Failure to Provide Proper Notice for Room Change
Summary
The facility failed to provide appropriate notice in a dignified manner regarding a room change for a resident, identified as R289, who was reviewed for room changes. R289, who had been admitted with diagnoses including an open wound of the abdominal wall, prostate cancer, and chronic kidney disease, was observed in a different room than initially assigned. Over the course of four days, R289 was moved three times without proper notification or explanation. On one occasion, staff attempted to move R289 at 2:00 AM without providing a reason, leading to the resident's refusal to move. The resident, who had intact cognition as indicated by a BIMS score of 13/15, expressed awareness of their rights and questioned the staff's actions. The Director of Nursing (DON) acknowledged that R289 should have been informed of the reason for the room change, especially during the early morning hours. An LPN involved in the attempted room change at 2:00 AM stated that they informed R289 of the reason but could not provide specific details, which led to the resident threatening to contact their attorney. The facility's policy on room changes requires that residents receive written notice, including the reason for the change, and that discussions occur with the resident or their representative. This policy was not followed, resulting in a deficiency in honoring the resident's rights.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple medical conditions was moved to a new room due to bed bugs, but the resident's representative was not notified in advance as required by facility policy. Staff interviews revealed that the responsibility for notification was not clearly executed, and the resident's family only learned of the change after the fact.
Three residents, each with significant medical conditions, were moved to different rooms without receiving the required written notification. Staff confirmed that only verbal discussions occurred and that no policy existed for written room move notifications, resulting in non-compliance.
A resident with cognitive impairment and multiple medical conditions underwent several room changes without proper documentation of the reasons or written notification to the resident and their representative. Staff interviews and record reviews confirmed the absence of required notifications and documentation.
A resident with moderate cognitive impairment and multiple medical conditions underwent several room changes, but the facility did not notify the resident's representative prior to all moves as required. Documentation of notification was delayed, and interviews confirmed that the representative was only informed of one of the recent room changes, contrary to facility policy.
A resident with severe cognitive impairment and multiple medical conditions was moved to a different room without receiving written notification prior to the change. Staff interviews confirmed that neither the resident nor their representative was shown the new room or given written notice, and the facility did not follow its own policy requiring notification for room changes.
A resident with impaired cognition and multiple medical conditions was moved to a different room without written notification to the resident or their POA, as required by facility policy. Staff acknowledged that while verbal and text communications may have occurred, there was no documentation or written agreement regarding the room transfer.
Failure to Notify Resident Representative of Room Change
Penalty
Summary
The facility failed to ensure that a resident's representative was notified in writing prior to a room change, as required by policy. A resident with diagnoses including acute kidney failure, dementia, and unspecified psychosis, who resided on a secured memory care unit and was assessed as having intact cognition, was moved to a different room due to the presence of bed bugs. Documentation in the medical record confirmed the room change, but there was no evidence that the resident's representative was notified of this change. Interviews with facility staff, including the prior DON and an LPN, revealed that the responsibility for notifying the family was assumed to have been handled by the DON, but no notification was actually provided. The resident's son confirmed he was not informed of the room change and only learned about it after being contacted by facility staff the following day. The facility's policy required that all parties, including residents and their representatives, receive at least a day's notice prior to any room or roommate assignment changes, which was not followed in this instance.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide written notification to residents prior to room changes, as required. Three residents were affected by this deficiency. One resident with dementia, CHF, and hypertension requested a room move, but there was no evidence of written notification in the medical record. Another resident with Parkinson's disease, COPD, and dementia agreed to a room move after a discussion with social services, but again, no written notice was documented. A third resident with CKD, osteoporosis, and atrial fibrillation was moved to accommodate another resident requiring isolation, with agreement from the emergency contact, but no written notification was found in the record. Interviews with facility staff confirmed that room moves were discussed verbally with residents or their representatives, but written notifications were not provided. Additionally, the facility did not have a policy in place regarding room moves. This lack of written notification and policy resulted in non-compliance with regulations regarding residents' rights to receive written notice before a room change.
Failure to Notify Resident and Representative of Room Changes
Penalty
Summary
The facility failed to properly notify a resident and the resident’s representative of multiple room changes, as required. Medical record review for a resident with diagnoses including dementia, spinal stenosis, cervical spine injury, neuromuscular dysfunction, bipolar disorder, and a history of opioid and alcohol abuse, revealed that the resident was cognitively impaired and dependent on staff for activities of daily living. The resident experienced room changes on three separate occasions, but there was no documentation in the medical record regarding the reasons for these moves or evidence that the resident or their representative had been notified in writing prior to the changes. Interviews with the facility Administrator and Social Services Director confirmed the absence of documentation for both the reasons for the room changes and the required notifications. Additionally, the resident’s representative confirmed that she had not been informed of the room changes. This lack of notification and documentation was identified during a complaint investigation and affected one of three residents reviewed for room changes.
Failure to Notify Resident Representative Prior to Room Change
Penalty
Summary
The facility failed to ensure that a resident's representative was notified prior to room changes, as required by both resident rights and facility policy. Medical record review showed that a resident with moderate cognitive impairment and multiple diagnoses, including dementia and depression, experienced several room moves. Documentation indicated that notification to the resident's representative was either delayed or not completed prior to the moves. Specifically, nurses' notes included late entries documenting notification after the fact, and the Director of Nursing confirmed that documentation of room changes was not made until a later date. Interviews revealed that the resident's representative was only notified of one of the recent room changes, despite multiple moves occurring. Facility policy requires that residents and their families be informed of room changes and that this information be documented in the medical record, including details such as the date and time of the move, who assisted, and how the resident tolerated the move. The failure to notify and properly document notification to the resident's representative prior to room changes led to the identified deficiency.
Failure to Provide Written Notice Prior to Resident Room Change
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple complex medical diagnoses, including cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease, was moved to a different room without receiving written notification prior to the change. The resident, who was dependent on staff for all activities of daily living and received nutrition via tube feeding, was moved in April 2025 as part of a facility effort to consolidate beds. The medical record review confirmed there was no evidence of written notification provided to the resident or their representative before the room change. Interviews with staff revealed that the resident was unhappy with the new room assignment, particularly because the new bed placement did not allow the resident to look out the window as before. Admissions staff confirmed that neither the resident nor their representative was shown the new room or given written notice prior to the move, and acknowledged that the facility did not provide written notice for room changes. Review of the facility's policy indicated that notification is required for changes such as room or roommate changes, but this procedure was not followed in this instance.
Failure to Provide Written Notification of Room Change
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident and their representative in writing prior to a room change. Record review showed that the resident, who had diagnoses including acute respiratory failure with hypoxia, heart failure, type 2 diabetes, and an amputation of the right lower leg, was admitted to the facility and had impaired cognition. There was no evidence in the medical record, including scanned documents, progress notes, or assessments, of any notification regarding the room change. The resident was unable to recall being notified about the transfer and did not know the date of the move, although she expressed comfort and no concerns with her care. Staff interviews confirmed that there was no documentation of notification to the resident or her Power of Attorney (POA) about the room change. The Social Services Designee (SSD) stated that while the POA was contacted by phone and text regarding the room change, there was no record of these communications or any written agreement from the POA. Facility policy requires written notification and documentation of room changes, but this was not followed in this instance. The deficiency was identified during a complaint investigation and affected one resident out of three reviewed for room changes.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
