Inspection

Bayshire San Dimas Post-acute

February 9, 2025 · San Dimas, CA · 1740 S San Dimas Ave
Citations 2
CMS Rating 4/5
Beds 45
Provider ID 555737
Healthcare Facility
Bayshire San Dimas Post-acute
San Dimas, CA  ·  View full profile →
Inspection Summary

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.

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Inspection Findings

FF678
Minimal harm or compressions to 2 breaths. The DSD stated performing proper CPR was important to ensure oxygen Few During an interview with the DSD on [DATE] at 11:23 AM, the DSD stated the DSD would like all the staff to affected

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

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAN DIMAS, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BAYSHIRE SAN DIMAS POST-ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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