DENVER, CO - Federal inspectors documented serious discharge violations at City Scape Rehabilitation & Care Center where staff forced a cognitively intact resident to a homeless shelter without required legal notifications or his medications.
Facility Forced Resident Out Using Police
The February 2024 inspection revealed that Resident #105, a man under 65 with rheumatoid arthritis and chronic pain conditions, was planning to discharge to an assisted living facility when the nursing home suddenly reversed course. Despite his preference for assisted living, staff discharged him to a homeless shelter against his wishes.
When the resident refused to leave, facility administrators called police to escort him from the property. Medical records show he was "escorted from the facility accompanied by law enforcement" and was "cooperative" during the forced removal.
The resident described the experience as "horrible" and "humiliating," stating he "was crying and begging at discharge not to be kicked out of his home." His family representative, who witnessed the discharge via video call, recorded him "crying and begging for the facility not to kick him out."
Federal Notification Requirements Ignored
Federal regulations require nursing homes to provide residents with 30-day written advance notice before facility-initiated discharges. This notice must include specific information including the reason for discharge, effective date, new location, and detailed appeal rights information.
City Scape failed to provide any written discharge notice to the resident or his representative. The facility's own policy, dated October 2022, clearly outlined these requirements but staff did not follow established procedures.
The nursing home also violated federal law by failing to notify the state ombudsman of the discharge. Regulations require facilities to send a copy of discharge notices to the ombudsman simultaneously with providing notice to residents.
Missing Medications and Discharge Instructions
Federal law requires nursing homes to provide proper discharge preparation including medications and instructions. The facility's Director of Nursing told inspectors that nurses should prepare all medications, provide education about how and when to take them, and document the discharge education provided.
However, medical records contained no documentation that Resident #105 received his medications or any discharge instructions. The resident confirmed he left the facility without his medications for conditions including rheumatoid arthritis, anxiety, depression, and chronic pain.
Missing medications can create immediate health risks for residents with chronic conditions. Sudden discontinuation of arthritis medications can cause increased pain and joint inflammation, while stopping anxiety medications without medical supervision can trigger withdrawal symptoms.
Retaliation Following Complaints
The resident and his representative believed the discharge was retaliation for his complaints about facility conditions. He had reported that the building was cold and his laundry was returned dirty or damaged.
Medical records show that on February 17, 2024, police responded to the facility after the resident called to report the heat was turned off and he was cold. Three days later, the facility discharged him.
Federal law prohibits nursing homes from retaliating against residents who file complaints about care or conditions. Facilities must demonstrate legitimate reasons for discharges and follow proper procedures regardless of resident complaints.
Consequences of Improper Discharge
Following the illegal discharge, the resident experienced significant hardships. He was forced to move between hospitals and homeless shelters, experiencing what he described as "a lot of confusion and anxiety." His representative confirmed he had been "in and out of the hospital and homeless shelters" since leaving the facility.
The resident was cognitively intact with a score of 15 out of 15 on mental status testing and was independent in all daily living activities. His discharge assessment showed no behavioral problems or care rejection, making the sudden facility-initiated discharge particularly questionable.
Administrative Failures Documented
When inspectors interviewed facility leadership, including the Regional Operations Consultant, Nursing Home Administrator, and Social Services Director, none could explain why proper discharge procedures were not followed. Staff acknowledged they "did not formally notify" the resident about the discharge and could not provide reasons for the facility-initiated discharge.
The administrator and operations consultant told inspectors they "did not know why it was determined" the resident would be discharged on February 20, 2024, when he did not want to leave. They also could not explain why the facility failed to issue the required 30-day discharge notice.
Industry Standards for Discharge Planning
Proper nursing home discharge planning involves coordinated care transitions with adequate preparation time. Best practices include comprehensive discharge assessments, medication reconciliation, care coordination with receiving facilities, and family involvement in planning.
The resident had been working with facility social services since January 2024 to arrange assisted living placement. Progress notes show he had toured facilities and was awaiting admission to his preferred location when the facility abruptly changed course.
Federal inspectors cited the facility for violations under F622 and F623 regulations, which govern transfer and discharge requirements and notification procedures. These violations carry the potential for enforcement actions including monetary penalties and increased oversight.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for City Scape Rehabilitation & Care Center LLC from 2024-07-16 including all violations, facility responses, and corrective action plans.
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