Resident #10 left Aviata at Lakeside Oaks on August 1st with multiple medical needs including diabetes, a 3.8-centimeter foot wound, difficulty walking, and cognitive communication deficits. Their discharge plan specified wound care would continue at home through home health services and physical therapy.
The discharge paperwork was blank where the home health provider's name and phone number should have appeared.
Staff never followed up. Federal inspectors found no documentation that anyone called to verify the diabetic resident received promised wound care after leaving the facility. Two requests for follow-up records came back empty.
The facility's own policy requires calling discharged residents within three days to confirm home health providers showed up and medical equipment was delivered. During interviews on August 28th, the Regional Social Services Director admitted these mandatory calls weren't completed for Resident #10 or another discharged resident.
Staff described a discharge process that relies on assumptions rather than verification. Staff O, a registered nurse, told inspectors that social services starts discharge documentation and notifies nurses. For controlled medications, she said they sometimes send remaining pills or prescriptions, "depending on the provider orders."
Licensed Practical Nurse Staff U said he receives discharge packets from the Director of Nursing, reviews orders with residents, and distributes remaining medications. He's told in advance about medical equipment deliveries and said wheelchairs "are usually delivered to the facility before discharge."
Usually isn't always.
The Director of Nursing confirmed they follow physician orders for controlled medications, sending prescriptions if residents don't have enough pills ordered. But the process breaks down after patients leave.
Resident #10's discharge plan documented a right foot wound measuring 3.8 centimeters by 1.5 centimeters by 0.3 centimeters deep, treated with collagen and calcium alginate dressing. The social services discharge summary noted the resident would receive home health services for wound care and therapy.
None of that matters if the family doesn't know who to call.
The facility's written policy, last revised in 2018, outlines detailed discharge procedures. Staff must obtain physician orders specifying discharge location and community resources required. They're supposed to complete discharge plans and provide medication lists.
The policy requires documenting "final disposition in the resident's clinical record" including the resident's admission goals, desired outcomes, and individualized interventions. It emphasizes maintaining resident abilities and desired outcomes through interdisciplinary approaches.
But policy and practice diverged. The Regional Social Services Director's admission that required follow-up calls weren't completed contradicted the facility's own standards.
For residents with complex medical needs like diabetes and open wounds, the gap between discharge planning and actual care coordination can be dangerous. Resident #10 needed ongoing wound care, physical therapy, and diabetes management. Without home health provider contact information, families must navigate the healthcare system alone during a vulnerable transition period.
The inspection revealed systemic problems beyond individual oversights. Multiple discharged residents didn't receive required follow-up calls, suggesting routine policy violations rather than isolated mistakes.
Staff interviews showed confusion about medication protocols and equipment delivery timing. The Licensed Practical Nurse's reliance on being "told in advance" about wheelchair deliveries and "usually" receiving equipment before discharge indicates informal processes where formal verification should occur.
The Director of Nursing's focus on physician orders missed the broader coordination failure. Following orders to send medications doesn't address whether residents can access promised home health services without provider contact information.
Federal regulations require nursing homes to ensure safe transitions to post-acute care. Discharge planning must include specific arrangements for continuing care, not vague promises that services will be provided.
Aviata at Lakeside Oaks failed this basic standard. Resident #10 left with a documented wound care plan but no way to reach the people supposed to provide it. The facility's promise to verify care arrangements went unfulfilled, leaving a diabetic patient with an open foot wound to navigate post-discharge care without essential information or institutional support.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aviata At Lakeside Oaks from 2025-08-28 including all violations, facility responses, and corrective action plans.