Bayshire San Dimas Post-acute
Inspection Findings
F-Tag F0698
F 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated 7/19/2025, the SBAR indicated Resident 2 missed dialysis. The SBAR indicated Medical Doctor (MD) 1 (primary physician for Resident 2) was informed that Resident 2 missed dialysis. The SBAR indicated Registered Nurse (RN) 2, was unable to reschedule Resident 2's dialysis due to insurance. The SBAR indicated MD 1 was informed with no new orders. During
a review of Resident 2's SBAR, dated 7/28/2025, the SBAR indicated Resident 2 missed dialysis due to transportation issues. The SBAR indicated MD 1 was informed that Resident 2 missed dialysis and MD 1 ordered to continue monitoring Resident 2 for fluid overload or fluid retention, for fatigue, muscle cramps, loss of appetite, and mental changes. 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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BAYSHIRE SAN DIMAS POST-ACUTE in SAN DIMAS, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.