Brookdale San Dimas

F-F678

Findings:

During an interview and concurrent record review CNA 6's personnel record, with the Director of Staff Development (DSD), on [DATE REDACTED] at 10:48 AM, the DSD stated CNA 6's had a current CPR/BLS card that expired on ,d+[DATE REDACTED]. The DSD stated it was important for all staff members to know the proper (effective) method to perform CPR because all staff members needed to help (residents) during emergency situations involving residents.

During an interview with CNA 6 on [DATE REDACTED] 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 21 555737 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 During an interview with the DSD on [DATE REDACTED] at 11:23 AM, the DSD stated if the resident (in general) was having a medical emergency and did not have a pulse, the correct compression to breath ratio was 30 Level of Harm - Minimal harm or compressions to 2 breaths. The DSD stated performing proper CPR was important to ensure oxygen potential for actual harm circulated in the blood because this saved lives.

Residents Affected - Few During an interview with the DSD on [DATE REDACTED] at 11:23 AM, the DSD stated the DSD would like all the staff to know how to do CPR because CPR was lifesaving and every second counted.

During a review of the facility's policy and procedure (P&P), titled Licensure, Certification, and Registration of Personnel, dated ,d+[DATE REDACTED], the P&P indicated a copy of recertifications (e.g. annual, bi-annual) must be presented to the human resources director/designee upon receipt of such recertifications and prior to the expiration of current licensure, certification, and/or registration. The P&P indicated a copy of the recertification must be filed in the employee's personnel record.

During a review of the facility's policy and procedure titled Emergency Procedure - Cardiopulmonary Resuscitation, dated ,d+[DATE REDACTED], the P&P indicated Cardiopulmonary Resuscitation and BLS will be initiated

in response to sudden cardiac arrest (heart stops). Emergency Procedure - CPR: if an individual is found unresponsive, briefly assess for abnormal or absence of breathing. The P&P indicated if sudden cardiac arrest is likely begin CPR. The P&P indicated after 30 chest compressions provide 2 breaths via ambu (artificial manual breathing unit) bag or manually. The P&P indicated all rescuers, trained or not, should provide chest compression to victims of cardiac arrest. The P&P indicated trained rescuers should also provide ventilations [breaths] with a compression-ventilation ratio of 30:2.

During a review of the facility's job description, titled Certified Nursing Assistant, dated [DATE REDACTED], the job description indicated First Aid Training (non-specific for emergency or non-emergency) as required.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 21 555737 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day.

Level of Harm - Minimal harm or 38108 potential for actual harm Based on interview and record review, the facility failed to post accurate nurse staffing information of actual Residents Affected - Few hours worked by the licensed and unlicensed nursing staff who were directly responsible for resident care per shift, daily. This information was not posted in a prominent location readily accessible to residents and visitors for viewing.

This failure resulted in no posting of nurse staffing hours and had the potential to result in lack of nurse staffing hour knowledge for residents and family members.

Findings:

During an interview and concurrent record review with the Director of Staff Development (DSD), on 2/9/2025 at 10:48 AM, the facility's Daily Staffing and Posting and Census dated 2/7/2025 and 2/8/2025 were reviewed. The DSD stated actual hours worked by the nursing staff for those dates were not recorded/posted. The DSD stated actual hours were calculated by the next business day and on weekends, actual hours worked were calculated by the following Monday. The DSD stated it was important to post actual working hours worked to ensure the correct number of worked hours and ensure staff were accounted for, and for resident awareness.

During a review of the facility's policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, revised August 2022, the P&P indicated the facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personal responsible for providing direct care to the resident.

The actual time worked during that shift for each category and the type of nursing staff; and the total number of licensed and non-licensed nursing staff working for that posted shift. Within two hours of the beginning of each shift, the charge nurse or designee computes the number of direct care staff and completes the Nurse Staffing Information (NSI) form.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 21 555737 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm 44027

Residents Affected - Few Based on interview and record review, the facility failed to follow through with the Consultant Pharmacists recommendations during the Medication Regiment Review (MRR, a review of all medications the resident is currently using to minimize adverse consequences and potential risks associated with medications) for one of five sampled residents (Resident 21).

This failure had the potential for Resident 21 to not receive the necessary blood tests for Resident 21's health and wellbeing.

Findings:

During a review of Resident 21's Admission Record (AR), the AR indicated the facility admitted Resident 21

on 1/8/2025, with diagnoses including cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain), urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra),and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar).

During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool), dated 1/15/2025,

the MDS indicated Resident 21 was moderately impaired in cognitive skills (ability to make daily decisions).

The MDS indicated Resident 21 was dependent (helper does all the effort) on staff for toileting, oral, and personal hygiene, dressing, and showering/bathing.

During a concurrent interview and record review on 2/8/2025 at 3:14 PM with Registered Nurse (RN) 1, Resident 21's two Consultation Reports, from the facility's Consultant Pharmacist both dated 1/15/2025 were reviewed. The first Consultation Report indicated the pharmacist recommended a thyroid-stimulating hormone (TSH- triggers the thyroid [a gland at the front of the neck that control the way the body uses energy] to release its hormone) blood test (measures the amount of TSH in the bloodstream) to be drawn for Resident 21. The second Consultation Report indicated the pharmacist recommended an A1C (a blood test that measures the average blood sugar [glucose] level over the past 2-3 months) to be drawn for Resident 21. Both Consultation Reports indicated Resident 21's physician accepted the recommendations to draw the laboratory tests for Resident 21. RN 1 stated the Consultant Pharmacist (Pharm 1) created the Consultation Reports during the monthly MRR. RN 1 stated the facility drew blood tests for Resident 21 on 1/16/2025 and 1/23/2025 but did not include the blood tests for A1C and TSH as recommended by Pharm 1 and approved by Resident 21's physician. RN 1 stated the facility did not follow through with Pharm 1's MRR recommendations.

During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Review, dated 12/1/2007, the P&P indicated, The Consultant Pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement. The P&P indicated, Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR. For those issues that require Physician/ Prescriber intervention, Facility should encourage Physician/Prescriber to either (a) accept and act upon the recommendations contained within the MAR, or (b) reject all or some of the recommendations contained in the MAR and provide an explanation as to why the recommendation was rejected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 21 555737 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 44027

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen when:

a. [NAME] (CK) 1 was not wearing a hair net over CK 1's beard.

b. A banana cream pie was observed in one of one walk-in freezer to be undated (not provided or marked with a date).

c. A tray of green beans was observed in one of one walk-in refrigerator to be uncovered and undated.

These failures had the potential for improper food storage and handling, which could lead to foodborne illnesses.

Findings:

During an initial tour of the kitchen on 2/7/2025 at 5:06 PM with CK 1, CK 1 was prepping food next to the kitchen stove. CK 1 was not wearing a hair net over CK 1's beard. CK 1 stated CK 1 should have a hair net over CK 1's beard.

During an initial tour of the kitchen on 2/7/2025 at 5:08 PM with CK 1, a frozen banana cream pie was observed in the walk-in freezer to be opened. The opened container was not dated. CK 1 stated the opened banana cream pie should be thrown in the trash.

During an initial tour of the kitchen on 2/7/2025 at 5:10 PM with CK 1, a tray of green beans was observed to be uncovered and undated in the walk-in refrigerator.

During an interview on 2/8/2025 at 1:09 PM with the Culinary Director (CD), the CD stated all opened food items needed to be labeled and dated with an expiration date. The CD stated the food was only good for three days after opening the container. The CD confirmed the green beans needed to be covered, labeled, and dated. The CD stated it was not healthy for residents (in general) to eat food that was too old. The CD stated hair needed to be covered when staff was working with food.

During a review of the facility's policy and procedure (P&P) titled, Food Storage, revised on 12/20/2019, the P&P indicated, Food covered, labeled, and dated The P&P indicated, All food should be dated when it was placed in the storeroom, refrigerator or freezer . Food in all refrigerators must have Use-by dates.

During a review of the facility's P&P titled, Personal Hygiene, revised on 5/25/2023, the P&P indicated, Wear

a clean hat or other hair restraint. Hair must be completely covered. Beards, mustaches, or any body hair that may be exposed (i.e., arms) must be covered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 21 555737 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 50016

Residents Affected - Few Based on interview and record review, the facility failed to ensure accurate medication administration documentation for one of one sampled resident (Resident 11) when, the facility inaccurately documented the administration of Resident 11's Vagisil (a medication used to relieve vaginal itching, irritation, and burning)

on 2/4/2025.

This deficient practice had the potential to lead to inconsistent and/or inaccurate treatments provided to Resident 11.

Findings:

During a review of Resident 11's Admission Record (AR), the AR indicated the facility admitted Resident 11

on 1/18/2025, with

diagnoses including malignant neoplasm of corpus uteri (endometrial cancer, a cancer of the lining of the uterus [a pear-shaped organ in the reproductive system of females]), type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and history of falling.

During a review of Resident 11's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/25/2025, the MDS indicated Resident 11 had moderate cognitive (the ability to think and process information) impairment. The MDS indicated Resident 11 required substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and partial/moderate assistance (helper does less than half the effort) with mobility.

During a record review of Resident 11's Order Summary Report (OSR), active orders as of 2/1/2025, indicated Resident 11 had an active order for:

-Vagisil External Cream 1% (Hydrocortisone Acetate Vaginal), apply to vaginal area topically (medication application on the surface of the body such as the skin) one time a day for vaginal itching. The order date for

the Vagisil was made on 2/1/2025 with a treatment start date of 2/2/2025.

During an interview and record review on 2/8/2025 at 3:07 PM, with Registered Nurse (RN) 1, Resident 11's Medication Administration Record (MAR) was reviewed. The MAR indicated the activity for the administration of Vagisil:

- On 2/2/2025, the medication was not administered due to medication not being available.

- On 2/3/2025, the medication was not administered due to medication not being available.

- On 2/4/2025, the medication was documented as being administered by Licensed Vocational Nurse (LVN) 2.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 21 555737 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 - On 2/5/2025, the medication was not administered due to medication not being available and documented by LVN 2. Level of Harm - Minimal harm or potential for actual harm - On 2/6/2025 the medication was held.

Residents Affected - Few RN 1 stated LVN 2 inaccurately documented the administration of Resident 11's Vagisil on 2/4/2025. RN 1 stated the facility had not received the medication from the pharmacy and Resident 11 had not started the treatment. RN 1 stated LVN 2 acted in good faith and did not intend to falsify the record, seeing that LVN 2 documented the Vagisil was not available for administration on 2/5/2025. RN 1 stated accurate MAR documentation helped with tracking the effectiveness of medications, identify side effects (unwanted, uncomfortable, or dangerous effects that a resident may have due to a medication), and ensured timely adjustments were made to the resident's treatment plan.

During an interview on 2/9/2025 at 8:30 AM, with the Director of Nursing (DON), the DON stated staff should ensure accurate MAR documentation. The DON stated accurate documentation allowed for clear communication between healthcare providers, and helped ensure the next caregiver or healthcare provider had a complete and accurate record of a resident's medication regimen, improving the quality of care. The DON stated proper documentation ensured there was no confusion or misunderstanding among staff members regarding medication administration, reduced the risks of errors due to miscommunication.

During a review of the facility's Policy and Procedure (P&P) titled, Charting and Documentation revision dated 7/2017, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 21 555737 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 50016 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain infection prevention and Residents Affected - Few control practices for one of one sampled resident (Resident 11) by failing to ensure Resident 11's wound vacuum (a suction device that is applied after a wound is dressed) drainage tubing did not have direct contact with the floor.

This deficient practice had the potential to result in the transmission of infectious microorganisms and increase the risk of infection for Resident 11.

Findings:

During a review of Resident 11's Admission Record (AR), the AR indicated the facility admitted Resident 11

on 1/18/2025, with diagnoses including malignant neoplasm of corpus uteri (endometrial cancer, a cancer of

the lining of the uterus [a pear-shaped organ in the reproductive system of females]), type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and history of falling.

During a review of Resident 11's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/25/2025, the MDS indicated Resident 11 had moderate cognitive (the ability to think and process information) impairment. The MDS indicated Resident 11 required substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and partial/moderate assistance (helper does less than half the effort) with mobility.

During an observation on 2/7/2025 at 6:31 PM, Resident 11 was observed with a wound vacuum that was attached to Resident 11's abdomen. The wound vacuum pump was resting on Resident 11's bed and the wound vacuum drainage tubing was touching the floor.

During an interview on 2/7/2025 at 6:48 PM, with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 11's wound vacuum tubing should not be touching the floor because [contact with the floor] could lead to cross contamination (process by which bacteria can be transferred from one area to another). CNA 4 stated if the tubing carried bacteria from the floor to the wound it could lead to an infection.

During an interview on 2/9/2025 at 8:12 AM, with Infection Preventionist (IP) 1, IP 1 stated keeping the wound vacuum tubing off the floor reduced the risk of contamination and ensured a wound healing process not disrupted by external pathogens (organism that causes disease to its host). IP 1 stated any part of the system that touched the floor could potentially break the sterile field, putting the wound at greater risk of becoming infected.

During a review of the facility's Policy and Procedure (P&P) titled, Infection Prevention and Control Program revision dated 10/2018, the P&P indicated an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 21 555737 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 50016 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure equipment used by residents Residents Affected - Few was maintained in a safe and operable condition, by failing to ensure the wheelchair brakes were fully functional for one of one sampled resident (Resident 11).

This deficient practice had the potential to result in harm and could have negatively impacted the safety, and well-being of Resident 11.

Findings:

During a review of Resident 11's Admission Record (AR), the AR indicated the facility admitted Resident 11

on 1/18/2025, with diagnoses including malignant neoplasm of corpus uteri (endometrial cancer, a cancer of

the lining of the uterus [a pear-shaped organ in the reproductive system of females]), type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and history of falling.

During a review of Resident 11's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/25/2025, the MDS indicated Resident 11 had moderate cognitive (the ability to think and process information) impairment. The MDS indicated Resident 11 required substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADL, term used in healthcare that refers to self-care activities) and partial/moderate assistance (helper does less than half the effort) with mobility.

During a concurrent observation and interview on 2/7/2025 at 6:31 PM, with Resident 11, Resident 11 stated

the safety brake located on the right side of the facility provided wheelchair did not work. Resident 11 stated

the wheelchair had been in this condition for more than a week. Resident 11 stated Resident 11 reported the concern to staff; however, the issue had not been addressed. Resident 11 stated Resident 11 utilized the wheelchair to go around the facility and for medical appointments. Resident 11 stated Resident 11 was concerned because the wheelchair could have rolled on her unexpectedly when transferring in and out of the wheelchair, becoming a safety issue. Upon checking Resident 11's wheelchair, the wheelchair brake located

on the right side did not lock.

During a concurrent observation and interview on 2/8/2025 at 9:33 AM, Resident 11's wheelchair was checked with the Social Services Director (SSD), the SSD stated Resident 11's right wheelchair brake was faulty. The SSD stated faulty brakes on a wheelchair compromised both the safety and independence of the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 21 555737 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0908 During an interview and record review on 2/8/2025 at 11:47 AM, the facility's maintenance log from 11/1/2024 through 2/6/2025 was reviewed with the Director of Maintenance (DOM), the DOM stated there Level of Harm - Minimal harm or was no record that indicated Resident 11's wheelchair brake was not working. The DOM stated wheelchair potential for actual harm inspections was a team effort and was typically done by the maintenance department, physical therapy department, the nursing team, and housekeeping. The DOM stated the expectation was for staff to report Residents Affected - Few any wheelchair issues immediately when identified, so that the maintenance team could fix the issues right away. The DOM stated wheelchairs should be checked and inspected before they are issued by the residents to ensure safety and comfort. The DOM stated daily wheelchair inspections ensured wheelchairs remained in proper working condition and wheelchairs were safe for residents to use. The DOM stated wheelchairs with only one operable brake was a safety issue as the chair might not stay stationary when the user was transferring in or out, increasing the risk of the wheelchair rolling unintentionally.

During an interview on 2/9/2025 at 8:30 AM, with the Director of Nursing (DON), the DON stated daily inspections of durable medical equipment ensured the equipment was in optimal working condition, contributing to a safe, comfortable, and well-managed environment for both residents and staff. The DON stated routine inspections ensured the equipment was functioning properly and reduced the likelihood of failures.

During a review of the facility's Policy and Procedure (P&P) titled, Maintenance Service revision dated 12/2009, the P&P indicated that the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 21 555737

F-F726

Findings:

During an interview and concurrent record review with the Director of Staff Development (DSD) of CNA 5's personnel record (employee personal information), on [DATE REDACTED] at 10:48 AM, the DSD stated the DSD was not able to provide a copy of CNA 5's current BLS/CPR card/certification because CNA 5's card was expired.

The DSD stated the facility was not able to provide a current BLS/CPR card nor provide any documentation to indicate CNA 5 took the necessary courses to obtain a BLS/CPR card.

During an interview with the Director of Nursing (DON), on [DATE REDACTED] 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 REDACTED] 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 REDACTED] at 12:55 PM, the DSD stated the facility did not have a policy specifically for CPR.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 21 555737 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 During an interview with the Administrator (ADM), on [DATE REDACTED] at 1:01 PM, the ADM stated the facility's practice was to obtain information from the State Operations Manual (SOM, is a federal document, issued by Level of Harm - Minimal harm or CMS, containing survey and certification rules and guidance) to develop policies and procedures (P&P). potential for actual harm

During a review of the facility's P&P titled Licensure, Certification, and Registration of Personnel, dated , Residents Affected - Few d+[DATE REDACTED], indicated a copy of recertifications (e.g. annual, bi-annual) must be presented to the human resources director/designee upon receipt of such recertifications and prior to the expiration of current licensure, certification, and/or registration. A copy of the recertification must be filed in the employee's personnel record.

During a review of the State Operations Manual, last updated 2017, the manual indicated to ensure that each facility is able to and does provide emergency basic life support immediately when needed, including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel. The manual indicated, staff must maintain current CPR certification for Healthcare Providers through a CPR provider whose training includes hands-on practice and in-person skills assessment; online-only certification is not acceptable. The manual indicated to ensure that each facility is able to and does provide emergency basic life support immediately when needed, including cardiopulmonary resuscitation (CPR), to any resident requiring such care prior to the arrival of emergency medical personnel.

During a review of the facility's P&P, titled Emergency Procedure - Cardiopulmonary Resuscitation [CPR], dated ,d+[DATE REDACTED], the P&P indicated CPR and BLS will be initiated in response to sudden cardiac arrest (heart stops). The P&P indicated emergency procedure - CPR: if an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely begin CPR. The P&P indicated after 30 chest compressions provide 2 breaths via ambu (artificial manual breathing unit) bag or manually. The P&P indicated all rescuers, trained or not, should provide chest compression to victims of cardiac arrest. The P&P indicated trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2.

During a review of the facility's job description, titled Certified Nursing Assistant, dated [DATE REDACTED], the job description indicated regarding education for CNAs, first aid training (non-specific for emergency or non-emergency) was as required.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 21 555737 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38108

Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide sufficient nursing services on 2/3/2025, 2/5/2026 and 2/6/2025, for two of two sampled residents (Resident 19 and Resident 27), as indicated in the facility's policy and procedure (P&P), titled, Staffing, Sufficient and Competent Nursing.

This deficient practice had the potential to affect the care provided to residents, quality of life, and the potential for the residents not to receive nursing services in a timely matter.

Findings:

A. During a review of Resident 19's Admission Record (AR), the AR indicted Resident 19 was admitted to

the facility on [DATE REDACTED] with diagnosis that included hemiplegia and hemiparesis (muscle weakness on one side of the body) of the right dominant side, muscle wasting, and difficulty walking.

During a review of Resident 19's History and Physical (H&P), dated 1/12/2025, the H&P indicated Resident 19 had the capacity to understand and make decisions.

During a review of Resident 19's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 1/17/2025, indicated Resident 19 was moderately impaired cognition and needed partial/moderate assistance (helper does less than half the effort) with showers and lower body dressing.

During a review of Resident 19's care plan (CP), titled ADL (Activities of Daily Living, basic self-care task performed daily), initiated 1/10/2025, the CP's focus indicated Resident 19 required assistance from 1-2 persons to start and complete most ADL task - toileting, transfers, hygiene/grooming, bathing and eating.

During an interview with Resident 19 on 2/8/2025 at 9 AM, Resident 19 stated at night (unknown days), Resident asked for assistance and needed to wait up to 30 minutes for a staff member to respond. Resident 19 stated, I don't know if there was enough staff or they were just too busy.

B. During a review of Resident 27's AR, the AR indicated Resident 27 was admitted to the facility on [DATE REDACTED] with diagnosis that included artificial right hip joint, dysphagia (difficulty swallowing), and anxiety (a feeling of worry, nervousness, or unease).

During a record review of Resident 27's MDS, dated [DATE REDACTED], the MDS indicated Resident 27 was cognitively intact. The MDS indicated Resident 7 needed maximal assistance (helper does more than half the effort) with oral and toilet hygiene, upper and lower body dressing, and sit to stand (ability to stand from sitting on a chair).

During an interview with Resident 27 on 2/7/2025 at 6:58 PM, Resident 27 stated Resident 27 pressed the call light to get assistance to use the restroom and had to wait up to 40 minutes before receiving assistance. Resident 27 stated they send the staff home because they don't want to pay overtime.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 21 555737 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During a review of the facility's CNA (Certified Nurse Assistance) Monthly Schedule, for the month of February 2025, the schedule indicated on 2/3/2025, 2/5/2026 and 2/6/2025, only 2 CNAs were scheduled to Level of Harm - Minimal harm or work the night shift (NOC, working hours from 11 PM to 7 AM). potential for actual harm

During an interview with the Director of Staff Development (DSD) on 2/9/2025 at 10:30 AM, the DSD stated Residents Affected - Few the facility staffed three CNA for the NOC shift. During a concurrent record review of the Nursing Staffing Assignment and Sign-In Sheet (NSASS), the NSASS indicated on 2/3/2025, 2/5/2026 and 2/6/2025, only 2 CNAs were scheduled and worked the NOC shift. The DSD stated it was important to schedule and have enough CNAs on the floor to assist residents timely and for resident safety.

During a review of the facility's P&P, titled Staffing, Sufficient and Competent Nursing revised 8/2022, the P&P indicated the facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all resident .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 21 555737 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38108

Residents Affected - Few Based on interview and record review, the facility failed to ensure one of six facility staff (Certified Nurse Assistant 6, CNA 6) had necessary competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) and skill sets required during a medical emergency. CNA 6 was not aware of the proper compression (hands to push down hard and fast in a specific way on the person's chest) to breath (giving breaths of oxygen) to breath ratio needed to be performed for Cardiopulmonary Resuscitation (emergency lifesaving procedure, consisting of a combination of chest compressions, mouth- to-mouth, or mechanical breathing [using a device to help someone breaths], performed when the heart stops beating or beats ineffectively and/or to restore breathing) for Basic Life Support (BLS, generally refers to the type of care that first-responders, healthcare providers and public safety professionals provide).

This deficient practice had the potential to result CNA 6 being unable to perform lifesaving support to residents who required emergency care.

Cross Reference