Timberwood Nursing and Rehabilitation Center's Director of Nursing and Administrator made the joint decision to discharge Resident #1 immediately following the February 18, 2025 incident. The Assistant Director of Nursing called the resident's wife and told her to pick up her husband immediately.
Nobody obtained a physician's order for the discharge.
The facility's own policy requires documentation of the basis for any transfer or discharge in the resident's medical record before removal. Staff documented nothing about Resident #1's discharge in his records prior to sending him home.
Federal regulations also require facilities to notify the state ombudsman of emergency discharges. No one at Timberwood made that call either.
"The DON told ADON A to call Resident #1's Family Member B and tell her to pick-up Resident up immediately for discharge," the Administrator told federal inspectors during a November 18 interview. "No staff member notified the ombudsman of the discharge or called the wife after the incident to follow-up with discharge instructions."
The Director of Nursing admitted she wasn't current on the facility's discharge policies. She and the Administrator had been out of town for work when the incident occurred, she said, resulting in what she called "an inappropriate discharge for Resident #1."
During her interview, the Assistant Director of Nursing said she had never encountered a situation where a male resident put his hand up a female resident's shirt. She acknowledged not being aware of facility discharge policies and procedures.
"The ADON A said she did not have a written physician's order for Resident #1 discharge, nor had she completed a discharge summary in his medical records," inspectors documented. "The ADON A said the facility did not follow facility policy and procedure on resident discharges."
The facility's social worker learned about the incident and discharge the following day from the Director of Nursing. She never contacted the resident's wife to discuss the discharge or provide medical resources after he left. She documented nothing in the resident's medical records about his removal.
Timberwood's written policy, last revised in December 2023, states that residents should remain in the facility unless discharge meets specific criteria. When transfers or discharges occur, the policy requires documentation in medical records and communication of appropriate information to receiving healthcare providers.
The policy specifically requires facilities to document when discharge is necessary because "the safety of individuals in the Facility is endangered due to the clinical or behavioral status of the resident."
None of this documentation occurred before Resident #1's wife arrived to collect him.
"The Administrator said the facility did not properly discharge Resident #1 nor did they follow their policy for resident discharges," inspectors wrote. He acknowledged the facility should have obtained a physician's order and documented the discharge basis in medical records beforehand.
The Director of Nursing told inspectors that failing to follow discharge policies "could cause residents to have improper discharges." The Assistant Director of Nursing said policy violations "will place residents at risk for improper discharges."
The Administrator called the physician to inform him of the incident but received no discharge order before sending the resident home.
Federal inspectors found the facility violated requirements for proper discharge procedures during their November 19 complaint investigation. The violation received a minimal harm designation affecting few residents.
The resident's wife received no follow-up call after collecting her husband. She received no discharge instructions or medical resources to help manage his care at home after the emergency removal from professional nursing supervision.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Timberwood Nursing and Rehabilitation Center from 2025-11-19 including all violations, facility responses, and corrective action plans.
Additional Resources
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