Bayshire San Dimas Post-acute
BAYSHIRE SAN DIMAS POST-ACUTE in SAN DIMAS, CA — inspection on August 29, 2025.
Found 1 citation. 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 a review of Resident 2's PN, dated 8/8/2025 and timed at 11:50 pm, the PN indicated Resident 2 was monitored for fluid retention and for elevated BUN and creatinine due to missing dialysis.
During a review of Resident 2's PN, dated 8/9/2025 and timed at 7:18 am, the PN indicated Resident 2 was being monitored for fluid retention due to missing dialysis.
During a review of Resident 2's PN, dated 8/10/2025 and timed at 9:36 am, the PN indicated Resident 2 was being monitored for fluid retention due to missing dialysis.
During a review of Resident 2's SBAR, dated 8/11/2025, the SBAR indicated Registered Nurse (RN) 1 received a call from the laboratory regarding Resident 2's abnormal BUN of 79 and creatinine of 8.4.
The SBAR indicated RN 1 informed MD 1 regarding Resident 2's abnormal BUN and creatinine levels and MD 1 ordered for Resident 2 to see a nephrologist (a medical doctor who specializes in diagnosing and treating kidney diseases).
The SBAR also indicated the last time Resident 2 had dialysis was on 7/23/2025.
During a review of Resident 2's laboratory results, dated 8/11/2025, the laboratory results indicated Resident 2's BUN level was 79 mg/dl and creatinine level was 8.4 mg/dl.
During a review of Resident 2's Progress Note (PN), dated 8/13/2025 and time at 7:58 pm, the PN indicated Resident 2 was being monitored for fluid retention or any change of condition due to not going to dialysis and for elevated blood urea nitrogen (BUN - medical test that measures the amount of urea in the blood.
Normal level range is 6 to 24 milligrams per deciliter [mg/dl]) of 79 mg/dl and creatinine (waste product from muscle and protein breakdown that healthy kidneys filter from the blood and remove through urine.
Normal level range for women is 0.6 to 1.1 mg/dl) and creatinine of 8.4 mg/dl.
During a review of Resident 2's PN, dated 8/13/2025 and timed at 9:30 pm, the PN indicated Resident 2 was transferred to GACH 1 via ambulance due to missed dialysis.
During a review of Resident 2's PN, dated 8/12/2025 and timed at 3:59 am, the PN indicated Resident 2 was being monitored for fluid retention and for elevated BUN and creatinine.
During a review of Resident 2's GACH 1 H&P, dated 8/14/2025, the H&P indicated Resident 2 had left-sided flank (on the side of the body between the ribs and the hip) pain with nausea for 1 week and was found to have metabolic likely due to missed hemodialysis (dialysis).
During an interview on 8/29/2025 at 11:06 am with the Director of Nursing (DON), the DON stated 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.
During an interview on 8/29/2025 at 11:11 am with MD 1, MD 1 stated a BUN level of 79 and a creatinine level of 8.4 indicated Resident 2 needed dialysis. 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.
Frequently Asked Questions
More Reports
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.