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 8/7/2025 and timed at 8:21 pm, the PN indicated Resident 2 was monitored for fluid retention due to not going to dialysis.
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.
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