The resident at Hartley Nursing and Rehab was sent to an apartment on December 3rd. Home health referrals weren't submitted until December 6th. Services didn't actually begin until December 10th.
"This was the first discharge she had made to independent living and was not aware of the resources the Resident needed," the social worker told state inspectors during an October complaint investigation.
The resident had lived at Hartley since March 2022 for rehabilitation following hospitalization. By August 2024, insurance reviewers determined the person no longer qualified for nursing home care. The denial notice was blunt: the resident had good mental status, needed no skilled nursing services, no daily medications, displayed no behavioral issues, and required no hands-on help with daily activities.
But when discharge day arrived four months later, nobody had arranged the transition services.
The social worker, identified as Staff #9 in inspection records, admitted she didn't know what referrals to make. A regional social worker had to step in and explain what the resident needed.
"Staff #9 should have ensured the referrals were in place at discharge," the regional social worker told inspectors.
The regional social worker, Staff #11, did ensure the resident left with medications and household items. She arranged for the nursing home to provide meals and educated the resident about a call system connecting the apartment to nursing home staff for emergencies.
The apartment was located behind a sister nursing facility. But proximity didn't solve the service gap.
Home health services finally started December 10th, a full week after discharge. The resident received physical therapy, skilled nursing visits, and home aide assistance.
The regional social worker made the home health referral on December 6th. Meals on wheels was also arranged that day, three days after the person had already moved out.
Federal regulations require nursing homes to ensure residents have necessary services lined up before discharge. The facility's director of nursing confirmed to inspectors that staff had failed this requirement.
This was one of four community discharges inspectors reviewed during the complaint survey. The other three met federal standards.
The violation carried minimal harm designation, meaning no actual injury occurred but the potential existed. State inspectors classified it as affecting few residents.
Insurance had denied continued nursing home coverage in August based on the resident's independence level. The person scored well on mental status tests, managed medications without help, and handled all activities of daily living alone.
Yet the transition to independent living stumbled on basic coordination. The social worker's inexperience with community discharges left essential services unscheduled.
The regional social worker's intervention salvaged the situation, but only after the resident had already spent three days in the apartment without arranged support services.
The facility's lapse occurred despite clear documentation of what the resident would need. Insurance reviewers had evaluated the person's capabilities months earlier. Discharge planning had time to develop appropriate community connections.
Instead, the resident moved to independent living with medications and meals but no formal home health structure in place. Physical therapy, skilled nursing checks, and home aide visits all had to wait for paperwork filed after the fact.
The call system linking the apartment to nursing home staff provided emergency backup. But it couldn't replace the comprehensive home health services the resident required for successful community living.
The inspection found Hartley's discharge process had broken down at a critical juncture. Moving someone from institutional care to independent living requires careful service coordination. This resident experienced the gap when that coordination failed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hartley Nursing and Rehab from 2025-10-29 including all violations, facility responses, and corrective action plans.