The resident required enteral feeding through a G-tube and had multiple stage VI pressure ulcers that were present when they arrived at the facility. They also had a deep tissue injury on their left heel.
The facility issued a discharge notice on November 26, 2025, but never created the required discharge plan to ensure the resident's needs would be met after leaving.
LVN L, the MDS nurse, told inspectors during interviews on December 19 that the social worker would typically initiate an interdisciplinary discharge plan for residents like this one. But the facility had not initiated any discharge plan when they issued the notice.
The social worker, identified only as "T," was supposed to write care plan conference notes for December 10. She never did.
She quit without notice on December 11.
LVN L revealed during the interview that Social Worker T had not initiated any discharge plan for the resident when the facility issued the discharge notice weeks earlier on November 26. The nurse said she didn't know why the facility had failed to conduct the scheduled orientation for discharge planning on December 5.
By December 11, the facility was scrambling to find a replacement. An advertisement dated that day showed they were actively hiring a social worker.
When state surveyors requested a copy of the social worker job description on December 18 at 12:45 PM, the facility administrator failed to provide it before inspectors completed their exit.
The resident's medical complexity made discharge planning particularly critical. Stage VI pressure ulcers represent the most severe category of these wounds, often extending through skin and tissue to underlying bone. Combined with the need for enteral feeding through a G-tube, this resident required careful coordination between the nursing home and receiving facility or home care services.
Federal regulations require nursing homes to develop comprehensive discharge plans that identify the resident's goals and preferences, assess their ability to perform daily activities, and coordinate necessary services. The process must involve multiple disciplines working together to ensure safe transitions.
The facility's failure began weeks before the social worker's sudden departure. Even when Social Worker T was still employed, she had not initiated the required discharge planning process after the November 26 notice was issued.
The December 5 orientation for discharge planning never happened, though LVN L could not explain why.
By December 10, when care plan conference notes should have been completed, the social worker was already preparing to leave. The notes were never written.
Her departure on December 11 left the facility without anyone specifically responsible for discharge planning coordination.
During the December 19 inspection, nearly a month after the discharge notice was issued, the resident still had no discharge plan. LVN L acknowledged that the facility had failed to ensure the resident's needs would be met after discharge.
The timing created particular risks for this medically complex resident. Stage VI pressure ulcers require specialized wound care and monitoring. Enteral feeding through a G-tube demands trained staff who understand proper techniques and can recognize complications.
Without a proper discharge plan, receiving facilities might not understand the full scope of care needed. Home care services might not be arranged. Family members might not receive adequate training for complex medical procedures.
The facility's inability to provide basic job description documentation to inspectors suggested broader organizational problems. When surveyors made a routine request for the social worker job description, the administrator failed to produce it despite having nearly 24 hours before the inspection concluded.
This administrative failure occurred while the facility was actively advertising for a replacement social worker, indicating they understood the position's importance but couldn't demonstrate its responsibilities to state regulators.
The resident remained at St. Teresa Nursing & Rehab Center as of the inspection date, nearly a month after receiving discharge notice, with multiple serious medical conditions and no plan for ensuring continuity of care after leaving the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St. Teresa Nursing & Rehab Center from 2025-12-19 including all violations, facility responses, and corrective action plans.
Additional Resources
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