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Deficiency Records for Bayshire San Dimas Post-Acute
A list of the most recent deficiencies for Bayshire San Dimas Post-Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Bayshire San Dimas Post-Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-07-18 | 2024-08-27 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-07-18 | 2024-08-27 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-07-18 | 2024-08-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-18 | 2024-08-27 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-06-26 | 2024-07-19 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-06-26 | 2024-07-19 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-29 | 2024-02-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-29 | 2024-02-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-29 | 2024-02-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-29 | 2024-02-25 | N |
| 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. | Health | 2024-01-29 | 2024-02-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-29 | 2024-02-25 | N |
| Post nurse staffing information every day. | Health | 2024-01-29 | 2024-02-25 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-29 | 2024-02-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-29 | 2024-02-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-29 | 2024-02-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-29 | 2024-02-25 | N |
| 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. | Health | 2024-01-29 | 2024-02-25 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-29 | 2024-02-25 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-01-29 | 2024-02-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-01-31 | 2024-02-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-31 | 2024-02-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-31 | 2024-02-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-31 | 2024-02-22 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-01-31 | 2024-02-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-31 | 2024-02-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-31 | 2024-02-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-31 | 2024-02-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-31 | 2024-02-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-27 | 2023-10-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-16 | 2023-06-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-16 | 2023-06-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-15 | 2023-04-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-15 | 2023-04-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-06 | 2023-04-13 | Y |
| 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. | Health | 2023-02-06 | 2023-04-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-08 | 2023-02-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-05 | 2023-01-09 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-05-05 | 2022-06-02 | Y |
| Provide immediate access to any resident. | Health | 2022-05-05 | 2022-06-02 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-01-06 | 2022-03-09 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-02 | 2022-02-09 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-02 | 2022-02-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-02 | 2022-02-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-02 | 2022-02-09 | N |
| 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. | Health | 2021-12-02 | 2022-02-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-02 | 2022-02-09 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-12-02 | 2022-02-09 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-02 | 2022-02-09 | N |
| Post nurse staffing information every day. | Health | 2021-12-02 | 2022-02-09 | N |
| 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. | Health | 2021-12-02 | 2022-02-09 | N |
| 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. | Health | 2021-12-02 | 2022-02-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-02 | 2022-02-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-02 | 2022-02-09 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-12-03 | 2022-02-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-12-03 | 2022-02-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-03 | 2022-02-07 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-12-03 | 2022-02-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-03 | 2022-02-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-03 | 2022-02-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-07-01 | 2019-08-27 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-07-01 | 2019-08-27 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-07-01 | 2019-08-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-01 | 2019-08-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-01 | 2019-08-27 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-01 | 2019-07-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-07-01 | 2019-07-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-01 | 2019-07-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-01 | 2019-07-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-07-01 | 2019-07-26 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-07-01 | 2019-07-26 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-07-01 | 2019-07-26 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-07-01 | 2019-07-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-01 | 2019-07-26 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-07-01 | 2019-07-26 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-07-01 | 2019-07-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-01 | 2019-07-26 | N |
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