Bayshire San Dimas: Stroke Patient Discharged Without Care - CA
Federal inspectors found the facility failed to maintain accurate medical records and discharged Resident 2 on July 9 despite the patient's severe disabilities from an ischemic stroke that had caused right-side paralysis, muscle wasting, and complete loss of spoken language.
Resident 2 had been admitted to Bayshire San Dimas on May 20 with multiple diagnoses from the stroke, including hemiplegia affecting the right dominant side, aphasia, gait abnormalities, muscle wasting and atrophy. The patient required assistance with personal care and was dependent on staff for toileting hygiene, bathing, lower body dressing, and putting on footwear.
According to facility assessments completed a week after admission, Resident 2 had complete absence of spoken words and difficulty communicating, though could sometimes finish thoughts if prompted or given time. The patient would miss part of conversations but could comprehend most of what was said. Staff noted some difficulty making decisions about daily tasks, but only in new situations.
The patient required substantial or maximal assistance with oral hygiene, upper body dressing, personal hygiene, and mobility. Despite these extensive care needs, a physician order dated July 9 at 6:29 PM directed the patient's discharge to home with unspecified home health services.
The order indicated Resident 2 "may have home health PT/OT & registered nurse for safety evaluation to follow." The facility discharged the patient at 5:40 PM that same day.
R2R, who held power of attorney for Resident 2, told inspectors during a July 17 telephone interview that the discharge "came as a total surprise." R2R said they did not think Resident 2 was ready for discharge from the facility.
Nobody had arranged the promised services.
"No home health RN, OT, PT visits were arranged," R2R told inspectors. The power of attorney then faced additional obstacles when trying to coordinate care independently.
R2R attempted to contact Resident 2's health insurance company but encountered resistance from staff who refused to release information, stating they would need to speak directly with Resident 2. R2R had to explain that Resident 2 was nonverbal and that R2R held legal decision-making authority through power of attorney documents on file.
"R2R was frustrated due to the runaround," inspectors documented.
The facility's admission records compounded the coordination problems. During the inspection, the Director of Nursing acknowledged that Resident 2's admission record incorrectly listed the patient as "self-responsible" rather than identifying R2R as the responsible party and legal decision-maker.
The Director of Nursing told inspectors the admission record "needed to be updated to reflect R2R as Resident 2's responsible party to prevent any confusion regarding the decisionmaker for Resident 2's care."
Federal regulations require nursing homes to maintain accurate medical records. The facility's own policy, titled "Charting Errors and/or Omissions" and revised in December 2006, states that "accurate medical records shall be maintained by the facility."
The case illustrates how documentation errors can cascade into care coordination failures, particularly for vulnerable patients with communication disabilities. Resident 2's stroke had left them unable to advocate for themselves or communicate directly with insurance companies, making accurate identification of the legal decision-maker critical for continuity of care.
The patient's clinical picture showed someone who needed extensive ongoing support. Beyond the communication challenges, Resident 2 had suffered muscle wasting and atrophy from the stroke, required help with basic activities like dressing and bathing, and needed substantial assistance with mobility.
Physical therapy, occupational therapy, and nursing assessments would typically be essential components of a safe discharge plan for someone with Resident 2's level of impairment. The physician order acknowledged this by specifying that home health services "may" follow, including PT, OT, and registered nurse safety evaluations.
But the conditional language in the order - "may have" rather than definitive arrangements - left the actual coordination unclear. No evidence in the inspection report indicated the facility had confirmed appointments or even contacted home health agencies before discharge.
The timing also raised questions about discharge planning adequacy. The physician order was written at 6:29 PM on July 9, and the patient was discharged less than an hour later at 5:40 PM the same day. This compressed timeline left little opportunity for care coordination or family preparation.
R2R's surprise at the discharge timing suggests the facility had not involved the legal decision-maker in discharge planning discussions, despite regulations requiring patient and family involvement in such decisions.
The insurance coordination problems that followed discharge highlighted another consequence of the facility's record-keeping failures. With admission records incorrectly showing the patient as self-responsible, insurance companies had no documentation of R2R's legal authority to make decisions and coordinate care.
This created a circular problem: R2R needed to arrange services the facility had promised but failed to coordinate, but couldn't access insurance information necessary to authorize those services because facility records didn't properly document their legal standing.
For stroke patients like Resident 2, gaps in care coordination can have serious consequences. The transition from skilled nursing facility care to home-based services represents a critical juncture where patients are vulnerable to falls, medication errors, missed therapy appointments, and other complications.
The patient's right-side paralysis and mobility limitations made home safety assessments particularly important. Occupational therapy evaluations could have identified necessary home modifications, while physical therapy could have established appropriate exercise routines and mobility aids.
Nursing assessments would have been essential for monitoring stroke complications, medication management, and identifying signs of decline that might require medical intervention.
Instead, Resident 2 went home without any of these safeguards in place, leaving R2R to navigate complex healthcare systems while managing the daily care needs of someone who couldn't speak for themselves.
The facility received a minimal harm citation for failing to maintain accurate medical records, affecting few residents. But for Resident 2 and R2R, the consequences of those record-keeping failures extended far beyond paperwork errors into the fundamental challenge of coordinating safe, appropriate care for someone whose stroke had left them entirely dependent on others to advocate for their needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bayshire San Dimas Post-acute from 2024-07-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
BAYSHIRE SAN DIMAS POST-ACUTE in SAN DIMAS, CA was cited for violations during a health inspection on July 18, 2024.
The patient required assistance with personal care and was dependent on staff for toileting hygiene, bathing, lower body dressing, and putting on footwear.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.