D67

BAYSHIRE SAN DIMAS POST-ACUTE

Grade D 67/100 composite score

For profit - Corporation

CMS Star Ratings

Overall
3/5
Health Insp.
2/5
Quality
5/5
Staffing
3/5
RN Staffing
Not rated

Certified Beds

45

Ownership

For profit - Corporation

Total Fines

$141,315

Last Survey

N/A

1740 S SAN DIMAS AVE, SAN DIMAS, CA 91773
9093940304

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.51h
LPN
1.09h
CNA
2.12h
Total
3.72h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

KIRBY, SCOTT

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Apr 2024

PETERSON, TANNER

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jan 2025

KIRBY, SCOTT

IndividualCORPORATE OFFICERSince Apr 2024

Penalties & Fines (9)

$141,315total fines
DateTypeDescriptionAmount
Nov 6, 2024Fine$12,048
Feb 20, 2024Fine$4,938
Feb 12, 2024Fine$4,938
Jan 29, 2024Fine$25,058
Jan 22, 2024Fine$14,814
Jan 8, 2024Fine$4,938
Jan 2, 2024Fine$4,587
Dec 11, 2023Fine$13,762
Feb 6, 2023Fine$56,232

Health Inspection Deficiencies (58)

August 29, 2025Health1 deficiency
0698DMinimal harm, Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Sep 19, 2025
February 9, 2025Health13 deficiencies
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Mar 5, 2025
0578EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Mar 5, 2025
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Mar 5, 2025
0584DMinimal harm, Isolated

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.

Resident Rights Deficiencies

Corrected Mar 5, 2025
0678DMinimal harm, Isolated

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Quality of Life and Care Deficiencies

Corrected Mar 5, 2025
0725DMinimal harm, Isolated

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies

Corrected Mar 5, 2025
0726DMinimal harm, Isolated

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.

Nursing and Physician Services Deficiencies

Corrected Mar 5, 2025
0732DMinimal harm, Isolated

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies

Corrected Mar 5, 2025
0756DMinimal harm, Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Corrected Mar 5, 2025
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Feb 20, 2025
0842DMinimal harm, Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Mar 5, 2025
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Mar 5, 2025
0908DMinimal harm, Isolated

Keep all essential equipment working safely.

Environmental Deficiencies

Corrected Mar 5, 2025
November 6, 2024Health2 deficiencies1 severe
0558EMinimal harm, Pattern

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Dec 1, 2024
0689GActual harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Nov 26, 2024
July 18, 2024Health4 deficiencies
0660DMinimal harm, Isolated

Plan the resident's discharge to meet the resident's goals and needs.

Resident Assessment and Care Planning Deficiencies

Corrected Aug 27, 2024
0661DMinimal harm, Isolated

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Resident Assessment and Care Planning Deficiencies

Corrected Aug 27, 2024
0745DMinimal harm, Isolated

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Quality of Life and Care Deficiencies

Corrected Aug 27, 2024
0842DMinimal harm, Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Aug 27, 2024
June 26, 2024Health2 deficiencies
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Jul 19, 2024
0624DMinimal harm, Isolated

Prepare residents for a safe transfer or discharge from the nursing home.

Resident Rights Deficiencies

Corrected Jul 19, 2024
January 29, 2024Health14 deficiencies1 severe
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Feb 25, 2024
0655EMinimal harm, Pattern

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Corrected Feb 25, 2024
0656EMinimal harm, Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Feb 25, 2024
0686GActual harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Feb 25, 2024
0693DMinimal harm, Isolated

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.

Quality of Life and Care Deficiencies

Corrected Feb 25, 2024
0695EMinimal harm, Pattern

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Feb 25, 2024
0732DMinimal harm, Isolated

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies

Corrected Feb 25, 2024
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Feb 25, 2024
0812DMinimal harm, Isolated

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Feb 25, 2024
0867DMinimal harm, Isolated

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Administration Deficiencies

Corrected Feb 25, 2024
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Feb 25, 2024
0887EMinimal harm, Pattern

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.

Infection Control Deficiencies

Corrected Feb 25, 2024
0921DMinimal harm, Isolated

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected Feb 25, 2024
0940EMinimal harm, Pattern

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Administration Deficiencies

Corrected Feb 25, 2024
October 27, 2023Health1 deficiency
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Oct 27, 2023
May 16, 2023Health2 deficiencies
0607EMinimal harm, Pattern

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jun 16, 2023
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jun 16, 2023
March 15, 2023Health2 deficiencies1 severe
0656HActual harm, Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 13, 2023
0689EMinimal harm, Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Apr 13, 2023
February 8, 2023Health1 deficiency
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Feb 13, 2023
February 6, 2023Health2 deficiencies1 severe
0686KImmediate jeopardy, Pattern

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Apr 13, 2023
0726EMinimal harm, Pattern

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.

Nursing and Physician Services Deficiencies

Corrected Apr 13, 2023
January 5, 2023Health1 deficiency
0755EMinimal harm, Pattern

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Jan 9, 2023
December 2, 2021Health13 deficiencies
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Feb 9, 2022
0607DMinimal harm, Isolated

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Feb 9, 2022
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Feb 9, 2022
0658DMinimal harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Feb 9, 2022
0688EMinimal harm, Pattern

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.

Quality of Life and Care Deficiencies

Corrected Feb 9, 2022
0689EMinimal harm, Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Feb 9, 2022
0690DMinimal harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Feb 9, 2022
0725EMinimal harm, Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies

Corrected Feb 9, 2022
0732BNo harm, Pattern

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies

Corrected Feb 9, 2022
0758DMinimal harm, Isolated

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.

Pharmacy Service Deficiencies

Corrected Feb 9, 2022
0761EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Feb 9, 2022
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Feb 9, 2022
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Feb 9, 2022

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Frequently Asked Questions

What is the CareGrader rating for BAYSHIRE SAN DIMAS POST-ACUTE?

BAYSHIRE SAN DIMAS POST-ACUTE in SAN DIMAS, California has a CareGrader grade of D (Below Average), with a composite score of 66.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for BAYSHIRE SAN DIMAS POST-ACUTE?

BAYSHIRE SAN DIMAS POST-ACUTE has an overall CMS star rating of 3 out of 5, a health inspection rating of 2/5, and a staffing rating of 3/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does BAYSHIRE SAN DIMAS POST-ACUTE have?

BAYSHIRE SAN DIMAS POST-ACUTE has 58 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has BAYSHIRE SAN DIMAS POST-ACUTE been fined?

Yes. BAYSHIRE SAN DIMAS POST-ACUTE has $141,315 in total fines from CMS enforcement actions across 9 penalties.

How many beds does BAYSHIRE SAN DIMAS POST-ACUTE have?

BAYSHIRE SAN DIMAS POST-ACUTE has 45 certified beds with approximately 37 current residents (82% occupancy). The facility is located at 1740 S SAN DIMAS AVE, SAN DIMAS, California 91773. It is a for profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.