College Oak Nursing & Rehabilitation Center violated federal discharge regulations when it removed Resident 1 without the mandatory 30-day advance notice or discharge instructions, according to inspection records. The resident confirmed to investigators that facility staff intended "to get rid of me and they did."
The resident told inspectors her discharge plan was to find transitional housing and confirmed she remains unhoused. She said the facility provided no written notification at discharge and was unaware of her right to appeal or who to contact for support.
"Their intention was to get rid of me and they did," the resident told investigators, according to the inspection report.
When inspectors interviewed the Social Services Director on the inspection date, the administrator said the facility should have provided a Notice of Transfer or Discharge form at least 30 days before discharge, including information on filing appeals. The director also confirmed copies should be sent to the local Ombudsman office.
But the Social Services Director admitted there was no documentation in the resident's medical record showing she had received the required notice before or on her discharge day. The administrator confirmed the resident was not given the required notices.
The Director of Nursing acknowledged during a separate interview that the facility was required to provide discharge notices under federal and state guidelines and send copies to the Ombudsman office.
A follow-up telephone interview with the local Ombudsman revealed the facility had failed to send required notifications. The Ombudsman told inspectors he has not received any recent discharge notifications from the facility and stated, "I have not received any [transfer or discharge] notifications from [the facility]."
The facility's own written policies, revised in March 2025, require extensive discharge procedures that were not followed. According to the Transfer or Discharge Notices policy, residents must be notified in writing at least 30 days prior to discharge in a language and manner they understand.
The policy mandates specific information must be provided in writing, including the reason for discharge, the effective date, the specific location where the resident is being transferred, and detailed appeal rights information. This includes the name, address, email and telephone number of the entity that receives appeals, information about obtaining appeal forms, and assistance with completing appeals.
The policy also requires providing the name, address and telephone number of the State Long-Term Care Ombudsman office, along with facility bed-hold policies.
Additionally, the facility must send a copy of the discharge notice to the State Long-Term Care Ombudsman at the same time notice is provided to the resident.
The facility has a separate policy for resident-initiated transfers or discharges, which covers situations where residents provide verbal or written notice of intent to leave. However, this policy notes that if the facility determines not to allow a resident to return from therapeutic leave, the transfer becomes a facility-initiated discharge subject to the full notification requirements.
The inspection found the facility failed to follow any of these required procedures when discharging the resident who became homeless.
Federal regulations require nursing homes to provide residents with specific discharge protections, including advance written notice and appeal rights, to prevent arbitrary or inappropriate discharges that could leave vulnerable residents without housing or care options.
The violation was classified as causing minimal harm or potential for actual harm to few residents, according to the inspection report. However, for the discharged resident, the facility's failure to follow federal discharge procedures left her without housing and unaware of her legal rights to challenge the decision.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for College Oak Nursing & Rehabilitation Center from 2025-11-20 including all violations, facility responses, and corrective action plans.
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