BAYSHIRE SAN DIMAS POST-ACUTE

1740 S SAN DIMAS AVE
SAN DIMAS, CA, 91773
9093940304
CCN: 555737
3
Overall
2
Health
3
Staffing
5
Quality
ChainBAYSHIRE SENIOR COMMUNITIES
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
KIRBY, SCOTTCORPORATE OFFICERNOT APPLICABLE
KIRBY, SCOTTOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
PETERSON, TANNEROPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (8)
DateTypeAmount
2024-11-06Fine$12K
2024-02-20Fine$5K
2024-02-12Fine$5K
2024-01-29Fine$25K
2024-01-22Fine$15K
2024-01-08Fine$5K
2024-01-02Fine$5K
2023-12-11Fine$14K
Health Deficiencies (60)
2025-12-11 · Health
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
D
F806 · Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
D
F552 · Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2025-08-29 · Health
D
F698 · Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
2025-02-09 · Health
D
F908 · Environmental Deficiencies
Keep all essential equipment working safely.
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
D
F732 · Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
D
F726 · Nursing and Physician Services Deficiencies
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.
D
F725 · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
D
F678 · Quality of Life and Care Deficiencies
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
D
F584 · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
E
F578 · Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2024-11-06 · Health
G
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
E
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
2024-07-18 · Health
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
D
F745 · Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
D
F661 · Resident Assessment and Care Planning Deficiencies
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
D
F660 · Resident Assessment and Care Planning Deficiencies
Plan the resident's discharge to meet the resident's goals and needs.
2024-06-26 · Health
D
F624 · Resident Rights Deficiencies
Prepare residents for a safe transfer or discharge from the nursing home.
D
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
2024-01-29 · Health
E
F940 · Administration Deficiencies
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
D
F921 · Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
E
F887 · Infection Control Deficiencies
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F867 · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
D
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
D
F732 · Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
E
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
D
F693 · Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
G
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
E
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
E
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
2023-10-27 · Health
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
2023-05-16 · Health
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
E
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
2023-03-15 · Health
E
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
H
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
2021-12-02 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F761 · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
D
F758 · Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
B
F732 · Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
E
F725 · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
D
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
E
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
E
F688 · Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
D
F658 · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
D
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
4.36
3.68
RN Hrs/Resident/Day
0.60
0.54
LPN Hrs/Resident/Day
1.28
0.81
CNA Hrs/Resident/Day
2.48
2.33
PT Hrs/Resident/Day
0.22
0.12
Data as of 2026-03-01