DENVER, CO - A federal inspection of City Scape Rehabilitation & Care Center LLC revealed significant procedural failures in the discharge of a resident who was ultimately escorted from the facility by law enforcement and transported to a homeless shelter without proper documentation or notice.
Resident Discharged Without Required Documentation
The July 2024 complaint investigation uncovered that Resident #105 was discharged from the Denver facility on February 20, 2024, without receiving the legally mandated written discharge notice. Federal regulations require nursing homes to provide residents with advance written notification before any facility-initiated discharge, typically 30 days in advance, to allow adequate time for the resident to arrange alternative housing and care.
According to facility records, the resident "was escorted from the facility accompanied by law enforcement" at approximately 3:50 p.m. on February 20, 2024. A psychosocial note from that day indicated the resident "was presented with multiple options when planning to discharge, however, he refused to comply with any option."
The documentation further revealed that staff "met with the resident along with a civilian emergency response team clinicians and the police because of the resident's refusal to leave after being successfully discharged from the facility and the resident was considered to be trespassing." Administrative staff then assisted with transporting the resident to a homeless shelter.
Multiple Documentation Failures Identified
Inspectors found the facility's electronic medical record for Resident #105 was missing several critical documents required by federal regulations:
- No discharge summary or assessment documentation - No nursing notes documenting appropriate orientation and preparation of the resident prior to transfer or discharge - No documented reason for the discharge in the medical record - No written discharge notice on file
These documentation gaps represent violations of federal requirements designed to protect nursing home residents from unsafe or improper discharges. The discharge summary and assessment are essential for ensuring continuity of care and providing the receiving facility or caregiver with necessary medical information.
Why Proper Discharge Planning Matters
Discharge planning serves as a critical safeguard in skilled nursing care. When residents are discharged without proper preparation, they face increased risks of medication errors, missed follow-up appointments, and gaps in ongoing treatment. For residents with complex medical needs, an abrupt discharge without coordination can lead to rapid health deterioration, hospital readmission, or preventable complications.
The requirement for written notice also provides residents with legal protections, including the right to appeal a discharge decision. Without this notice, residents lose their opportunity to contest a discharge they believe is improper or to request additional time to secure appropriate housing.
Ombudsman Notification Concerns
Federal regulations require nursing facilities to notify the state long-term care ombudsman when initiating a resident discharge. The ombudsman serves as an independent advocate for nursing home residents, helping to ensure their rights are protected during the discharge process.
While a psychosocial note dated February 21, 2024, indicated the ombudsman was contacted the previous day "about an emergency discharge of Resident #105 due to the ombudsman being a part of the discharge planning from the beginning," the facility could not produce documentation of the required written notification.
When interviewed on July 11, 2024, the social services director confirmed he "did not issue a written facility-initiated discharge notice to Resident #105 or the ombudsman."
Facility Leadership Unable to Explain Actions
During a joint interview on July 15, 2024, the nursing home administrator and regional operations consultant acknowledged the facility's failures. Both confirmed that the facility did not issue a facility-initiated discharge notice to the resident or provide written notice to the ombudsman.
Most notably, both administrators stated they did not know the reason why the facility discharged the resident or why the facility had not issued a 30-day discharge notice. This admission raises serious questions about oversight and communication within the facility's administrative structure.
Industry Standards for Discharge
Proper discharge procedures in skilled nursing facilities require a comprehensive approach. Facilities must document a legitimate reason for discharge that falls within the categories permitted by federal regulation, such as the resident's welfare, safety of other residents, or nonpayment. Staff must prepare residents for the transition through education and coordination with receiving providers. The 30-day advance notice requirement exists specifically to prevent situations where residents are left without adequate time to secure safe, appropriate housing.
Additional Issues Identified
The inspection also referenced related violations under F622, which governs transfer and discharge requirements more broadly. The facility was cited at a level indicating minimal harm or potential for actual harm, with few residents affected.
Regulatory Context
This inspection was conducted as a complaint investigation, meaning state or federal surveyors responded to a specific concern raised about the facility's care or operations. The findings documented in this report represent conditions observed during the July 2024 survey period.
City Scape Rehabilitation & Care Center LLC, located at 3345 Forest Street in Denver, is required to submit a plan of correction addressing the identified deficiencies. Facilities found out of compliance with federal regulations must demonstrate how they will prevent similar violations in the future and protect residents' rights going forward.
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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