The Grove at Kirkwood sent the resident home on January 28 despite multiple staff members expressing safety concerns about the discharge plan. The resident had been receiving physical therapy but missed two days due to COVID illness.
"In her expertise, she was not sure how the resident could get up the steps to his/her home," the Director of Physical and Occupational Therapy told inspectors on January 28. She said the resident could only take six or seven steps when his home evaluation showed approximately 12 stairs at the entrance.
The therapy director said the resident's legs were extremely weak and he still required assistance with toileting and dressing. He could walk only with one person and a gait belt. "He/She would benefit from more therapy. He/She would be unsafe with stairs," she told inspectors.
She did not feel it was safe to discharge the resident back to his home.
The resident had attempted to appeal his discharge notice but said his appeal failed during an interview on January 28. He expressed concern about the stairs leading to his front door and said he was unsure if he could make it up them. He arranged his own transportation home.
When the resident tried to get help with his appeal, the facility's social worker told him she couldn't assist. During an interview on January 27, the social worker said "she could not help residents file appeals."
The social worker later told inspectors she had received no education or guidance about her job duties at the facility. She said if a resident wanted to appeal their discharge notice, "to her knowledge, she was not allowed to do it for them." She could not recall who informed her she wasn't allowed to assist with appeals.
She had never performed a home assessment for a resident being discharged.
The facility's Admissions Coordinator said the resident changed his discharge plan and the new plan was unsafe. Staff attempted to contact the resident's family member, who would not return phone calls. When they realized the resident would not have 24-hour care at home, "they realized it would be an unsafe discharge."
The Admissions Coordinator was told staff could not appeal discharges for residents.
The resident had been admitted on November 17, 2025, and was cognitively intact with diagnoses including high blood pressure, peripheral vascular disease, diabetes, and depression. His admission assessment showed he needed moderate assistance with showering and was not ambulatory at baseline.
During his 15 days of physical therapy, the resident participated on some days while having COVID but was too sick to participate on others. The Occupational Therapist said his baseline was self-care with some help needed.
A second resident case revealed additional discharge planning failures. Resident #11 was discharged on December 20, 2025, but inspectors found no physician order authorizing the discharge. The medical record contained no documentation of discharge planning, referrals, resources, or a discharge summary.
The facility's Director of Nursing told inspectors on January 29 that she expected the social worker to assist residents with discharge planning. All services to be provided upon discharge should be documented in the resident's medical record, along with a discharge summary.
Yet the social worker said discharge planning was new to her since she had only worked in assisted living facilities previously, where notices of Medicare non-coverage were not used.
The inspection was conducted following a complaint about the facility's discharge practices. Federal regulations require nursing homes to ensure safe discharge planning and allow residents to appeal discharge decisions they believe are inappropriate.
The resident who could barely navigate seven steps was sent home to climb more than 12 stairs to reach his front door, after being told the facility couldn't help him challenge a discharge multiple staff members considered unsafe.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grove At Kirkwood, The from 2026-01-29 including all violations, facility responses, and corrective action plans.