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F0559
D

Failure to Follow Through on Resident Room Change Request

Los Angeles, California Survey Completed on 05-06-2025

Penalty

Fine: $119,34011 days payment denial
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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

A deficiency occurred when the facility failed to accommodate and follow through on a resident's request for a room change. The resident, who had diagnoses including monoplegia of a lower limb, hemiplegia, hemiparesis, chronic obstructive pulmonary disease (COPD), and unspecified depression, was admitted on 12/20/2022. The resident's Minimum Data Set indicated intact cognition and a need for supervision with certain mobility activities. The resident requested a room change in February 2025 and was offered two rooms, both of which were refused. After these offers, the Social Services Designee (SSD) did not follow up further with the resident regarding their room change preference. During interviews, the SSD acknowledged responsibility for ensuring room change requests were followed through and admitted to not following up after the initial offers. The Director of Nursing (DON) also confirmed that the resident's room change request should have been addressed and honored, in accordance with facility policy, which requires that residents' needs and preferences for room or roommate changes be considered and accommodated to the extent practical. The facility's failure to continue addressing the resident's request resulted in the deficiency.

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