Bayshire San Dimas Post-Acute

In the surveyor’s words

From the most serious findings on record at Bayshire San Dimas Post-Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF686Feb 6, 2023

  Based on observation, interview, and record review, the facility failed to provide pressure ulcers/injuries (PIs, injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care, and treatments for six of six sampled residents (Residents 4, 5, 6, 7, 8, and 9) by failing to: 1. Implement the facility's policies on Pressure Injury Risk Assessment, Quality of Care-Pressure Injuries, when the licensed nurses (in general) did not update the care plans, assess, measure, and follow the physician's orders to treat the following: a. […]

• Actual harm, patternF656Mar 15, 2023

  Based on interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan to prevent a fall for one of two sampled residents (Resident 1), who had blindness on both eyes (visual impairment/unable to see) and a history of falls by failing to: Ensure the Interdisciplinary Team (IDT, a team of health care professionals who work together to establish plans of care for the residents) met and updated Resident 1's Fall Care Plan as indicated in the facility's policy and procedure, titled Falls - Assessing Falls and Their Causes, after Resident 1 fell on [DATE], 1/6/2023, and 1/13/2023. […]

• Actual harm, isolatedF689Nov 6, 2024

  Based on observation, interview, and record review, the facility failed to supervise (observe/watch) one of three sampled residents (Resident 1), who was at risk for elopement (leaving the facility without notice, leaving a safe area unsupervised without notice and permission) as indicated in the facility's policy and procedures (P&P), titled, Safety and Supervision of Residents, and Wandering and Elopements, by failing to: 1. Ensure Resident 1 did not leave the facility unsupervised on 10/17/24. 2. […]

• Actual harm, isolatedF686Jan 29, 2024

  Based on observation, interview, and record review, the facility failed to provide care and services, for one of three sampled residents (Resident 14), to prevent the development of new pressure ulcers [PU/PI, localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear (mechanical force that cause the skin to break off) and/or friction (movement of one surface of the skin against the others)] by failing to: Provide a Bariatric bed (specialized, heavy duty, wider and longer than a standard bed for tall resident) for Resident 14 who was six feet and five inches (6'5) tall. […]

• No harm, potential for more than minimal, patternF656Apr 9, 2026

  Based on interviews and record review, the facility failed to develop and implement a comprehensive, individualized, person-centered care plan (CP), for two of two sampled residents (Resident 1 and Resident 53), that addressed:A. The use of an anticoagulant medication [Eliquis] apixaban (medication used to treat and prevent harmful blood clots from forming or getting bigger) for Resident 1.B. The use of an anticoagulant (medications used to help prevent harmful blood clots) medication [Xarelto] rivaroxaban (a medication that helps keep the blood from forming dangerous clots) for Resident 53.This deficient practice had the potential to result in unmet individualized anticoagulant therapy needs for Residents 1 and 53 and the potential to affect the resident's physical well-being.Findings: A. […]