Community Care Center discharged Resident #5 on July 29 after an 11-day stay for rehabilitation following right shoulder replacement surgery. The 15-year-old policy manual sitting in administrators' offices detailed exactly what should happen when residents leave: a comprehensive discharge summary covering medical status, functional abilities, nutritional needs, and a detailed plan for continuing care at home.
None of that happened.
The resident left with heart failure, chronic kidney disease, and ongoing rehabilitation needs. Physical therapists had documented she remained a fall risk and oxygen dependent. They recommended continued services to improve strength and balance, noting she was leaving "against PT recommendations."
Her medical record contained no discharge summary. No care plan. No documentation that staff provided discharge instructions of any kind.
The Progress Notes from July 29 at 11:30 AM noted simply that "the resident discharged from the facility." Nothing more.
When federal inspectors arrived in October, Director of Nursing and Assistant Director of Nursing admitted the facility "does not send a Discharge Summary or Plan of Care home with residents at the time of discharge." They said therapy details and care needs are "discussed" with residents and families during the stay, but rehabilitation notes aren't included in any paperwork given to residents or their representatives.
The facility's own policy, revised September 27, 2017, contradicts this practice entirely.
The policy assigns specific responsibilities to the Director of Nursing, Social Worker, Food Service Supervisor, Activity Director, and licensed nurses. Its stated purpose: "To provide information regarding the care needed after discharge. To document education completed upon discharge. To summarize the course of the resident's stay at the facility."
The policy requires discharge summaries to include a "recapitulation of the resident's stay" and a detailed status report covering medical condition, functional abilities, sensory and physical impairments, nutritional requirements, special treatments, psychosocial status, cognitive status, and drug therapy.
Most critically, it mandates "a post-discharge plan of care that developed with the participation of the resident and his/her family, which will assist the resident to adjust to his/her new living environment."
The guidelines specify this plan should describe "the resident's and family's preferences for care, how they will access and pay for these services, and how care should be coordinated if continuing treatment involves multiple caregivers." It should identify specific needs like personal care assistance, sterile dressings, and physical therapy, while describing what residents and caregivers need to know to manage care at home.
Resident #5's case illustrates the gap between policy and practice. Her MDS assessment from July 25 showed completely intact cognition with a perfect BIMS score of 15 out of 15. She began Medicare occupational and physical therapy services on July 18 following her shoulder surgery.
Physical therapy notes from July 28 documented her complex needs. She required a one-person assist with a gait belt for walking. She was continent and could feed herself, meeting basic functional levels. But therapists identified ongoing fall risk and oxygen dependence, recommending continued services she wouldn't receive at home.
The Transfer/Discharge Report from July 28 captured some functional details but omitted any summary of occupational or physical therapy services. For a resident leaving rehabilitation against professional recommendations, this represented a critical omission.
Federal regulations require these discharge summaries for residents returning to private homes, other nursing facilities, or residential care settings. The only exception: residents discharged directly to hospitals.
The facility's policy acknowledges the importance of coordinated discharge planning, noting that proper documentation helps residents "adjust to his/her new living environment" when "continuing treatment involves multiple caregivers."
For Resident #5, managing heart failure and chronic kidney disease while recovering from shoulder surgery would clearly involve multiple caregivers. Physical therapists had recommended continued services. Her oxygen dependence and fall risk required ongoing monitoring.
Instead, she left with whatever verbal instructions staff may have provided during her stay. No written summary of her medical status. No care plan for managing complex conditions at home. No documentation that discharge education occurred at all.
The inspection found this wasn't an isolated oversight. Administrators confirmed the facility routinely discharges residents without the required summaries and care plans, despite maintaining detailed policies requiring exactly these documents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Community Care Center from 2025-10-14 including all violations, facility responses, and corrective action plans.