Failure to Notify Guardian of Room Change Reason
Summary
The facility failed to honor a resident's right to receive written notice before a change in room or roommate was made. This deficiency was identified for a resident who was moved to another room following an incident with his roommate. The resident's guardian was not informed of the specific reason for the room change, which was due to the roommate's inappropriate behavior of sprinkling water on the resident. The guardian was only told that the facility wanted to try the resident in another room without being given the specifics of the incident. The report highlights that the facility did not ensure that the resident's legal guardian was informed in advance of the risks and benefits of the proposed room change. The social worker documented the room change but did not notify the guardian of the alleged incident between the resident and his roommate. The Director of Nursing (DON) assumed the social worker had informed the guardian of the situation, but this was not the case. The resident involved had a medical history that included muscle wasting, dementia, schizoaffective disorder, anxiety disorder, and major depressive disorder. The resident was dependent on staff for various activities and had severe cognitive impairment. The failure to inform the guardian of the specific reason for the room change could place the resident at risk of remaining in an inappropriate situation if the guardian did not give permission for the move.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with moderate cognitive impairment, whose primary language was not English, was moved from a long-standing private room to a shared room so the private room could be used for an incoming isolation case. The facility’s policy required at least one hour advance written notice of room changes to the resident and representative, including reasons for the move and appeal rights, but staff only left a voicemail for the responsible party, did not wait for a response, and began moving the resident’s belongings despite a request for more time. The required Notification of Room Change form was incomplete, lacking dates, approval status, and signatures, and the explanation of the move was given to the resident only in English without use of a translator, even though translation resources were available. The resident and responsible party reported that the rushed move and packing were very distressing for the resident.
A resident with multiple cardiac and metabolic conditions, impaired cognition, and dependence for ADLs requested a room change due to another resident across the hall who frequently yelled and screamed, disturbing his rest. The resident and his family reported the noise problem and asked a supervisor for a room change, but were told it was not possible due to other residents needing proximity to the nurses’ station. An LVN stated she informed the DON and DSS of the room change request, while the DSS and DON both reported they were unaware of any such request from this resident. Surveyor observations documented the neighboring resident repeatedly yelling loudly with the door often open and no call light activated. The facility’s own room change and noise control policies required honoring resident room change requests, advance notice, documentation, and referral of room change and noise complaints to appropriate leadership, but these processes were not effectively carried out for this resident.
The facility failed to provide written notice, including the reason for the change, to a resident and/or his representative before assigning a new roommate. One resident with generalized muscle weakness, dementia, intact cognition on BIMS, and identified behavioral issues was verbally informed by Social Services that he would be getting a roommate and agreed, but no written notice specific to the roommate assignment was given. A prior general letter had informed residents that some private rooms would be converted to semi-private and that they might receive a roommate, but it did not state when this would occur. When another resident was admitted as the new roommate, the facility could not produce any written notice for that specific change, and both Social Services and administrative staff acknowledged that only verbal notification was provided and that the room-move policy did not address written notice requirements.
A resident was transferred from one room and nursing station to another, but there was no documentation in the medical record that the resident or responsible party was notified of the room change. During interviews, the DON acknowledged that facility expectations require notification and documentation of room changes, yet no record of such notification could be found or produced to surveyors.
A resident with a hip fracture diagnosis and intact cognition experienced multiple room transfers between different halls, but the facility failed to provide and document required written notice before these room changes. Facility policies required prompt written and advance notice to the resident and, when applicable, the representative for any room or roommate transfer. Registration records showed several room changes, yet only one room/roommate change notice form was found, and staff interviews (including SSD, CNA, LPN, DON, and the Administrator) confirmed that while notification and documentation were expected practices, there was no documentation of notifications for several of the resident’s room moves.
A resident with schizoaffective disorder, insomnia, anxiety, depression, and dementia, who was assessed as cognitively intact, was moved from one room to another without receiving a proper written explanation for the transfer as required by facility policy. The facility’s room change policy required a written rationale and an opportunity for the resident to see the new location, meet a new roommate, and ask questions. However, the room-to-room transfer form documented only that the POA was notified, with no explanation of why the move was required, and the Social Services Manager later acknowledged the form was not completed correctly. This failure created the potential for psychosocial harm related to the room change.
Failure to Provide Adequate Written and Language-Appropriate Notice of Room Change
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and written notice of a room change, in accordance with its own policy and resident rights requirements, for one of five sampled residents. The facility’s policy on Room Change/Roommate Assignment, revised 3/2021, required that residents and their representatives receive at least one hour advance written notice of any room or roommate change, including the reason for the change and information to help them become acquainted with a new roommate. For this resident, who had been in a private room for five years and had a BIMS score of 9 indicating moderate cognitive impairment, the facility initiated a move from a private to a shared room because the private room was needed for an incoming resident requiring isolation. The Social Services Director (SSD) left a voicemail for the resident’s responsible party about the move but did not wait for a response before proceeding, and staff began moving the resident’s belongings despite the responsible party’s request for more time. The Notification of Room Change form for this resident was incomplete and did not contain the date of notification for either the resident or the responsible party, their approval status, or the required signatures and dates. The SSD stated that the purpose of the form was to notify all parties of the room change and inform them of their rights to appeal, but acknowledged that the form was not completed and that the move proceeded even though they had not actually spoken with the responsible party. Additionally, the resident’s facesheet identified a primary language other than English (Farsi), yet the SSD communicated the room change to the resident only in English and did not use a translator or translation service, despite the facility having access to a translator line or staff translators. The resident and responsible party reported that the rapid packing and moving of belongings was very distressing for the resident. The Admissions Director and Administrator both confirmed that the Notification of Room Change form was incomplete and that the resident spoke very little English, confirming the failures in written notification and communication in the resident’s primary language.
Failure to Act on Resident’s Room Change Request Related to Ongoing Noise Disturbance
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to request a room change and to provide appropriate notice and follow-through on that request. One male resident with multiple complex medical conditions, including heart failure, atrial fibrillation, diabetes mellitus, peripheral vascular disease, and general anxiety disorder, was admitted in November and had impaired cognition and dependence on staff for toileting and transfers per his MDS. This resident was housed across the hall from a female resident who had encephalopathy, delusional disorder, anxiety disorder, insomnia, bipolar disorder, chronic kidney disease, and other conditions, and who was known to yell and scream. The facility’s policy stated that room changes would be made when the facility deemed it necessary or when requested by the resident, with documentation in the medical record and involvement of Social Services for inquiries. According to interviews, the male resident and his family member reported that he had complained about the female resident’s constant yelling and screaming, which made it difficult for him to sleep. The family member stated that a supervisor was asked for a room change and responded that a room change was not possible because other residents needed to be closer to the nursing station. The resident himself stated that he had requested a room change about three weeks prior and that no one followed up with him. The LVN reported that multiple residents, including this resident, had complained about the yelling and that the resident requested a room change about two weeks earlier, with the family member calling about one week later to follow up. The LVN stated she informed the DON and the Director of Social Services of the room change request. In contrast, the Director of Social Services stated she was not aware of any complaints from the current room regarding the yelling and screaming and was not aware of any room change request from this resident. The DON stated that any staff member could receive a room change request and that such requests should be reported to the DON and Social Services, but the DON was not aware that this resident had complained or requested a room change. Observations on the survey date documented the female resident repeatedly yelling loudly from her room, sometimes with the door open and without the call light activated, while the male resident’s door was open or slightly open across the hall. The failure of the LVN and/or facility to ensure that the resident’s room change request was effectively communicated, acted upon, and documented resulted in the resident remaining in a room across from a resident who was frequently yelling, contrary to the facility’s room change and noise control policies and the resident’s right to request a room change.
Failure to Provide Written Notice Before Roommate Assignment
Penalty
Summary
The facility failed to provide written notice, including the reason for the change, to a resident and/or his representative before assigning him a new roommate. The resident had diagnoses of generalized muscle weakness and dementia with behavioral disturbances, but his most recent MDS documented a BIMS score of 15, indicating intact cognition, and his CAA noted he was highly active in his ADLs and preferred to do what he could for himself. His care plan identified a behavior problem and directed staff to administer medications as ordered and monitor behavior episodes. A social service note documented that on 02/11/26, staff verbally notified the resident that he would be getting a roommate in the next couple of days, and the resident verbalized understanding and agreement. The facility produced a general notice, dated 11/26/24, addressed to the resident and his representative, stating that effective 01/01/25 the facility would be transitioning some private rooms to semi-private accommodations and that if the resident received the letter, his room was one being converted. This notice did not specify when he would actually receive a roommate. The resident received a roommate when another resident was admitted on 02/13/26, but the facility was unable to provide any written notice specific to that roommate assignment. During interviews, the resident stated he never received written notice prior to the roommate moving in and was only told verbally. Social Services staff confirmed she verbally informed the resident and documented a note but did not provide written notice, and administrative staff confirmed residents were told at least the day before they were getting a roommate but not in writing. The facility’s Room Moves policy directed Social Services to inform residents and families of room moves but did not address written notice of room or roommate changes.
Failure to Notify Resident/Responsible Party of Room Change
Penalty
Summary
Facility staff interviews and surveyor record review identified a failure to provide required notification of a room change to a resident and/or the resident’s responsible party. Record review of a closed medical record for Resident #107, conducted on 3/13/2026, showed that the resident was transferred from room [ROOM NUMBER]-A on station 2 to room [ROOM NUMBER]-B on station 1 on 2/4/2026. The medical record contained no documentation indicating that the resident or the responsible party had been notified of this room change. During an interview on 3/13/2026 at 8:38 AM, the DON was informed by the surveyor that there was no documentation of notification for the room transfer. The DON stated she would look for the room change notification. In a follow-up interview at 9:20 AM the same day, the DON reported she was unable to locate any documentation of notification for the room change, while acknowledging that the facility’s expectation was to notify the resident and/or responsible party of room changes and to document such notifications in the medical record. By the time of survey exit, no information or documentation of notification for Resident #107’s room change had been provided.
Failure to Provide and Document Written Notice of Room Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide and document written notice to a resident before multiple room changes, contrary to its own policies on room and roommate transfers and notification guidelines. The facility’s policies required prompt written notification to the resident and, when applicable, to the resident’s representative for any change in room or roommate assignment, as well as advance notice of such transfers. Resident #1, admitted with a diagnosis including a fracture of the neck of the left femur and assessed as cognitively intact on the MDS, experienced several room changes between different halls. Registration records showed the resident was admitted to a room on the 100 hall, then transferred to the 200 hall, later moved back to the 100 hall for quality-of-care purposes, and then again transferred to the 200 hall. Record review showed only one room/roommate change notice form dated 04/18/25 for a move to the 100 hall, and no documented room/roommate change notices for the other room changes. The Social Service Director reported that staff typically call the family or speak with the resident regarding room changes, provide a room/roommate change request card, and do not move residents if they do not want to move, but she could not find documentation of notifications for the resident’s moves back to the 200 hall. CNA and nursing staff interviews indicated that social services are responsible for informing residents of room changes and that staff should document room changes and consent in progress notes, but such documentation was absent in this case. The DON and Administrator both stated that staff are expected to document room changes and resident/family notification in the progress notes, yet this was not done for Resident #1, resulting in noncompliance with the requirement to provide written notice before room changes.
Failure to Provide Proper Written Notice and Explanation Before Room Change
Penalty
Summary
The facility failed to honor a resident’s right to receive written notice and explanation before a room change when staff moved Resident #13 to a new room without properly completing the required written notification. The facility’s “Resident Room Changes & Roommate Rights” policy, revised 8/31/25, required that when a resident is moved at the request of facility staff, the resident, family, and/or representative must receive a written explanation of why the move is required and be given an opportunity to see the new location, meet the new roommate, and ask questions. Resident #13, who had multiple diagnoses including schizoaffective disorder, insomnia, anxiety, depression, and dementia, and was documented as cognitively intact on a quarterly MDS assessment, was re-admitted to the facility and later transferred from one room to another. The “Notice of Room-to-Room Transfer” form for this move, signed 11/13/25, listed only “POA Notified” as the rationale for the transfer, with no further written explanation of the reason for the move. During interview, the Social Services Manager acknowledged that the notification of room change was not filled out correctly and should have identified in writing why the resident was moving rooms. This deficient practice created the potential for psychosocial harm if Resident #13 was not provided an opportunity to see the new location, meet a new roommate, or have questions answered related to the move.
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