Cycle 1
Health 2025-02-09 · Fire 2025-02-09
20 health deficiencies
Top issue: Resident Rights (7 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
San Dimas, CA
Bayshire San Dimas Post-Acute
3-star overall rating with 2-star inspections with $85,083 in total fines with 20 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1740 S San Dimas Ave, San Dimas, CA
(909) 394-0304
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bayshire Senior Communities
Operator or chain grouping
Approved since
1999-05-05
CMS approved date
Coverage
Medicare
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.60
Registered nurse staffing
LPN hours / resident day
1.28
Licensed practical nurse staffing
Aide hours / resident day
2.48
Nurse aide staffing
Weekend hours
4.31
Weekend nurse staffing
RN turnover
60%
Annual RN turnover
Total nurse turnover
50%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 0.0% |
13.7%
13.7 pts better
|
19.6%
19.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
94.0%
5.8 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.8% |
11.2%
8.4 pts better
|
12.0%
9.2 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.5% |
93.2%
6.3 pts better
|
79.7%
19.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.0% |
23.2%
1.2 pts better
|
23.9%
1.9 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-29 · Fire 2024-01-29
22 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2021-12-02 · Fire 2021-12-02
18 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-02-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-09
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2025-03-06
C · Minimal harm
2025-02-09
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-02-28
F · Potential for more than minimal harm
2024-01-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-01-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-01-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-22
E · Potential for more than minimal harm
2024-01-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-29
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-02-22
D · Potential for more than minimal harm
2024-01-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-22
C · Minimal harm
2024-01-29
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-02-22
F · Potential for more than minimal harm
2021-12-02
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-02-07
F · Potential for more than minimal harm
2021-12-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-02-07
F · Potential for more than minimal harm
2021-12-02
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-02-07
F · Potential for more than minimal harm
2021-12-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-02-07
D · Potential for more than minimal harm
2021-12-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-02-07
D · Potential for more than minimal harm
2021-12-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-02-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-12-11
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-12-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-12-11
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-12-11
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-12-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-01-05
D · Potential for more than minimal harm
2025-08-29
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-02-09
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2025-03-05
E · Potential for more than minimal harm
2025-02-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-20
D · Potential for more than minimal harm
2025-02-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-09
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-09
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-09
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-09
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-09
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-09
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-09
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-03-05
G · Actual harm
2024-11-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-26
E · Potential for more than minimal harm
2024-11-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-01
D · Potential for more than minimal harm
2024-07-18
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-18
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-18
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-06-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-26
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-07-19
G · Actual harm
2024-01-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-25
E · Potential for more than minimal harm
2024-01-29
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-02-25
E · Potential for more than minimal harm
2024-01-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-25
E · Potential for more than minimal harm
2024-01-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-25
E · Potential for more than minimal harm
2024-01-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-25
E · Potential for more than minimal harm
2024-01-29
F887 · Infection Control Deficiencies
Health
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.
Corrected 2024-02-25
E · Potential for more than minimal harm
2024-01-29
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-29
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-29
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-29
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-02-25
D · Potential for more than minimal harm
2024-01-29
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-02-25
D · Potential for more than minimal harm
2023-10-27
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-05-16
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-16
H · Actual harm
2023-03-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-03-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-13
E · Potential for more than minimal harm
2021-12-02
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2022-02-09
E · Potential for more than minimal harm
2021-12-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-02-09
E · Potential for more than minimal harm
2021-12-02
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-02-09
E · Potential for more than minimal harm
2021-12-02
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-02-09
E · Potential for more than minimal harm
2021-12-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-02-09
E · Potential for more than minimal harm
2021-12-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-09
D · Potential for more than minimal harm
2021-12-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-02-09
D · Potential for more than minimal harm
2021-12-02
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-02-09
D · Potential for more than minimal harm
2021-12-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-02-09
D · Potential for more than minimal harm
2021-12-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-02-09
D · Potential for more than minimal harm
2021-12-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-02-09
D · Potential for more than minimal harm
2021-12-02
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-02-09
B · Minimal harm
2021-12-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-02-09
Penalties and ownership
What sits behind the stars
$12,048
2024-11-06
Fine
Fine · fine $12,048
Fine
$4,938
2024-02-20
Fine
Fine · fine $4,938
Fine
$4,938
2024-02-12
Fine
Fine · fine $4,938
Fine
$25,058
2024-01-29
Fine
Fine · fine $25,058
Fine
$14,814
2024-01-22
Fine
Fine · fine $14,814
Fine
$4,938
2024-01-08
Fine
Fine · fine $4,938
Fine
$4,587
2024-01-02
Fine
Fine · fine $4,587
Fine
$13,762
2023-12-11
Fine
Fine · fine $13,762
Fine
Ownership
Kirby, Scott
Operational/Managerial Control · Individual
Kirby, Scott
Corporate Officer · Individual
Peterson, Tanner
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Citrus Heights Health Center
Covina, CA
5-star overall rating with 4-star inspections with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Casa Bonita Convalescent Hospital
San Dimas, CA
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Arbor Glen Care Center
Glendora, CA
1-star overall rating with 1-star inspections with 26 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Jump out