Columbia Crest Center denied readmission to a cognitively intact resident who used an electric wheelchair and required assistance with personal care. The resident had been approved for unsupervised community outings and was considered a long-term care resident once skilled therapy was completed.
The resident signed themselves out for a therapeutic leave of absence on December 7, planning to return several days later. But when they contacted the facility on December 12 requesting to return, they were told they needed emergency room evaluation first after reporting a fall during their absence.
The resident went to the local hospital emergency room, where they were evaluated for skin breakdown on their tailbone caused by three days of diarrhea. The ER nurse contacted Columbia Crest on behalf of the resident, asking about their return.
Facility staff told the hospital the resident could not return until they were reviewed as a new resident referral for admission. This process could not be completed until the next day, leaving the resident without their planned housing.
During interviews with federal inspectors, facility staff provided conflicting explanations for the denial.
"The reason Resident 1 was denied readmission to the facility was related to financials," one staff member told inspectors on December 23. The same staff member said they considered the resident's discharge to the hospital to meet the requirement of a safe discharge, and stated the resident's care needs had not significantly increased or changed.
The Director of Nursing offered a different account. She said she directed the resident to be evaluated at the emergency room before returning to ensure they were medically stable, but told inspectors she did not know why the resident was not permitted to return on December 12 after being evaluated.
A third staff member, the Market Resource Clinician, said they believed facility policy required reviewing residents as new admissions if their therapeutic leave lasted longer than three nights. This staff member expressed concern that the resident had developed new health issues including a wound to their tailbone.
"That information should have been explained to Resident 2, and that was the basis of the decision not to allow Resident 2 to return to the facility," the clinician told inspectors.
The resident had a documented history of incontinence during community outings. A nursing note from November 11 showed the resident informed facility staff they were incontinent of bowel and bladder during their outings and were aware this caused skin breakdown to their tailbone. The resident stated they preferred to be assisted with incontinent care and application of skin healing ointment upon their return.
The facility's own comprehensive assessment from October showed the resident was cognitively intact and independent with mobility using their electric wheelchair. Their care plan indicated they were able to go out in the community unsupervised, with staff responsible for assisting with preparations such as verifying their wheelchair battery was charged.
When inspectors interviewed staff about the resident's current status, they received vague responses. One staff member said they were unsure of the resident's desire or need to readmit to the facility because they had not spoken with them directly. The staff member said the resident's friend and caregiver had contacted the facility asking about the resident's mail, and they believed the resident was staying with that person.
The inspection found the facility failed to ensure the resident received proper discharge planning and violated state regulations governing resident transfers and discharges.
Federal inspectors determined the violations caused minimal harm or potential for actual harm and affected few residents. The inspection was conducted in response to a complaint filed about the facility's practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Columbia Crest Center from 2025-12-24 including all violations, facility responses, and corrective action plans.