Failure to Establish Resident Rights Compliance Structure
Summary
The facility failed to establish a structure to comply with the residents' right to refuse transfers within the nursing home. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy did not include individualized mechanisms to ensure compliance with CMS Medicare requirements, and it was a 13-page document that consolidated all 483.10 resident rights statements into one policy.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with severe dementia, anxiety, and psychotic disorder was moved from a skilled unit to a locked memory care unit and then back again without a documented relocation planning conference with his RP and the ED. The resident’s son said he was not told why the move occurred and only learned later that his father had been transferred; the record lacked documentation of required notification details, a unit tour offer, or clear consent/waiver information for the non-emergent room changes.
A resident with intact cognition was moved from a private room on a hallway near therapy after the facility redesignated that area for rehab use and told residents they would have to pay a daily private-room fee to stay. The resident said she did not want to move, but was transferred anyway, and staff confirmed the change was intended to save therapy staff time and steps by keeping rehab residents closer to the therapy gym.
A resident with mental health and seizure disorders, who had been placed in a private room for behavioral reasons, was moved to another room so that another resident with similar needs could have the private room. The transfer was made for facility convenience rather than the resident's needs, violating the resident's right to refuse non-requested transfers.
Surveyors found that several residents with cognitive deficits were moved between rooms multiple times without documentation of notification or explanation to their representatives, despite facility policy requiring such communication. Interviews and record reviews confirmed that families were not informed, and staff were unaware of the notification policy.
A resident who was cognitively intact and his own responsible party was moved from a private to a semi-private room despite repeatedly refusing the change. Staff proceeded with the move based on payer status and the need for the private room, but there was no documented clinical need or isolation requirement for another resident. The facility's actions did not align with its own policy, which allows residents to refuse certain room changes.
Facility staff did not inform a resident of the reason for a room transfer or document the notification, despite facility policy requiring both. The resident expressed dissatisfaction with the new room and was unaware of the reason for the move, which staff later attributed to a roommate conflict but failed to record.
Failure to Document Required Planning and Notification for Room Transfers
Penalty
Summary
The facility failed to ensure a relocation planning conference was held with the resident’s responsible party and the Executive Director before moving Resident H to a locked memory care unit and before moving him back to the skilled unit. Resident H had diagnoses including severe dementia with behavior disturbances, anxiety disorder, and psychotic disorder with delusions, and he had lived in the same room on the skilled unit since admission in 2020. The record showed an intra-facility transfer on 4/21/26 from the skilled unit to the memory care unit and another on 4/28/26 back to the skilled unit. Resident H’s son, who was the responsible party, stated he was not informed why his father was moved to the dementia unit and did not know his father had later been moved back until speaking with the surveyor. He described finding Resident H’s belongings removed from the room and learning the resident was on the dementia unit only after asking staff. He also reported having to pass through two locked doors to reach the unit and seeing a stop sign across the resident’s room entrance. The facility’s documentation for the first move showed the transfer reason as transitioning to the Cottage memory care unit, but the record did not document the contact number or date of notification, and the ED’s note did not include the reason for the move, whether a unit tour was offered, or whether the responsible party was offered or refused the right to waive 48-hour notice, a relocation planning conference, or written notice. For the second move back to the skilled unit, the transfer form again showed the waiver options checked, but no progress note documenting notification to the responsible party was found in the record. The ED stated she contacted the son by telephone for the first move and left a voice message for the second move. Staff interviews indicated the expected process for non-emergent intra-facility transfers was to notify and explain the reason for the move, answer questions, tour the unit and room, obtain consent before transfer, observe the resident after the move, and document the process, but those steps were not documented for Resident H’s transfers.
Resident Room Transfer Without Right to Refuse
Penalty
Summary
The facility did not protect a resident’s right to refuse a room transfer when the move was made solely for staff convenience. Surveyors found that the facility planned to redesignate the 400 hall for therapy residents so therapy staff could save time and steps by keeping residents closer to the therapy department. Residents on the 400 hall were sent letters stating they would be moved to the 100 or 200 halls unless they chose to pay $390 per day for a private room, and the letters said the 400 hall would be reserved for therapy patients. One resident, R41, had intact cognition with a BIMS score of 15 out of 15 and had lived in a room on the 400 hall since 11/21/22. R41 told surveyors she did not want to move, but was told she would have to pay the private room fee if she stayed. She was moved to the 100 hall on 9/11/25. R41 stated she was the only resident on the hallway who had to move and that she was actively participating in physical therapy at the time. The social worker and administrator confirmed the purpose of the room changes was to return the 400 wing to a rehabilitation wing because it was closer to therapy. The administrator stated the facility told R41 she had an increase in care and needed closer observation, but also acknowledged that R41 had been moved to a Hoyer lift and no longer used it. The administrator further stated the facility does not have specific beds licensed for Medicare and Medicaid residents and acknowledged concern about the room transfers.
Resident Rights Violation: Unwarranted Room Transfer for Staff Convenience
Penalty
Summary
A resident with diagnoses of schizophrenia, anxiety disorder, and seizure disorder was admitted to the facility and had been residing in a private room for an extended period due to behavioral reasons. According to the clinical record and census review, the resident occupied the private room from 6/21/24 to 7/10/25. Staff interviews revealed that the resident was moved out of the private room to accommodate another resident who also required a private room for behavioral reasons. The social worker confirmed that the decision to move the resident was based on facility needs rather than the resident's needs, and that the resident was not able to pay for the private room. The facility failed to ensure that the room change was not completed for staff convenience, as required by resident rights regulations. The social worker acknowledged that the move was made to meet facility needs and not the needs of the resident, despite being aware that both residents had similar behavioral concerns necessitating a private room. This action resulted in a deficiency related to the protection of the resident's right to refuse certain types of non-requested transfers within the facility.
Failure to Notify Residents or Representatives of Room Changes
Penalty
Summary
The facility failed to notify residents or their representatives of room changes or provide explanations for these changes for four residents with varying degrees of cognitive impairment. Observations, interviews, and record reviews revealed that residents with severe to moderate cognitive deficits were moved between rooms multiple times without documentation of family notification or explanation for the moves. In several cases, residents exhibited behaviors such as wandering, confusion, and verbal altercations, yet there was no evidence that families were informed or involved in care conferences regarding these changes. For example, one resident with a history of wandering and elopement risk was moved four times, and her family reported not being notified or invited to care conferences. Another resident, also with severe cognitive impairment and anxiety, was moved twice in a short period, with nursing notes indicating increased confusion and distress, but no documentation of family notification or rationale for the moves. Additionally, two other residents with moderate cognitive deficits and complex medical histories were moved between rooms without documented explanations or notifications to their families. The facility's policy required social services to complete a room change form and notify residents or their representatives, but staff interviews indicated a lack of awareness of this policy. The administrator acknowledged that the social worker was not aware of the notification policy and stated that she would expect staff to communicate with residents and their representatives prior to room changes. However, the records reviewed did not show that these procedures were followed.
Failure to Honor Resident's Right to Refuse Room Change
Penalty
Summary
Facility staff failed to honor a resident's right to refuse a room change, resulting in the involuntary relocation of a cognitively intact resident from a private to a semi-private room. The resident, who was his own responsible party and had no documented behaviors or clinical need for a private room, was actively involved in discharge planning to return to the community. Despite the resident's clear and repeated refusals to move, as documented in progress notes and staff interviews, the facility proceeded with the room change. On the day of the move, multiple staff members, including the social worker, director of admissions, and a CNA, entered the resident's room to assist with packing and moving. The resident became visibly upset, yelling at staff and demanding they leave his belongings alone. Despite his protests and physical resistance, staff continued to pack and relocate him to the new room. Staff interviews confirmed that the resident had not agreed to the move and that the facility's rationale was based on payer status and the need to use the private room for another resident, although documentation did not support an immediate clinical need for the private room. Facility policy states that residents have the right to refuse room changes if the move is solely for staff convenience or involves relocation between skilled and non-skilled units. In this case, the move was not supported by a documented clinical need or isolation requirement for another resident, and available room options were not fully explored or offered to the resident. The facility's actions were inconsistent with their own policy and the resident's rights, as evidenced by the lack of documentation supporting the necessity of the move and the resident's clear refusal.
Failure to Notify and Document Reason for Resident Room Change
Penalty
Summary
Facility staff failed to provide a resident with the reason for a room change and did not document the notification or rationale for the transfer. The resident, who had recently been moved to a new room, reported dissatisfaction with her current room and was unaware of the reason for the move. Review of the clinical record confirmed the room transfer but showed no evidence that the resident was informed of the reason. Staff interviews revealed that the move was due to a conflict with a roommate, but this was not documented in the resident's record. Facility policy requires that residents be notified of room or roommate changes, including the reason, and that this notification be documented, but this was not followed in this instance.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.