Federal Nursing-Home Survey Record
BAYSHIRE SAN DIMAS POST-ACUTE
Does BAYSHIRE SAN DIMAS POST-ACUTE have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), BAYSHIRE SAN DIMAS POST-ACUTE (CCN 555737), in SAN DIMAS, CA, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 20 deficiencies; the most serious carries scope/severity E on CMS's A–L scale — CMS's "potential for harm" tier, below actual harm. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. CMS has $85,083 in civil money penalties on file against the facility. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
CMS has $85,083 in civil money penalties on file against this facility.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Civil money penalties on file
$85,083
CMS has $85,083 in civil money penalties on file against this facility.
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 3 · CMS state average: 3.2
Deficiency timeline — full federal history
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Ensure that residents are fully informed and understand their health status, care and treatments.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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.
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Keep all essential equipment working safely.
Provide and implement an infection prevention and control program.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Post nurse staffing information every day.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
38 citations from earlier inspection cycles — historical, not current (expand)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Reasonably accommodate the needs and preferences of each resident.
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Plan the resident's discharge to meet the resident's goals and needs.
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Reasonably accommodate the needs and preferences of each resident.
Prepare residents for a safe transfer or discharge from the nursing home.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide safe and appropriate respiratory care for a resident when needed.
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
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.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide and implement an infection prevention and control program.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Post nurse staffing information every day.
Ensure each resident receives an accurate assessment.
Ensure that residents are free from significant medication errors.
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.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Respond appropriately to all alleged violations.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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.
Reasonably accommodate the needs and preferences of each resident.
Ensure services provided by the nursing facility meet professional standards of quality.
Post nurse staffing information every day.
Document what happened
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