Health inspection·June 26, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for two of three sampled residents (Residents 2 and 3). Residents Affected - Few This deficient practice had the potential to result in the delay of care for Residents 2 and 3 when Residents 2 and 3 were unable to reach their call lights to call staff for assistance. Findings: a. During a review of Resident 2's admission Record (AR), the AR indicated, the facility admitted Resident 2 on 5/21/2024, with diagnoses of viral pneumonia (an infection of the lung caused by a virus) and chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) with acute exacerbation (a sudden worsening of symptoms that lasts for several days). During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/28/2024, the MDS indicated, Resident 2 was understood by others and had the ability to understand others. The MDS indicated, Resident 2 required substantial/maximal assistance (helper lifted or held trunk or limbs and provided more than half the effort) with oral hygiene, toileting hygiene, showering/bathing self, lower body dressing, putting on/taking off footwear, and personal hygiene. During a concurrent observation and interview on 6/26/2024 at 12:30 pm with Resident 2, Resident 2 was sitting up in a recliner chair in the corner of the room eating lunch. Resident 2's call light was attached to the bed and not reachable by Resident 2. Resident 2 stated staff (unidentified) who assisted her to the recliner chair did not ask her if she had a call button. b. During a review of Resident 3's AR, the AR indicated, the facility admitted Resident 3 on 5/10/2024, with diagnoses that included acute kidney failure (when the kidneys are suddenly not able to filter waste products from the blood) and fractures of second cervical vertebra (bone in the neck area of the spine that allows rotation of the head), pelvis (the area below the abdomen that contains the hip bones, bladder, and rectum), sacrum (large, triangle-shaped bone in the lower spine), humerus (upper arm bone), and left arm. During a review of Resident 3's MDS dated [DATE], the MDS indicated, Resident 3 was understood by others and had the ability to understand others. The MDS indicated, Resident 3 was dependent (helper did all the effort) with toileting hygiene, showering/bathing self, upper body dressing, lower body dressing, and putting on/taking off footwear. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555737 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555737 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)