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F0559
E

Failure to Provide Written Notice and Orientation for Room Changes

Lancaster, California Survey Completed on 04-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide written notice indicating the reason for room changes for three residents, as required by its own policy and federal regulations. Each resident was moved to a different room without receiving written documentation explaining the reason for the change. Interviews revealed that one resident, who is blind and had been in her previous room for over a year, was moved to a smaller room at the far end of the building, which made it difficult for her to navigate and caused her distress. Another resident reported being moved without being asked or given any documentation, leading her to feel disregarded and unable to exercise her right to make decisions about her living arrangements. A third resident, after complaining about a noisy roommate, was told she had to move because she was the complainant, and was not oriented to her new room or roommate. Review of facility policy confirmed that written notice, including the reason for the room change, should be provided to residents, and that social services staff are responsible for assisting with orientation to the new room and roommate. The Social Service Director acknowledged that no written notifications were given to the affected residents or their responsible parties. The lack of written notice and orientation resulted in the residents feeling their rights were violated and left them feeling upset and disempowered.

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