Failure to Document and Notify Regarding Resident's Return Post-Hospitalization
Summary
The facility failed to ensure proper documentation and notification procedures were followed when they did not allow a resident to return after hospitalization. The resident, who had diagnoses including bipolar disorder, anxiety, and depression, was noted to have intact cognition with a BIMS score of 14 out of 15. After an electroconvulsive therapy (ECT) treatment, the resident exhibited erratic behaviors such as urinating on the floor and undressing in public areas, which were out of character according to staff interviews. Despite these behaviors, the facility did not document the clinical decision-making process regarding the resident's inability to return, nor did they consult with a provider or specify which needs they could not meet. Additionally, the facility failed to provide the resident's family with necessary information regarding appeal rights, including contact details for the entity handling such requests and assistance in completing appeal forms. Interviews with staff revealed that the resident was generally pleasant and cooperative prior to the incident, and the sudden change in behavior was unexpected. The facility's administrator admitted to lacking documentation related to the decision-making process and mistakenly believed that appeal notices were unnecessary if the resident was out of the facility for more than ten days.
Penalty
A facility failed to re-admit a resident after hospitalization, despite being informed of the return. The resident, with dementia and behavioral issues, was refused re-entry by the Admissions Coordinator due to a lack of notification and updated information. The resident was returned to the hospital without a discharge notice, and the facility lacked a re-admission policy.
A resident was denied re-entry to a facility after hospitalization despite being medically cleared, violating the bed-hold policy. The resident had previously received a 30-day discharge notice, which was appealed successfully. Facility staff could not provide a clear reason for the denial, and the resident's family faced challenges retrieving personal belongings and finding alternative placement.
A facility failed to collaborate with a hospital to assess a resident's condition before refusing their return after hospitalization. The resident, with a history of mental health issues, was deemed stable by the hospital, but the facility did not perform an onsite visit or communicate effectively. An immediate discharge notice was improperly handled, and the facility did not evaluate the resident's condition as required by policy.
A facility failed to readmit a paraplegic resident after hospitalization, discharging them to a homeless shelter despite their need for substantial assistance. The resident had behavioral issues, including an incident with an LPN, leading to an emergency discharge. The facility claimed the resident's health had improved and their needs could not be met, but hospital staff confirmed the facility refused readmission and sought alternative placement.
A resident with complex medical and behavioral issues was not allowed to return to the LTC facility after an emergency room evaluation, violating the bed-hold policy. The facility issued an immediate discharge notice without adequate preparation or justification, citing safety concerns due to the resident's behaviors. The resident was transferred to a hospital, which did not admit him for psychiatric care, and the facility refused to take him back, leaving the resident without appropriate placement.
A resident was not re-admitted to the facility after hospitalization despite available capacity, due to an internal policy of reserving beds for potential admissions from sister facilities. The resident's son was not given a bed-hold notice and was informed that a bed could not be held, contrary to the facility's policy allowing unlimited bed-hold days for Medicare Advantage payers. The resident was eventually admitted to another nursing home.
Facility Fails to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating the bed-hold policy. Resident #137, who had been admitted with diagnoses including unspecified dementia, epilepsy, and bipolar disorder, was transferred to a mental facility for stabilization due to increased behavioral agitation. Despite plans to return the resident to the facility, the Admissions Coordinator refused to accept the resident back, citing a lack of notification and updated information from the hospital. Interviews with hospital staff and medical transport personnel revealed that the facility was informed of the resident's return, but the Admissions Coordinator claimed not to have received proper notification or an updated report. The transport crew, upon delivering the resident to the facility, was told by the Admissions Coordinator that the resident could not stay and was supposed to go to another hospital. Consequently, the resident was returned to the hospital, and no discharge notice was provided to the resident. The facility's Administrator confirmed that the resident was not denied re-admission but emphasized the need for an update before accepting the resident back. The facility billed Medicaid for bed-hold days until the resident was discharged, yet no discharge notice was issued. The Administrator also acknowledged the absence of an admission/re-admission policy, contributing to the mishandling of the resident's return.
Facility Denies Resident Re-Entry After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating the bed-hold policy. The resident, who had been living in the facility since 2022, was transferred to the hospital due to a syncopal episode. Despite being medically cleared to return, the resident was denied re-entry to the facility. The facility's staff, including the Social Service Designee and the Director of Nursing, were unable to provide a clear reason for the denial, and the Administrator cited the inability to meet the resident's needs without specifying what those needs were. The resident had received a 30-day discharge notice in November 2024, which was appealed and won, allowing the resident to remain in the facility. However, after the hospitalization in January 2025, the resident was not allowed back, and no new 30-day discharge notice was provided. Interviews with facility staff, including LPNs and CNAs, indicated that the resident was appropriate for long-term care and did not require more care than other residents. The family of the resident reported being denied access to the facility to retrieve personal belongings and had to involve the police to obtain them. The hospital Care Transition Manager confirmed that the resident was admitted to another hospital due to having no safe place to return. The facility's refusal to readmit the resident led to difficulties in finding alternative placement, as other facilities were influenced by negative comments from the original facility. The facility did not provide any policy or procedure related to discharge, and the Director of Nursing indicated a willingness to accept a citation rather than deal with the resident's family.
Failure to Collaborate with Hospital for Resident's Return
Penalty
Summary
The facility failed to collaborate with the hospital to ascertain the accurate status of a resident's condition before refusing to allow the resident to return to the facility after hospitalization. The resident, who had a history of schizoaffective disorder, anxiety, and other mental health issues, was transferred to the hospital for an acute psychiatric stay due to worsening psychotic behaviors. Despite the hospital's assessment that the resident was stable and ready for discharge back to the facility, the facility did not perform an onsite visit or communicate effectively with the hospital to evaluate the resident's condition. The facility issued an immediate discharge notice to the resident, citing safety concerns, but failed to properly notify the resident's legal guardian and mother. The discharge notice was placed in the resident's belongings and not directly communicated to the resident or their family. Interviews with facility staff revealed that there was no attempt to collaborate with the hospital to assess the resident's mental health status or determine if the resident was stable for discharge back to the facility. The facility's actions were based on their assessment of the resident's behavior prior to hospitalization, without considering the hospital's findings. The facility's policy required them to evaluate the resident's condition to ensure their needs were within the facility's scope of care, which they failed to do. The lack of communication and collaboration with the hospital and the improper handling of the discharge notice contributed to the deficiency. The resident's legal guardian and mother expressed a desire for the resident to return to the facility, but the facility did not take the necessary steps to facilitate this process.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to ensure a resident, who was hospitalized, was able to return to the facility following their hospital stay. The resident, who was paraplegic and required substantial assistance for daily activities, was discharged to a homeless shelter despite needing care that could not be provided in such an environment. The resident had a history of behavioral issues, including an incident where they punched an LPN, which led to an emergency discharge. The facility's discharge summary indicated that the resident's health had improved sufficiently, and their needs could not be met at the facility, which justified the discharge. Interviews with facility staff and hospital personnel revealed discrepancies in the facility's actions. The Social Services Director mentioned that psychiatric hospitals refused the resident due to their payor type, and the facility lacked the staff for one-on-one care, leading to the decision to discharge the resident to a homeless shelter. However, the hospital's Behavioral Health Social Worker confirmed that the facility refused to readmit the resident and requested the hospital to hold the patient until alternative placement was found. The facility's Transfer and Discharge Policy stated that a resident could be readmitted to the next available and appropriate bed, but the facility did not provide documentation that the resident was approved to return.
Facility Failed to Permit Resident's Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after an emergency room evaluation, violating the bed-hold policy. The resident, who had a history of encephalopathy, hallucinations, and other complex medical conditions, was initially readmitted to the facility but exhibited challenging behaviors such as wandering, aggression, and non-compliance with medication. Despite these behaviors, the facility did not provide adequate notice or preparation for the resident's discharge, which was executed on an emergency basis without sufficient justification. The resident's behaviors included impulsivity, aggression, and wandering, which were documented in progress notes. The facility attempted to manage these behaviors with medication adjustments and one-on-one supervision, but the interventions were not given adequate time to determine their effectiveness. The facility issued an immediate discharge notice, citing safety concerns, and transferred the resident to a hospital without a court order or proper discharge planning. The hospital did not admit the resident for psychiatric care, as he did not meet the criteria for admission, and the facility refused to take him back, leaving the resident without appropriate placement. The hearing officer found that the facility did not comply with state regulations regarding discharge notice and preparation. The facility failed to demonstrate that an emergency existed to justify the immediate discharge and did not provide evidence of a comprehensive care plan to address the resident's behavioral issues. The resident's sister and the hospital social worker confirmed that the facility did not assist in finding alternative placement, resulting in the resident remaining in the hospital until a new facility was found.
Failure to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to allow a resident to return after hospitalization, violating their own bed-hold policy. Resident #27, who had diagnoses including restlessness, agitation, chronic kidney disease, Alzheimer's disease, and delirium, was transferred to the hospital after a fall and subsequent femur fracture. Despite the facility having available capacity, the Admission Director was instructed to refuse readmission to reserve beds for potential admissions from sister facilities. This decision was made despite the facility's policy, which allows for unlimited bed-hold days for Medicare Advantage payers with payment of the daily room rate. The resident's son did not receive a bed-hold notice upon the emergency discharge and was informed that a bed could not be held for his mother, despite contacting the facility within 24 hours to request it. The facility's policy stated that residents should be readmitted if their needs could be met by the facility and if they required the services provided. The resident was eventually discharged from the hospital and admitted to another nursing home, highlighting the facility's non-compliance with their bed-hold and return policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
