Country Care Manor blocked the resident's return after a hospitalization that began October 17, 2025, according to a federal inspection completed November 21. The facility's administrator told the ombudsman that the resident lacked proper physician oversight and could not return to the facility.
But the ombudsman suspected the real reason was conflicts with the resident's family member, not medical issues.
The administrator never notified the resident or family about the discharge through conversation or letter. Instead, he communicated only with the ombudsman, violating the facility's own policies requiring 30-day written notice before any discharge.
When the resident formally appealed the discharge, the facility still refused readmission. The administrator told inspectors the resident could not return during the appeal period because no physician was available to oversee his care.
The physician dispute began months earlier. The facility's primary doctor terminated the resident as a patient in August 2025. The facility's second physician was not accepting new patients, so the resident selected his outpatient doctor to provide care at the nursing home.
That outpatient physician, identified in the report as MD B, had been overseeing the resident's care at the facility. But the administrator complained that MD B did not meet their expectations for responsiveness when staff tried to contact him after hours.
"Because of the lack of responsiveness from MD B, he felt readmitting Resident #1 under MD B's care would be a disservice," the inspection report stated.
The administrator was unsure whether the resident had been given an opportunity to select a different physician before the facility refused readmission.
MD B's office told inspectors a different story. The physician's medical assistant said the last communication from the facility came October 16, 2025, to the after-hours on-call service regarding a change in the resident's condition.
MD B had not been notified by the facility that the resident had been discharged.
The facility requested a discharge summary from MD B at the end of October, but the document had not been returned by the time of the inspection.
Country Care Manor's own admission and discharge policy, dated September 2022, states that residents are permitted to return after hospitalization or therapeutic leave. The policy requires 30-day advance notice for any transfer or discharge.
The policy also specifies that if the facility determines a resident who was transferred with an expectation of returning cannot come back, the facility must comply with transfer and discharge requirements.
None of those requirements were followed in this case.
The ombudsman, who advocates for nursing home residents, became aware of the refusal during the hospitalization and immediately notified the administrator that the resident had a right to return. The ombudsman called the facility's actions "dumping," a practice where nursing homes discharge difficult or costly residents without following proper procedures.
Federal law requires nursing homes to provide adequate notice and justification for discharges. Facilities cannot discharge residents solely because they become difficult to manage or require expensive care.
The inspection found the facility violated federal regulations regarding transfer and discharge procedures. The violation was classified as causing minimal harm or potential for actual harm, affecting few residents.
The case highlights ongoing problems with nursing home discharge practices. Facilities sometimes pressure residents to leave during hospital stays, when families are focused on medical crises rather than nursing home policies.
The resident remained in the hospital while the discharge appeal was pending, unable to return to the facility where he had been living. The ombudsman continued advocating for his readmission, but the facility maintained its refusal.
The administrator's admission that he was communicating only with the ombudsman, rather than the resident or family, suggests the facility was trying to avoid formal discharge procedures that would have given the resident stronger legal protections.
Without proper discharge notice, residents cannot prepare for transitions or exercise their appeal rights effectively. The 30-day requirement exists to prevent exactly this type of situation, where residents find themselves stranded during medical emergencies.
The inspection did not specify how long the resident remained hospitalized or whether he eventually found alternative placement. The facility's refusal to readmit him during the appeal process left him in medical limbo, dependent on hospital social workers and the ombudsman to find solutions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Country Care Manor from 2025-11-21 including all violations, facility responses, and corrective action plans.