Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bayshire San Dimas Post-acute during CMS and state inspections, most recent first.
Delayed and Missing Anticoagulant Care Plans: Two residents receiving anticoagulants did not have timely, individualized CPs addressing their therapy. One resident had Eliquis ordered for AFib, but the anticoagulant CP was not initiated until much later. Another resident received Xarelto for DVT prophylaxis, yet no CP was in place. Both residents lacked decision-making capacity, and the RN confirmed the facility expected an anticoagulant CP when the medication was ordered.
A facility failed to follow its OTC self-administration process for two residents who had OTC products at the bedside without physician orders or consent: one resident had Eucerin lotion and another had Gold Bond body powder. The RN stated orders and consent were required to monitor for SE and prevent sharing, and the facility policy required unauthorized bedside meds to be given to the charge nurse. The facility also failed to notify the physician about a newly admitted resident’s soiled right hip surgical dressing, which was observed saturated with drainage and peeling at the edges; the TN stated the physician should have been notified to obtain an order to change it.
Pressure ulcer care was not provided appropriately for two residents when pressure redistribution surfaces were not set according to weight or comfort level. One resident with impaired cognition, malnutrition, and dependence for ADLs had an APP set at 200 lbs. despite weighing 84 lbs., and stated the mattress was very firm and uncomfortable. Another resident with multiple PIs, including stage 4 and unstageable wounds, had a LALM set at 250 lbs. despite weighing 100 lbs.; the order and care plan called for the mattress to be set per weight range and/or comfort level.
Unsafe food storage practices were observed in Kitchen 1. An opened package of cotija cheese in the walk-in refrigerator was unlabeled and missing an open date, one refrigerator shelf had amber discoloration and peeling paint above an unsealed box of lettuce, and food and debris were found on the walk-in freezer floor. The DDS stated the cheese should be marked with an open date, chipped paint could fall onto the lettuce, and the freezer should be clean.
A resident on EBP with wounds and a stage 4 pressure ulcer was cared for by CNAs who did not consistently wear gown and gloves during direct care and transfer-related activities. In the clean laundry area, a laundry attendant stored personal items with clean linens, and the IP confirmed staff belongings should be separated from clean laundry. The IP also maintained inaccurate influenza vaccine records for two staff members, including one who had not received the current season’s flu vaccine and another whose record incorrectly showed vaccination.
Inaccurate Psychotropic Medication Consent: A resident with anxiety disorder, MDD, and intact cognition received alprazolam for anxiety, but the psychotropic consent on file authorized lorazepam instead. The MAR showed alprazolam was administered as ordered, and the RN confirmed the consent was not accurately completed because it did not match the actual psychotropic medication, dose, frequency, and indication.
MDS Incorrectly Coded UTI Diagnosis: A resident’s MDS inaccurately listed a UTI in the last 30 days even though the admission eval showed no active infection, no antibiotic therapy, and no need for an infection or UTI care plan. The MDS Nurse stated the UTI was coded because it was part of the admitting diagnoses, but acknowledged the submitted MDS should not have included UTI because the resident had no active UTI and was never treated for one at the facility.
A resident who required a two-person assist for transfers was placed on a bedpan by an LVN and staff, despite being able to use the toilet with assistance and expressing a desire not to use the bedpan. The LVN cited low staffing as the reason, though facility leadership confirmed staffing was adequate. This action was not consistent with the resident's care plan or facility policy, resulting in the resident feeling disrespected.
A resident with a recent hip fracture and moderate cognitive impairment was not informed when their pain medication was changed from tramadol to norco. The resident only became aware of the change after requesting pain medication, and there was no documentation that staff had notified the resident, despite facility policy requiring such notification.
A resident with a history of hip dislocation reported acute pain and suspected another dislocation after attempting to retrieve an abductor pillow. An LVN texted the attending physician but did not receive a response and failed to escalate the issue or make further contact attempts, resulting in a delayed physician notification and assessment.
A resident with multiple medical conditions, including neuropathy and a recent hip injury, did not receive scheduled doses of bupropion SR and gabapentin upon admission because the pharmacy processed the medications the next day. Staff did not consult with or document communication with the attending physician regarding the delay, as required by facility policy.
A resident's banana allergy was not properly documented in assessment notes or on the dietary tray card, as required by facility policy. Instead, bananas were only listed as a dislike, and the allergy section was left blank, despite the resident reporting an allergic reaction to bananas. The Dietary Supervisor confirmed the inability to enter the allergy in the system and did not update the tray card accordingly.
A resident with a history of hip dislocation experienced acute pain and a possible dislocation after attempting to retrieve an abductor pillow. An LVN failed to document the condition change on the day it occurred, inaccurately recorded the event date and physician notification, and did not report the incident to the RN supervisor, resulting in incomplete and inaccurate medical records.
The facility failed to offer and provide information about advance directives (ADs) to three residents, including one with dementia and psychosis who lacked decision-making capacity. Despite facility policy requiring inquiry about ADs upon admission, there was no documented evidence that these residents or their responsible parties were informed about their right to formulate an AD, potentially leading to unwanted care or treatment.
The facility failed to maintain kitchen sanitation and proper food storage. A staff member was observed preparing food without a hair net over their beard, violating hygiene policies. Additionally, a banana cream pie in the freezer and a tray of green beans in the refrigerator were found undated and uncovered, contrary to the facility's food storage policy. These lapses could lead to foodborne illnesses.
A resident with cognitive impairment and dysphagia was referred to as a 'feeder' by a CNA during a dining observation, which was confirmed by the Director of Staff Development as disrespectful and against facility policy. The facility's policies emphasize treating residents with dignity and avoiding labels.
A resident experienced delayed treatment for vaginal itching due to the facility's failure to notify the physician about pharmacy delays in receiving Vagisil. Despite the resident's discomfort and the facility's policy requiring prompt notification of changes in condition, the nursing staff did not inform the physician, resulting in a delay in care.
A resident's bathroom toilet leaked, causing water to puddle on the floor, which was observed by staff and confirmed as a safety risk. The resident, who required substantial assistance for daily activities, reported the issue after plumbing work was done. The facility's policy on maintaining a homelike environment was not upheld.
A CNA at the facility did not maintain current BLS/CPR certification, as revealed during a review of personnel records. The Director of Staff Development could not provide documentation of renewal, and the tracking log for CPR certification was incomplete. The Director of Nursing stressed the importance of CPR, but the facility lacked a specific policy, relying instead on the State Operations Manual. This deficiency could affect the facility's ability to provide immediate emergency care.
The facility failed to provide sufficient nursing services on specific dates, affecting two residents who experienced significant delays in receiving assistance. One resident, with hemiplegia, reported waiting up to 30 minutes for help, while another, requiring maximal assistance, waited up to 40 minutes. The facility's CNA schedule showed inadequate staffing on these nights, contrary to their policy, as confirmed by the DSD.
A CNA at the facility demonstrated a lack of competency in performing CPR, incorrectly stating the compression-to-breath ratio as 10:10 instead of the correct 30:2. Despite having a current CPR/BLS card, the CNA's misunderstanding posed a potential risk to residents in need of emergency care. The facility's policies clearly outlined the correct procedure, indicating a gap in ensuring staff maintained necessary skills.
The facility did not post accurate nurse staffing information, failing to display the actual hours worked by nursing staff responsible for resident care per shift. The Director of Staff Development (DSD) acknowledged that actual hours were calculated after the fact, contrary to the facility's policy requiring daily posting within two hours of each shift's start.
A facility failed to follow a Consultant Pharmacist's recommendations during a Medication Regimen Review for a resident with multiple diagnoses, including cerebral infarction and type 2 diabetes. Despite the physician's acceptance of the recommendations for TSH and A1C blood tests, the facility did not conduct these tests, contrary to their policy and procedure.
A resident with endometrial cancer and diabetes experienced a documentation error when Vagisil was inaccurately recorded as administered, despite the medication not being available. The error was identified during a review, and the DON emphasized the importance of accurate MAR documentation for effective communication and care.
A resident's wound vacuum drainage tubing was observed touching the floor, violating infection control practices. The resident, with endometrial cancer and diabetes, required significant assistance with daily activities. Staff confirmed the tubing should not contact the floor to prevent cross-contamination, as per the facility's infection control policy.
A resident's wheelchair had a faulty right-side brake, which was not addressed despite being reported. The resident, with a history of falling and other health issues, expressed safety concerns. Inspections confirmed the brake issue, but the maintenance log showed no record of it being reported. The facility's policy requires equipment to be maintained safely at all times.
A resident with dementia and identified as an elopement risk left an LTC facility unsupervised through an unlocked door, resulting in a fall and serious injuries. The facility's staff failed to monitor the resident effectively, and a laundry attendant mistook the resident for a visitor, failing to report their presence outside the designated area. The exit door alarm was deactivated during the day, contributing to the incident.
The facility failed to provide timely care for residents, leading to delays in assistance for basic and emergent needs. Residents reported inconsistent response times to call lights, with some waiting up to 20 minutes or more without receiving assistance. Staffing shortages, particularly during the 3 p.m. to 11 p.m. shift, contributed to these delays, as confirmed by resident council notes and family member observations.
A resident with multiple diagnoses was discharged from an LTC facility without proper discharge planning. The facility failed to consider the caregiver's capacity, assess the need for assistive devices, and arrange home health services as ordered. The discharge was rushed due to the resident's insurance coverage ending, leading to an unsafe discharge without necessary support and equipment at home.
A resident with multiple diagnoses was discharged from a facility without an accurate discharge summary or proper post-discharge plan, leading to a lack of continuity of care. The resident's representative was unprepared for the discharge, and necessary home health services and equipment were not arranged. The facility's policy for discharge planning was not followed due to short notice from the insurance company.
A resident with multiple health issues and moderate cognitive impairment did not receive adequate social services for discharge planning. The Social Services Director failed to document timely referrals to Medicaid-certified LTC facilities and did not update the resident's discharge care plan. Despite claims of sending referrals, there was no evidence of these actions, and the resident's responsible party was referred to a third-party individual for assistance. The Director of Nursing highlighted the importance of proper documentation, which was not maintained, potentially impacting the resident's well-being.
A facility failed to accurately document a resident's legal decisionmaker, leading to confusion during the resident's discharge. The resident, with multiple diagnoses including cerebral infarction and aphasia, was discharged without the legal decisionmaker's knowledge, and no home health services were arranged. The Director of Nursing recognized the need to update records to prevent such issues.
The facility failed to ensure call lights were within reach for two residents, potentially delaying care. One resident with respiratory issues and another with multiple fractures were unable to access their call lights. Staff interviews revealed that call lights were sometimes not long enough, and the facility's policy required accessibility, which was not followed.
A resident was discharged without the necessary home health services and equipment ordered by the physician, including physical and occupational therapy and a wheelchair. The facility's Social Services Director did not confirm the arrangement of these services, and the resident reported not receiving them post-discharge. This failure to adhere to the facility's discharge policy resulted in a deficiency.
Delayed and Missing Anticoagulant Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized, person-centered care plan for two sampled residents who were receiving anticoagulant therapy. For one resident, the record showed admission with diagnoses including acute respiratory failure, pulmonary embolism without acute cor pulmonale, and unspecified atrial fibrillation. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS showed moderately impaired cognitive skills for daily decision making, with dependence for several ADLs. The physician ordered Eliquis 5 mg twice daily for atrial fibrillation on admission, but the anticoagulant care plan was not initiated until 4/9/2026. For the second resident, the record showed admission with diagnoses including atrial fibrillation, abnormalities of gait and mobility, and orthopedic aftercare. The admission evaluation indicated the resident required partial/moderate assistance with ADLs and that mobility was not attempted due to medical condition and/or safety concerns. The physician ordered Xarelto 15 mg daily for DVT prophylaxis beginning 4/3/2026, and the MAR showed the medication was administered from 4/3/2026 through 4/8/2026. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, yet there was no care plan in place addressing rivaroxaban use. During interview and record review, the RN stated the facility’s policy was to create an anticoagulant care plan when the anticoagulant was ordered and acknowledged that one resident’s Eliquis care plan was initiated late and that the other resident had no anticoagulant care plan despite receiving Xarelto. The facility policy stated that a comprehensive, person-centered care plan with measurable objectives and timeframes is to be developed and implemented for each resident and developed within seven days of completion of the comprehensive assessment.
OTC Medications at Bedside Without Orders and Unreported Soiled Surgical Dressing
Penalty
Summary
The facility failed to follow its process for OTC product self-administration for two residents. One resident with diagnoses including hemiplegia, hemiparesis following cerebral infarction, and type 2 diabetes mellitus had a 16.9 fl. oz. bottle of Eucerin Advanced Repair Lotion labeled with the resident’s name on the nightstand in the room. The resident stated the lotion was brought by the resident’s mother and that the facility did not educate the resident about OTC products. The resident’s H&P indicated the resident had capacity to understand and make decisions, while the MDS indicated moderately impaired cognition and dependence for ADLs. The resident’s OSR did not include an order for the lotion. A second resident with diagnoses including need for assistance with personal care and essential hypertension had an unlabeled 10 oz. container of Gold Bond Medicated Original Strength Body Powder on the nightstand in the room. The resident stated the powder had been used for itching since admission, that the resident’s son brought it to the facility because the facility was out of Johnson’s Baby Powder, and that the resident did not have permission from the facility to use it, although staff knew it was being used. The resident’s H&P indicated capacity to understand and make decisions, while the MDS indicated moderately impaired cognitive skills for daily decision making and the need for substantial to maximal assistance with ADLs. The resident’s OSR did not include an order for the body powder. During interview and record review, the RN stated both products were OTC items not provided by the facility and that a physician’s order and consent to self-administer OTC products were required so staff could monitor for side effects and prevent sharing with other residents. The RN also stated staff should check resident rooms for OTC products during rounds. The facility’s policy on self-administration of medications stated residents may self-administer medications if the interdisciplinary team determines it is clinically appropriate and safe, and that medications found at the bedside without authorization should be given to the charge nurse for return to the family or responsible party. The facility also failed to notify the physician about a newly admitted resident’s soiled surgical dressing. The resident had recently undergone surgery for a right intertrochanteric femur fracture with intramedullary nailing and arrived at the facility with two intact surgical dressings on the right hip. The admission evaluation identified fracture care plan interventions to change the surgical incision dressing as per order and as needed. On observation, the resident was in bed, anxious, appeared uncomfortable, and pointed to the right hip area. The right hip surgical dressing was moderately saturated with red to serosanguineous drainage and the transparent cover was peeling off at the edges. A CNA also observed that the dressing was old and dirty. Record review showed no documented evidence that the physician was notified about the soiled dressing. The treatment nurse stated orthopedic physicians usually did not want staff to remove the dressing until follow-up, but that the resident’s soiled dressing should have prompted notification of the physician to obtain an order to change it. The treatment nurse stated changing the soiled dressing was important to prevent infection and maceration. The DON stated assessing the dressing and verifying with the orthopedic physician was important because the resident was newly admitted and the surgical site needed to be monitored.
Pressure Redistribution Mattress Settings Not Set Correctly
Penalty
Summary
Appropriate pressure ulcer care was not provided for two residents when the facility did not set pressure redistribution surfaces according to the residents’ weight or comfort level. Resident 29 was admitted and later readmitted with diagnoses including moderate protein-calorie malnutrition, muscle wasting and atrophy of both upper arms, and need for assistance with personal care. The skin care plan identified the resident as at risk for impaired skin integrity related to decreased mobility and included a redistribution/reduction mattress for prevention of skin breakdown. The resident’s cognition was moderately impaired, and the resident was dependent for ADLs and mobility. During observations, Resident 29’s alternating pressure pump was set at 200 lbs. even though the resident’s most recent documented weight was 84 lbs. The resident stated the mattress was very firm and uncomfortable, that staff never asked about the firmness, and that no adjustments were made despite the discomfort. The treatment nurse stated the mattress setting should always be adjusted to the resident’s comfort level and that setting it too high or too low could reduce the therapeutic effect and result in ineffective pressure redistribution. The nurse also stated that setting the mattress at 200 lbs. for a resident weighing 84 lbs. could increase the risk for skin breakdown. Resident 46 was admitted with multiple pressure injuries, including stage 1, stage 4, unstageable, and deep tissue pressure injury areas involving the upper back, sacrum, left buttock, and right heel. The resident’s history and physical indicated the resident did not have the capacity to understand and make decisions. The physician ordered a low air loss pressure redistribution mattress set per weight range for wound care, and the care plan directed that the specialty bed be set per weight range and/or comfort level each shift. However, the mattress pressure dial was observed set at 250 lbs. while the resident’s documented weight was 100 lbs., and both the CNA and treatment nurse observed the same setting. The treatment nurse stated the mattress should be set to 100 lbs. and that correct setting was important so the resident’s wounds did not get worse.
Unsafe Food Storage and Cleanliness in Kitchen 1
Penalty
Summary
Safe and sanitary food storage practices were not maintained in Kitchen 1. During observation with the Director of Dietary Services, an opened package of cotija cheese in the walk-in refrigerator was found unlabeled and without an open date. The Director of Dietary Services stated the cheese did not indicate when it was opened and that the opened bag should be marked with an open date. Also in the walk-in refrigerator, one of two shelving racks had amber discoloration, peeling blue paint, and was not smooth to touch, with an unsealed box of lettuce stored below it. The Director of Dietary Services stated chipped paint from the shelving unit could fall onto the lettuce below. In the walk-in freezer, food and debris were observed on the ground, including a breadstick on the floor that the Director of Dietary Services picked up and discarded. The Director stated the freezer should be clean and was cleaned daily.
Infection Control Lapses With PPE, Laundry Storage, and Flu Vaccine Records
Penalty
Summary
The facility failed to implement infection prevention and control practices for a resident on enhanced barrier precautions (EBP). The resident was admitted with diagnoses including type 2 diabetes mellitus and a stage 4 sacral pressure ulcer, and the record showed the resident had intact cognitive skills and required assistance with activities of daily living and transfers. EBP signage and a PPE cart were posted outside the resident’s room, but during observation a CNA entered the room wearing only a surgical mask and began cleaning the resident without donning a gown. In a later observation, another CNA assisted the resident with transfer and preparation for showering without wearing PPE, while the IP confirmed the resident had wounds and was on EBP. The IP stated gowns and gloves were important to prevent transmission of MDROs. The facility also failed to keep staff personal belongings separated from the clean area of the laundry room. In the clean laundry area, newly ordered bath towels and folded laundered linens were stored on shelving, while the same shelving area contained multiple non-laundry items belonging to the laundry attendant, including office supplies, a personal bag, a reusable tumbler, a make-up pouch, condiments, a drinking cup, and a glass food storage container. The laundry attendant stated the items were personal belongings, and the Assistant Infection Preventionist stated staff personal belongings should be separated from clean laundry to prevent cross contamination and for infection control. The facility’s laundry and linen policy stated clean linen should remain hygienically clean and protected from environmental contamination. The Infection Preventionist also failed to maintain accurate influenza vaccination records for two sampled staff members. Review of the staff vaccination tracking records showed one staff member marked as refusing the flu vaccine and another staff member documented as already having received the season’s annual influenza vaccine. However, the Infection Preventionist later stated one staff member had not received the vaccine and the other staff member reported receiving the flu vaccine at an outside pharmacy rather than at the facility. The MDS Nurse stated the flu vaccine had not been received for the current season, and the Infection Preventionist confirmed checking the immunization registry showed one staff member had not received the vaccine. The facility’s influenza vaccine policy required annual offering of the vaccine and documentation of refusals, and stated the Infection Preventionist would maintain surveillance data on influenza vaccine coverage.
Inaccurate Psychotropic Medication Consent
Penalty
Summary
The facility failed to obtain and/or ensure an accurate informed consent for alprazolam before administering the psychotropic medication to Resident 15. Resident 15 was admitted with diagnoses including anxiety disorder, major depressive disorder, and chronic kidney disease, and the MDS indicated cognition was intact. The record showed a psychotropic consent dated on admission that authorized lorazepam 0.5 mg three times a day, but the resident’s OSR showed a physician order for alprazolam 0.5 mg by mouth three times a day for anxiety, with the start date the day after admission. The MARs showed alprazolam was administered from the start date through the date of review and remained active at the time of the surveyor interview. During concurrent record review, the RN confirmed the consent on file was completed for lorazepam instead of alprazolam and stated the psychotropic medication consent was not accurately completed. The RN stated a consent should have been obtained specifically for alprazolam prior to administration, and that informed consent must include the correct medication name, dosage, frequency, and indication.
MDS Incorrectly Coded UTI Diagnosis
Penalty
Summary
The facility failed to ensure that Resident 27’s assessment accurately reflected the resident’s status in the MDS. Resident 27 was admitted with diagnoses including acute kidney failure and UTI. The admission initial evaluation dated 1/5/2026 indicated the resident did not have an active infection, was not on antibiotic therapy, and did not require a care plan for an infection or UTI. The MDS dated [DATE] indicated the resident’s cognitive skills were intact and that the resident was dependent with ADLs requiring supervision or touching assistance. However, Section I-Active Diagnoses on the MDS indicated a UTI in the last 30 days. During interview, the resident stated there was no UTI and no treatment for UTI while at the facility. The MDS Nurse stated the UTI was coded because it was part of the admitting diagnoses, but acknowledged the MDS submitted to CMS on 3/2/2026 should not have been coded for UTI because the resident no longer had an active UTI and was never treated for one at the facility.
Resident Denied Dignified Toileting Assistance
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) instructed staff to place a resident on a bedpan instead of assisting the resident to the bathroom, despite the resident's ability to communicate needs and a care plan indicating that transfers could be safely performed with two staff members. The resident, who had diagnoses including abnormalities of gait, muscle wasting, and required assistance with personal care, expressed distress and did not want to use the bedpan. The resident's caregiver had specifically requested that the resident be assisted to the toilet, noting that the resident had previously been able to use the bathroom with assistance. The LVN cited low staffing as the reason for not assisting the resident to the toilet, although facility leadership later confirmed that staffing was adequate at the time. Review of the resident's care plan and Kardex confirmed that a two-person assist was required for transfers, and the Director of Staff Development stated that the resident should have been allowed to use the toilet, as this was their right and promoted dignity. Facility policy emphasized the importance of caring for residents in a manner that enhances well-being and prohibits practices that compromise dignity, including failing to promptly respond to toileting requests. The actions taken by the LVN and staff did not align with the resident's care plan or facility policy, resulting in the resident feeling disrespected and distressed.
Resident Not Informed of Pain Medication Change
Penalty
Summary
A resident was admitted to the facility with a history of a right femur fracture, right hip dislocation, and required assistance with personal care. Upon admission, the resident was prescribed tramadol for pain management, as indicated in the discharge documentation from the previous hospital. The resident was assessed as moderately impaired in cognitive skills but was determined to have the capacity to understand and make decisions regarding care and treatment. On the day following admission, the resident's pain medication was changed from tramadol to norco by physician order. The resident was not informed of this change and only discovered the switch when requesting pain medication. During interviews, the resident stated that nursing staff did not notify them of the change, and review of the medical record confirmed there was no documentation of resident notification. Facility policy requires residents to be informed of and participate in care planning and treatment, but this was not followed in this instance.
Failure to Promptly Notify Physician of Resident's Suspected Hip Dislocation
Penalty
Summary
The facility failed to promptly notify a resident's physician after the resident complained of pain and suspected a right hip dislocation. The resident, who had a history of right femur fracture and hip dislocation and was dependent on staff for personal care, reported waking up in pain after hearing a pop in the right hip while attempting to retrieve an abductor pillow. The resident expressed that the hip felt dislocated and requested to be sent to the emergency room. Documentation showed that a nurse texted the attending physician about the resident's condition, but the physician did not respond during the nurse's shift, and no further attempts were made to contact the physician or escalate the issue to the medical director as required by facility policy. The physician was not made aware of the resident's complaint until later that afternoon, at which point an X-ray was ordered. The facility's policy required nursing staff to contact the physician based on the urgency of the situation and to escalate to the medical director if there was no timely response. The delay in physician notification and lack of escalation resulted in the resident not receiving timely assessment and intervention for the reported hip dislocation and pain.
Failure to Provide Scheduled Medications and Document Physician Consultation
Penalty
Summary
The facility failed to provide scheduled medications to a resident who was admitted with multiple diagnoses, including a femur fracture, hip dislocation, and neuropathy. Upon admission, the resident had physician orders for bupropion SR and gabapentin, both of which were due to be administered at 9:00 PM on the day of admission. However, the medications were not given as scheduled because the pharmacy did not process the order until the following day. There was no documentation in the resident's medical record indicating that the attending physician was consulted about delaying the initiation of these medications. The resident was moderately impaired in cognitive skills and dependent on staff for personal care, as documented in the Minimum Data Set. The facility's policy required staff to consult with the prescriber and document any changes if a medication could not be started as ordered, but this was not done. The failure to provide the scheduled medications and to document physician consultation constituted a deficiency in meeting the pharmaceutical needs of the resident.
Failure to Document and Communicate Food Allergy on Dietary Records
Penalty
Summary
The facility failed to ensure that a resident's documented food allergy to bananas was properly recorded and communicated according to its own policies and procedures. The resident, who was moderately impaired in cognitive skills and dependent on staff for daily care, reported an allergy to bananas that caused mouth swelling. Despite this, the allergy was not documented in the resident's assessment notes, Nutrition Risk Review Form, or admission evaluation. The resident's tray card, which is used by kitchen staff to prepare and deliver meals, did not indicate the banana allergy in the allergy section; instead, bananas were only listed as a dislike, and the allergy section was left blank. During interviews, the Dietary Supervisor confirmed responsibility for updating dietary records and tray tickets with resident allergies but stated that the system would not allow banana to be entered as an allergy, so it was only marked as a dislike. Facility policies require that all reported food allergies be documented in assessment notes and included on tray cards. The failure to document and communicate the banana allergy as required by policy had the potential for the resident to experience an allergic reaction.
Failure to Accurately Document and Communicate Resident's Acute Condition Change
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who had a history of right femur fracture and hip dislocation and required assistance with personal care. On the morning of the incident, the resident experienced acute pain and a possible hip dislocation after attempting to retrieve an abductor pillow. The Licensed Vocational Nurse (LVN) on duty did not document the resident's acute condition change on the day it occurred. Instead, the LVN created the Change in Condition Evaluation (CIC) document the following day, and the documentation inaccurately recorded the event as having started on the later date. Additionally, the documentation incorrectly indicated that the attending physician was notified at a time when there was no response from the physician during the LVN's shift. The LVN also failed to report the resident's complaint of pain and possible hip dislocation to the Registered Nurse (RN) supervisor during shift change, and the CIC was not completed before the LVN left the facility. As a result, the RN supervisor was unaware of the resident's acute condition change. The facility's policies required timely, objective, complete, and accurate documentation of acute condition changes, including reporting to the appropriate staff and physician, which was not followed in this instance.
Failure to Offer Advance Directives to Residents
Penalty
Summary
The facility failed to ensure that three residents, identified as Residents 7, 27, and 83, were offered and provided information regarding their right to formulate an advance directive (AD). This deficiency was identified through interviews and record reviews. Resident 7, who was cognitively intact and required maximal assistance with daily activities, did not have an AD, and the Social Services Director (SSD) acknowledged that the resident should have been offered one. Similarly, Resident 27, also cognitively intact and requiring maximal assistance, had no documented evidence of being offered an AD, and the Registered Nurse was unsure if the resident had been provided with information about ADs. Resident 83, who was diagnosed with dementia and psychosis and lacked the capacity to make decisions, also did not have an AD. The SSD confirmed that there was no documented evidence that an AD was offered to Resident 83's responsible party. The facility's policy and procedure, revised in September 2022, indicated that residents have the right to formulate an AD and that the social services director or designees should inquire about the existence of any written ADs prior to or upon admission. The failure to adhere to this policy resulted in the potential for residents to receive unwanted care or treatment.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the kitchen, as observed during a survey. A kitchen staff member was found preparing food without a hair net over their beard, which is against the facility's personal hygiene policy. This policy requires all hair, including beards, to be completely covered when staff are working with food. The staff member acknowledged the requirement for a hair net over their beard, indicating a lapse in adherence to the facility's hygiene standards. Additionally, during the kitchen tour, a banana cream pie was found in the walk-in freezer without a date, and a tray of green beans was observed in the walk-in refrigerator uncovered and undated. The Culinary Director confirmed that all opened food items should be labeled and dated with an expiration date, and that food is only good for three days after opening. The facility's policy on food storage mandates that all food should be covered, labeled, and dated, with use-by dates for items in refrigerators. These oversights in food storage and handling could potentially lead to foodborne illnesses.
Resident Referred to as 'Feeder' by CNA
Penalty
Summary
The facility failed to treat a resident with dignity and respect when a Certified Nursing Assistant (CNA) referred to the resident as a 'feeder.' This incident involved a resident who was admitted to the facility with a history of a compression fracture of the T11-T12 vertebra, a history of falling, and dysphagia. The resident was moderately impaired in cognitive skills and required assistance with daily activities such as toileting hygiene, showering, and personal hygiene. During a dining observation, the CNA referred to the resident as a 'feeder' in the presence of another staff member while assisting the resident with their meal. The Director of Staff Development confirmed that referring to residents as 'feeders' is considered disrespectful and is against the facility's policy. The facility's policy on Assistance with Meals emphasizes feeding residents with attention to safety, comfort, and dignity, explicitly advising against using labels like 'feeders.' Additionally, the facility's Resident Rights policy mandates that all employees treat residents with kindness, respect, and dignity. This incident highlights a failure to adhere to these policies, potentially leading to the resident feeling disrespected.
Failure to Notify Physician of Pharmacy Delays
Penalty
Summary
The facility failed to notify the physician regarding pharmacy delays and the inability to carry out the physician's order for Vagisil for a resident. The resident, who was admitted with diagnoses including endometrial cancer, type 2 diabetes mellitus, and a history of falling, had an active order for Vagisil to be applied daily for vaginal itching. Despite the order being placed, the medication was not received from the pharmacy, resulting in a delay in treatment. The resident expressed frustration and discomfort due to the lack of treatment for her symptoms, which included vaginal itching and burning. Interviews with the nursing staff and the Director of Nursing revealed that the nursing staff should have informed the physician about the delay in receiving the medication. The facility's policy requires prompt notification of the physician and resident representative regarding changes in the resident's condition or status, which was not adhered to in this case.
Leaking Toilet Creates Unsafe Environment for Resident
Penalty
Summary
The facility failed to provide a safe and homelike environment for Resident 27, as evidenced by a leaking toilet that caused water to puddle on the bathroom floor. This issue was observed during a visit to Resident 27's bathroom, where a puddle of water was found on the floor between the toilet and the wall. Resident 27 reported that the toilet began leaking after three unidentified men worked on the plumbing, and the resident had informed some nurses about the issue. The leaking toilet persisted for three days, creating a potential safety risk for Resident 27. Resident 27 was admitted to the facility with diagnoses including type 2 diabetes mellitus, aftercare following joint replacement surgery, and anxiety disorder. The Minimum Data Set indicated that Resident 27 had no cognitive impairments and required substantial assistance for daily activities such as oral care, toileting, personal hygiene, and dressing. The Plant Operations Director confirmed the presence of the water puddle and acknowledged the safety risk it posed. The facility's policy on maintaining a homelike environment emphasized the importance of providing a clean, sanitary, and orderly setting, which was not upheld in this instance.
CNA Lacks Current CPR Certification
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA 5) maintained current Basic Life Support (BLS) and Cardiopulmonary Resuscitation (CPR) certification. During an interview and record review, it was revealed that CNA 5's BLS/CPR certification had expired, and the facility could not provide documentation of renewal or completion of necessary courses. This deficiency was identified during a review of CNA 5's personnel record by the Director of Staff Development (DSD), who acknowledged the absence of a current BLS/CPR card and the incomplete tracking log for CPR certification dates. The Director of Nursing (DON) emphasized the importance of CPR in emergencies, stating that all staff should be prepared to perform CPR to save lives. However, the facility lacked a specific policy for CPR, and the Administrator indicated reliance on the State Operations Manual for policy development. The facility's policy required recertifications to be presented before expiration, but this was not adhered to in CNA 5's case. The State Operations Manual mandates that staff maintain current CPR certification, which was not met, potentially impacting the facility's ability to provide immediate emergency care.
Insufficient Nursing Staff Leads to Delayed Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing services on specific dates, as required by their policy and procedure titled 'Staffing, Sufficient and Competent Nursing.' This deficiency was observed through the experiences of two residents. Resident 19, who was admitted with conditions including hemiplegia and hemiparesis, reported having to wait up to 30 minutes for assistance at night. The resident's care plan indicated a need for assistance from 1-2 persons for most activities of daily living, highlighting the importance of timely staff response. Similarly, Resident 27, who required maximal assistance for various activities due to conditions such as an artificial hip joint and dysphagia, reported waiting up to 40 minutes for help after pressing the call light. The facility's CNA schedule showed that only two CNAs were scheduled for the night shift on the dates in question, despite the facility's policy to staff three CNAs. The Director of Staff Development confirmed the importance of adequate staffing for resident safety and timely assistance.
CNA Lacks Competency in CPR Procedure
Penalty
Summary
The facility failed to ensure that Certified Nurse Assistant 6 (CNA 6) possessed the necessary competencies and skills required during a medical emergency, specifically in performing Cardiopulmonary Resuscitation (CPR). During an interview, CNA 6 demonstrated a lack of understanding of the correct compression-to-breath ratio for CPR, stating it was 10 compressions followed by 10 breaths per cycle, which is incorrect. The Director of Staff Development (DSD) confirmed that the correct ratio should be 30 compressions to 2 breaths. This deficiency was identified during a review of CNA 6's personnel record, which showed a current CPR/BLS card, indicating that CNA 6 had been trained but was not competent in the procedure. The facility's policy and procedure for CPR and Basic Life Support (BLS) clearly outlined the correct method for performing CPR, including the 30:2 compression-to-breath ratio. Despite this, CNA 6's misunderstanding of the procedure posed a potential risk to residents requiring emergency care. The facility's job description for Certified Nursing Assistants required First Aid Training, but the deficiency highlighted a gap in ensuring that staff maintained the necessary skills and knowledge to perform lifesaving procedures effectively.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate nurse staffing information, specifically the actual hours worked by licensed and unlicensed nursing staff responsible for resident care per shift, on a daily basis. This information was not displayed in a prominent location accessible to residents and visitors. During an interview and record review with the Director of Staff Development (DSD), it was revealed that the actual hours worked by nursing staff for specific dates were not recorded or posted. The DSD explained that actual hours were calculated by the next business day, and on weekends, they were calculated by the following Monday. The facility's policy and procedure, revised in August 2022, required daily posting of nurse staffing data, including the number of nursing personnel providing direct care, within two hours of the beginning of each shift. However, this procedure was not followed, resulting in the absence of posted nurse staffing hours.
Failure to Follow Pharmacist's Recommendations for Blood Tests
Penalty
Summary
The facility failed to follow through with the Consultant Pharmacist's recommendations during the Medication Regimen Review (MRR) for a resident. The resident, who was admitted with diagnoses including cerebral infarction, urinary tract infection, and type 2 diabetes mellitus, was moderately impaired in cognitive skills and dependent on staff for daily activities. During the MRR, the Consultant Pharmacist recommended a thyroid-stimulating hormone (TSH) blood test and an A1C test, both of which were accepted by the resident's physician. However, the facility did not conduct these tests as recommended. The facility's policy and procedure for Medication Regimen Review indicated that the Consultant Pharmacist would conduct MRRs and that the facility should encourage the physician or prescriber to act upon the recommendations. Despite this, the facility did not follow through with the pharmacist's recommendations, even though the physician had accepted them. This oversight had the potential to impact the resident's health and wellbeing, as the necessary blood tests were not performed.
Inaccurate Medication Documentation for Resident
Penalty
Summary
The facility failed to ensure accurate medication administration documentation for a resident, identified as Resident 11, who was admitted with diagnoses including endometrial cancer, type 2 diabetes mellitus, and a history of falling. The resident required substantial assistance with activities of daily living and moderate assistance with mobility. The deficiency occurred when the facility inaccurately documented the administration of Vagisil, a medication prescribed for vaginal itching, on February 4, 2025. The Medication Administration Record (MAR) indicated that the medication was administered on that date, despite the facility not having received the medication from the pharmacy. The error was identified during an interview and record review with a registered nurse, who confirmed that the medication had not been available and had not been administered. The nurse noted that the licensed vocational nurse responsible for the documentation acted in good faith and did not intend to falsify the record. The Director of Nursing emphasized the importance of accurate MAR documentation for clear communication between healthcare providers and to ensure a complete and accurate record of a resident's medication regimen. The facility's policy on charting and documentation requires that records be objective, complete, and accurate.
Infection Control Breach with Wound Vacuum Tubing
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for a resident by allowing the wound vacuum drainage tubing to come into direct contact with the floor. This was observed during a visit when the tubing, attached to the resident's abdomen, was seen touching the floor while the wound vacuum pump rested on the bed. The resident had been admitted with diagnoses including endometrial cancer, type 2 diabetes mellitus, and a history of falling, and required substantial assistance with activities of daily living and mobility due to moderate cognitive impairment. Interviews with facility staff, including a Certified Nursing Assistant and the Infection Preventionist, confirmed that the tubing should not have been in contact with the floor as it could lead to cross-contamination and increase the risk of infection. The facility's policy on infection prevention and control, revised in 2018, emphasized maintaining a safe and sanitary environment to prevent the transmission of infections, which was not adhered to in this instance.
Failure to Maintain Wheelchair Brakes in Safe Condition
Penalty
Summary
The facility failed to maintain equipment in a safe and operable condition, specifically the wheelchair brakes for a resident. The resident, who was admitted with diagnoses including endometrial cancer, type 2 diabetes mellitus, and a history of falling, reported that the right-side brake of the facility-provided wheelchair was not functioning. This issue had persisted for more than a week despite being reported to the staff. The resident expressed concern about the potential safety risk, as the faulty brake could cause the wheelchair to roll unexpectedly during transfers. Upon inspection, both the Social Services Director and the Director of Maintenance confirmed the brake was faulty. The maintenance log showed no record of the issue being reported or addressed. The Director of Maintenance stated that wheelchair inspections were a collaborative effort among various departments and emphasized the importance of immediate reporting and daily inspections to ensure safety. The Director of Nursing also highlighted the significance of routine inspections to maintain equipment in optimal working condition. The facility's policy indicated that the maintenance department was responsible for ensuring all equipment was safe and operable at all times.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to adequately supervise a resident at risk for elopement, resulting in the resident leaving the facility unsupervised. The resident, who had a history of dementia and was identified as an elopement risk, managed to exit the facility through an unlocked door adjacent to their room. This door led to a transition space and ultimately to the outside of the building. The facility's policy required monitoring of residents at risk for elopement, but the resident was able to leave without being noticed by staff. On the day of the incident, the resident was seen by a laundry attendant standing by a storage room on the assisted living side of the facility. The attendant did not recognize the resident and did not report the sighting to nursing staff, mistaking the resident for a visitor. The resident subsequently left the facility, fell outside, and sustained significant injuries, including multiple mandibular fractures and facial trauma, requiring hospitalization. Interviews with staff revealed that there was a lack of clear communication and understanding of the resident's care plan and elopement risk. Although staff were aware of the resident's tendency to wander, there was no effective system in place to ensure the resident's safety. The exit door used by the resident was frequently accessed by staff and had its alarm deactivated during the day, further compromising the facility's ability to prevent the resident's elopement.
Delayed Response to Call Lights Due to Staffing Issues
Penalty
Summary
The facility failed to provide timely care for eight of 11 sampled residents, leading to delays in assistance for basic and emergent needs. Resident 4, who was admitted with chronic obstructive pulmonary disease, tachycardia, and major depressive disorder, required substantial assistance for daily activities. However, Resident 4 reported inconsistent response times to call lights, sometimes waiting up to 20 minutes without receiving assistance. Resident 2, admitted with acute kidney failure and respiratory failure, was dependent on staff for daily activities. This resident experienced a significant delay in care, waiting in a soaked diaper for three and a half hours despite multiple requests for assistance. The resident attempted to gain staff attention by going to the doorway, highlighting the facility's staffing issues. The report also noted observations of staff behavior, such as a CNA using a phone while on duty, which the Director of Nursing acknowledged as neglectful. Resident 10, with a history of UTIs and diabetes, reported long wait times for call light responses, particularly during the 3 p.m. to 11 p.m. shift due to staffing shortages. Family members and resident council notes corroborated these issues, indicating a pattern of inadequate staffing and delayed responses to resident needs.
Failure in Discharge Planning for Resident
Penalty
Summary
The facility failed to ensure timely discharge planning for a resident, leading to several deficiencies in the discharge process. The resident, who had multiple diagnoses including cerebral infarction with hemiplegia and aphasia, was discharged without proper consideration of the caregiver's capacity and capability to provide necessary care. The resident's representative was not provided with caregiver training prior to discharge, and the facility did not assess the need for assistive devices at home to safely perform activities of daily living and mobility. Additionally, the facility did not arrange and confirm home health services as ordered by the resident's physician before discharge. The discharge summary indicated that home health services were arranged, but this was not confirmed, and no outpatient therapy services were arranged. The resident's representative was surprised by the discharge and expressed concerns about the lack of support and equipment at home, as well as the absence of arranged home health services. Interviews with facility staff revealed that the discharge planning process was rushed due to the resident's health insurance company's decision to stop coverage, leading to a discharge without proper arrangements. The Director of Nursing acknowledged that discharge planning should begin on the first day of admission and that the facility failed to ensure a safe discharge by not confirming home health services and assessing the caregiver's ability to provide care. The facility's policies and procedures for discharge planning and social services were not followed, resulting in an unsafe discharge for the resident.
Failure to Ensure Accurate Discharge Summary and Post-Discharge Plan
Penalty
Summary
The facility failed to ensure an accurate discharge summary and post-discharge plan for a resident, leading to a lack of continuity of care and a delay in services. The resident, who had multiple diagnoses including cerebral infarction with hemiplegia and aphasia, was discharged without proper arrangements for home health services or necessary medical equipment. The discharge summary inaccurately stated that home health services were arranged, but no such services were confirmed or provided. The resident's representative was surprised by the discharge and disagreed with the insurance's decision to stop coverage. The representative was not prepared to care for the resident at home, lacking the necessary skills and equipment to assist with mobility and personal care. The facility's Director of Nursing admitted that home health services were not arranged prior to discharge, and the Social Services Director failed to document any referrals made to home health agencies. The facility's policy required a discharge summary and post-discharge plan to be developed and reviewed with the resident and family at least 24 hours before discharge. However, due to short notice from the insurance company, the facility did not adhere to this policy, resulting in the resident being discharged without the necessary support and services in place.
Inadequate Social Services and Discharge Planning for a Resident
Penalty
Summary
The facility failed to provide adequate social services to a resident, identified as Resident 1, which resulted in deficiencies in discharge planning. Resident 1 was admitted with multiple diagnoses, including a wedge compression fracture, history of falling, and moderate cognitive impairment. The resident was dependent on staff for various activities of daily living. Despite these needs, the Social Services Director (SSD) did not document timely referrals to Medicaid-certified long-term care (LTC) facilities, which was necessary for the resident's continued care after the expiration of Medicare benefits. Interviews and record reviews revealed that the SSD did not update or individualize Resident 1's discharge care plan to reflect the need for placement in a Medicaid-certified LTC facility. The SSD claimed to have sent referrals to multiple LTC facilities, but there was no documented evidence of these referrals or the responses from the facilities. The SSD also referred the resident's responsible party to a third-party individual for assistance, but this was not documented as part of the facility's efforts to secure appropriate placement. The Director of Nursing (DON) acknowledged the lack of documentation and emphasized the importance of complete and accurate records to demonstrate the facility's efforts in assisting Resident 1. The facility's policy and procedure required social services to document referrals and maintain contact with the resident's family, but these were not followed. The failure to provide sufficient and appropriate social services had the potential to impact Resident 1's physical and psychosocial well-being due to inadequate discharge planning.
Failure to Document Legal Decisionmaker
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident, specifically regarding the documentation of the resident's legal decisionmaker. The resident was admitted with multiple diagnoses, including cerebral infarction with hemiplegia and aphasia, and required assistance with personal care. The admission record inaccurately indicated that the resident was self-responsible, despite the history and physical examination noting the resident's inability to make medical decisions. The deficiency was further highlighted when the resident was discharged home without the knowledge of the legal decisionmaker, who was surprised by the discharge and found that no home health services were arranged. The legal decisionmaker faced difficulties communicating with the resident's health insurance company due to the lack of proper documentation of their authority. The Director of Nursing acknowledged the need to update the admission record to reflect the correct responsible party, as per the facility's policy on maintaining accurate medical records.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a potential delay in care. Resident 2, who was admitted with viral pneumonia and chronic obstructive pulmonary disease, was observed sitting in a recliner chair with the call light attached to the bed and out of reach. The resident stated that the staff who assisted her did not ask if she had access to a call button. Similarly, Resident 3, admitted with acute kidney failure and multiple fractures, was found sitting in a wheelchair with the call light by the bed, making it inaccessible. Resident 3 confirmed she was unable to call for assistance due to the call light's location. Interviews with facility staff, including a CNA and the Director of Staff Development, revealed that call lights were sometimes not long enough for residents to reach, and residents were supposed to have a bell if the call light was not reachable. The facility's policy, revised in September 2022, stated that call lights should be accessible to residents in various locations, including from the bed, toilet, and shower. Despite this policy, the observations and interviews indicated a failure to adhere to these guidelines, resulting in the deficiency.
Failure to Ensure Safe Discharge for Resident
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident, resulting in the resident being discharged without the necessary services ordered by the physician. The resident, who had been admitted with fractures and an open wound, was dependent on assistance for various activities of daily living. The physician had ordered home health services, including physical and occupational therapy, and a safety evaluation by a registered nurse, as well as the provision of a wheelchair. However, upon discharge, these services and equipment were not arranged or confirmed. Interviews revealed that the Social Services Director did not follow up to confirm the arrangement of home health services or the delivery of the wheelchair. The resident reported not receiving the wheelchair or any home health services after discharge. The facility's policy and procedure for preparing a resident for discharge required that nursing services obtain orders for discharge and ensure recommended services and equipment were in place, which was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4,133 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Dimas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Citrus Heights Health Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Casa Bonita Convalescent Hospital | 2.3 mi | ★★★★★ | 1 | 0 |
| Arbor Glen Care Center | 2.6 mi | ★★★★★ | 27 | 0 |
| Woods Health Services | 2.9 mi | ★★★★★ | 25 | 0 |
| Laurel Park Behavioral Health Center | 3 mi | ★★★★★ | 15 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bayshire San Dimas Post-acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.