Health inspection·August 29, 2025

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care and services needed for one of three sampled residents (Resident 2), who required dialysis (treatment to clean one's blood by removing waste and extra fluid when the kidneys are unable to) by failing to ensure Resident 2 was provided with a means of transportation to and from dialysis treatments three times a week between 7/25/2025 and 8/13/2025. As a result of this failure, Resident 2 did not receive nine (7/25/2025, 7/28/2025, 7/30/2025, 8/1/2025, 8/4/2025, 8/6/2025, 8/8/2025, 8/11/2025, 8/13/2025) dialysis treatments. Resident 2 was transferred to General Acute Care Hospital (GACH) 1 on 8/13/2025 at 9:30 pm. Resident 1 was diagnosed with metabolic acidosis (condition where the body produces too many acids or cannot eliminate them effectively, leading to a decrease in blood pH [acidity], uremia (the build-up of urea [an organic chemical waste product that is produced in the liver and filtered from the blood by the kidneys to be excreted in urine] and other waste products in the blood due to kidney failure), and abdominal pain. Resident 2 was admitted to GACH 1 for dialysis. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 7/15/2025 and was readmitted on [DATE] with diagnoses that included dependence on renal (kidney) dialysis, unspecified chronic kidney disease (CKD- damage to the kidneys so they cannot filter blood the way they should), and type II diabetes mellitus (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as a source of energy). During a review of Resident 2's Order Summary Report (OSR), dated 8/13/2025, the OSR indicated Resident 2 had a physician's order to have dialysis Mondays, Wednesdays, Fridays at 1:15 pm. For transportation to dialysis, the OSR indicated Resident 2's husband would pick up Resident 2. The OSR indicated Resident 2's primary care provider/Medical Doctor (MD) 1 reviewed and approved the plan of care and certified that Resident 2 continued to need this level of care unless otherwise specified and to continue orders for 45 days. During a review of Resident 2's History and Physical (H&P), dated 7/16/2025 and timed at 1:36 pm, the H&P indicated Resident 2 had end stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life). The H&P indicated Resident 2 was receiving hemodialysis (dialysis) three times per week and to continue current schedule. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 7/22/2025, the MDS indicated Resident 2 had intact cognition (ability to think, remember, and function). The MDS indicated Resident 2 required dialysis and had renal insufficiency (improperly functioning kidneys), renal failure, or ESRD. The MDS indicated Resident 1 was dependent (helper does ALL the effort) on others for all activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) with chair/bed-to-chair transfers. The MDS indicated the activity was not attempted due to medical condition or safety concerns for sitting to standing, car transfers and walking 10 feet. During a review of Resident 2's SBAR (situation, background, assessment, Residents Affected - Few (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 2 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 08/29/2025 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)