Failure to Notify Correct Responsible Party of Room Change
Summary
The facility failed to ensure that the correct responsible party (RP) for a resident was accurately documented in the medical record and failed to notify the correct RP of a room change. The resident in question was admitted with diagnoses including cerebral palsy, altered mental status, and quadriplegia, and was determined to lack the capacity to make decisions. The resident required total assistance with activities of daily living and was dependent on staff for care. When the resident tested positive for COVID-19, a room change to the COVID-19 unit was required. Documentation showed that the facility notified an RP listed on the admission record, but did not verify that this was the correct RP. Interviews with facility staff confirmed that the standard procedure is to notify the resident or their RP of any room change, complete the necessary documentation, and inform the ombudsman. However, in this instance, the DON acknowledged that although a listed RP was contacted, staff did not confirm that this was the correct RP as documented in the admission record. The facility's policy requires advance written notice to all involved parties prior to a room or roommate change, but this was not properly followed in this case.
Plan Of Correction
F 559 CHOOSE/BE NOTIFIED OF ROOM/ROOMMATE CHANGE CFR(s): 483.10(e)(4)-(6) IMMEDIATE CORRECTIVE ACTION: Resident 1 was discharged on 1/3/25. ACTION TAKEN TO IDENTIFY ALL OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE AND CORRECTIVE ACTION TAKEN: All residents had the potential to be affected by this deficient practice. The Medical Records Director (MRD) reviewed five (5) residents with room change requests in the last 30 days, to check if written notice of room change was provided to the resident and/or resident's RP. No other residents were affected by this deficient practice. PROCESS AND ACTION TAKEN TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR: The Director of Nursing Services (DON) conducted an in-service education with the licensed staff on 6/30/25, regarding facility policy on Room Change, ensuring that advance notice is provided to the resident and/or RP prior to room change. The Administrator conducted an in-service with Social Services department staff on 7/7/25, regarding facility policy on Room Change, ensuring that advance notice is provided to the resident and/or resident's RP prior to room change. Effective 7/7/25, the MRD or her designee will review weekly room change requests to ensure completion of the advance notice and notification of resident and/or resident's RP. The Social Services Director or the Social Services Designee will immediately correct any deficient practice identified in the audit. The DON and/or her designee and the MRD will randomly review five (5) resident charts weekly for the next 30 days to ensure residents' RPs were notified and documentation completed regarding room changes. MONITORING PERFORMANCE TO ENSURE THAT CORRECTION IS ACHIEVED AND SUSTAINED: As part of the facility's Continuous Quality Improvement (CQI) program, the DON will report findings to the Quality Assessment and Assurance Committee (QAA) regarding weekly random reviews for the next 30 days. The MRD will also report findings to the QAA regarding weekly random reviews for the next 30 days. The Administrator will monitor compliance through review of DON and MRD reports. CORRECTIVE ACTION COMPLETION: July 7, 2025 This page intentionally left blank
Penalty
Resources
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Failure to Notify Residents Before Room Changes: The facility did not properly notify several residents before room changes. A cognitively intact resident with RA, PTSD, and mobility issues, another cognitively intact resident with DM2, HTN, CKD, and weakness, a cognitively intact resident with PE history and prediabetes, and a moderately cognitively impaired resident with COPD, ESRD, and CHF all stated they were not informed before being moved. Records showed multiple room changes, and one resident’s belongings were moved while he was out of the facility.
A resident with confusion and some dementia was moved to different rooms multiple times, but the resident’s POA/family member was not notified in writing before the moves and was not given the reason for the change. The family member reported finding the resident’s belongings already moved after returning from lunch, and the record lacked documentation of advance notice for at least one room change. Staff and leadership confirmed that written notice should be provided before a room transfer.
A resident with intact cognition and significant visual impairment was threatened by a roommate, who had dementia and mental health diagnoses, when the roommate placed a plastic knife to the resident’s neck after the resident called out for assistance. Following the incident, the DON instructed an LPN to move the victim rather than the aggressor, and the resident was relocated to a room at the end of a corridor four rooms away, with no alternate route of access, requiring the resident to pass the aggressor’s room to reach common areas. The resident reported feeling they had no real choice but to move and later expressed anger and ongoing nervousness about the situation. Interviews and census review showed that private rooms on another unit had been available for the aggressor, and facility leadership acknowledged that the victim was not offered the option to remain in the original room, despite resident rights policies guaranteeing notice and choice regarding roommate changes.
A cognitively intact resident with cerebral ischemia, anxiety, and depression was moved to a different room after continuing to receive informal assistance with ADLs from a cognitively intact roommate with anemia, anxiety, and depression, despite prior counseling to stop this practice. The facility’s own policies require at least 30 days’ written notice, inclusion of the reason and new room assignment, and consultation with the resident and representative, as well as honoring the right to share a room with a chosen roommate when practicable. In this case, the resident was only verbally informed of the move, was not given written notice or an opportunity to refuse, and the representative was not notified in advance, while leadership staff later reported they were unaware of the move and that such changes are generally discussed and not carried out if a resident objects.
The facility failed to provide and document required written notice, including reasons, before changing a resident’s room and assigning new roommates for four cognitively intact residents. One resident with multiple chronic conditions, including DM2, major depressive disorder, delusional disorder, and COPD, had a room change without any documented notification to her POA, and she reported not signing any room-change document. Three other residents with conditions such as schizophrenia, COPD, asthma, hypertension, low back pain, and obesity had new roommates without documented family notification or written notice. During interviews, residents reported not recalling written notifications, and facility leadership and psychiatric rehab staff acknowledged that neither written notices nor progress note documentation of these room and roommate changes were completed, contrary to facility policy and stated resident rights.
A resident with a BIMS of 14 was moved to a different room without being told the reason in advance and said she would have preferred to stay in her old room. She found another resident in her bed and was then informed by staff that she had been moved. The AD said room changes were part of his responsibility and acknowledged that more notice would have been a good idea.
Failure to Notify Residents Before Room Changes
Penalty
Summary
The facility failed to properly notify 4 of 6 residents reviewed for room change notification before moving them to different rooms. R5, who was cognitively intact and had diagnoses including rheumatoid arthritis of the left hip, PTSD, unsteadiness on feet, and need for assistance with personal care, stated she was not informed of her room change before being moved and that her family was not notified. The census record showed she was moved from one room to another on 1/15/26. R7, also cognitively intact and diagnosed with type 2 diabetes mellitus, hypertension, chronic kidney disease, and muscle weakness, stated she was not notified before room changes. Her census record showed multiple room changes, including changes on 2/1/26, 3/9/26, and 4/1/26. R12, who was cognitively intact and had diagnoses including pulmonary embolism without acute cor pulmonale, prediabetes, and a personal history of venous thrombosis and embolism, stated he was not notified prior to his room move. His census record showed multiple room changes between 2/1/26 and 5/17/26. R14, who was moderately cognitively impaired and had diagnoses including COPD, gait and mobility abnormalities, muscle weakness, hypertension, ESRD, and chronic diastolic CHF, stated he was not informed his room would be changing and found his belongings gone when he returned. His grievance stated he was not notified about moving to a different room and was not present during the moving of his personal items. The administrator stated the facility was not doing room move notifications properly and that R14 had been moved while out of the facility without notification.
Failure to Provide Written Notice Before Room Transfer
Penalty
Summary
The facility failed to ensure that a resident and the resident’s family were notified in writing before the resident was moved to a different room, and the notice did not include the reason for the move. The deficiency involved one of three residents reviewed for resident rights. The resident had been admitted for rehabilitation and had confusion with some dementia at times. The resident’s family member, who was the first contact and power of attorney, stated that on one occasion the resident returned from lunch to find the room already changed and belongings moved, and that she was not notified beforehand. She also stated the resident had several room moves during the stay and she was not informed in advance. The resident’s electronic census report showed room moves on 1/1/26, 2/27/26, and 3/11/26. The medical record did not contain documentation that the resident or family member were notified of the room move on or before 1/1/26. A Room Transfer/New Roommate form dated 2/27/26 documented a move from one room to 402 due to a new admission, but the form listed the date of notice as 2/27/26 and left the date of room change blank. Staff stated that when residents are transferred rooms, they tell the resident and call families with the reason and document it in nursing notes, while the Social Service Director and Administrator confirmed that residents should receive written notice before a room move and that family should be notified if the resident is not alert and oriented.
Failure to Honor Resident Room Choice After Resident-to-Resident Threat
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose whether to remain in their room and to receive appropriate notice before a room change following a resident‑to‑resident altercation. One resident with intact cognition, muscle weakness, type II diabetes mellitus, and absolute glaucoma was dependent on staff for bed mobility and required assistance with transfers and ambulation. This resident ambulated independently with a rolling walker in the room and throughout the facility and enjoyed walking out of the room, socializing with friends, and going to the dining room for meals. Another resident, who had Alzheimer’s disease, major depressive disorder with psychotic symptoms, generalized anxiety disorder, and moderately impaired cognition, had a care plan identifying poor impulse control, lack of safety awareness, potential for manipulative behaviors, and a history of making accusatory statements, with interventions including the use of plastic utensils and staff support for coping and behavior. On the date of the incident, the cognitively intact resident reported that the dinner cart was outside the room and began calling out “hello” for help. The roommate became aggravated, approached the resident’s side of the room, told the resident to use the call bell, and then placed a plastic knife to the resident’s neck and moved it across. The victim reported that the roommate cursed, called names, and threatened that if the resident did not “shut up” it would be worse next time. Staff documentation and interviews confirmed that the victim was removed from the room to the hallway, assessed with no acute injury noted, and that the aggressor was placed on one‑to‑one observation and sent to the ED for evaluation. The victim was described as calm but slightly anxious and later expressed being upset and worried about the aggressor returning. Following the altercation, the DON directed staff to move the victim to a different room, despite the aggressor being the one who initiated the threatening behavior. The LPN asked the victim if they were agreeable to the move and proceeded with the room change without offering the option to remain in the original room. The new room was located at the end of a hallway four rooms away from the aggressor’s room, with no alternate route of exit or access, requiring the victim to routinely pass the aggressor’s room to reach common areas and the dining room. The victim later reported feeling they had no real choice but to move in order to feel safe, expressed anger that the aggressor ended up with a private room, and continued to feel nervous about having to walk past the aggressor’s room. Interviews with facility leadership acknowledged that the victim should have been offered the choice to remain in the original room, that the aggressor should have been moved instead, and that private rooms on another unit had been available at the time. The facility’s Residents’ Bill of Rights policy stated that residents have the right to notice before a roommate is changed, to be treated equally with other residents, and to be free from abuse, but there was no specific policy available for room transfers following resident‑to‑resident altercations.
Failure to Provide Required Notice and Consultation Before Resident Room Change
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive written notice and be consulted before a room change, as required by facility policy and resident rights regulations. The facility’s Room Changes policy states that residents must receive at least 30 days’ notice before any planned room change, except in emergencies, and that the notice must include the reason for the change and the new room assignment. The policy also requires consultation with the resident and their representative, and affirms the resident’s right to refuse a room change made for staff convenience or that moves them outside a distinct part of the nursing home. The Resident Rights policy further states that residents have the right to share a room with a roommate of choice when practicable, if both live in the same facility and agree. Resident #43, who was cognitively intact per the MDS and had diagnoses including cerebral ischemia, anxiety, and depression, had been rooming with Resident #129, who was also cognitively intact and had diagnoses including anemia, anxiety, and depression. A social worker note documented that on 07/24/2025, Resident #43 was counseled about maintaining appropriate boundaries and reminded that their roommate should not provide or assist with any aspects of care, including physical assistance or hygiene tasks, and Resident #43 agreed to refrain from asking or accepting such help. Despite this, a subsequent social worker note on 08/07/2025 documented that a room change occurred that day due to safety concerns related to Resident #43’s non-compliance with seeking physical assistance from their roommate. Interviews and documentation showed that the room change was carried out without written notice to Resident #43 or their representative, and without offering the opportunity to disagree or decline the move. Resident #43 reported being verbally informed of the room change because the roommate was helping with activities such as putting on shoes and retrieving items from the closet, and was observed to be tearful about being separated. Resident #129 stated they were helping with tasks like getting items from the closet but were never asked about the move and that the residents were “just separated.” Resident Representative #1 stated they were never informed of the room change by facility staff and only learned of it when the resident called them in distress. RN #6 confirmed the residents were separated after both had been educated not to assist with care and stated that the social worker notified families, but could not specify when, while the Director of Social Work and DON both reported they were unaware of the move and indicated that, in general, moves are discussed in meetings and not done if a resident objects. No written notice or documented consultation consistent with policy was evident prior to the room change.
Failure to Provide and Document Required Written Notice of Room and Roommate Changes
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to receive written notice, including the reason, before a room or roommate change, and to document notification to residents and their representatives. Four cognitively intact residents were affected. One resident with Type 2 diabetes mellitus, major depressive disorder, delusional disorder, and COPD had a documented room change, but there was no progress note between 03/20/2026 and 03/28/2026 showing that her POA was notified of the room change. This resident stated she had a room change a couple of weeks prior, identified her POA, and reported she did not know if the facility had spoken to the POA and that she did not sign any document regarding the room change. Another resident with schizophrenia, low back pain, and myalgia, who was responsible for her own decisions and had been in her current room since 10/07/2022, had no documentation in her progress notes during the same review period that her family was notified of a new roommate. A third resident with COPD, asthma, and hypertension, and a fourth resident with hypertension, low back pain, and obesity, both cognitively intact and responsible for themselves, had been in their current rooms since 12/31/2023 and 08/22/2023 respectively. For both of these residents, there was no documentation in the progress notes that family members were notified of new roommates during the review period. During interviews, one resident stated she observed staff showing the new roommate the room but said she was not presented with written notification of the roommate change, while another resident could not recall being introduced to the new roommate or receiving written notification. Staff interviews confirmed that required notifications and documentation did not occur. The Assistant Administrator stated she relies on Social Services to contact the POA regarding room changes and acknowledged that residents were verbally notified of a new roommate but that these notifications were not documented. The Psychiatric Rehabilitation Services Director and Assistant Director both stated they did not notify the POA of the room change and did not notify or document notification to the families of the other affected residents regarding roommate changes. The Assistant Administrator further confirmed that no written notice was provided to residents or the POA regarding the room and roommate changes prior to the move, despite facility policy and the facility’s Statement of Resident Rights requiring residents to receive written notice, including the reason for the change, before their room or roommate is changed.
Room Change Without Resident Choice or Timely Notice
Penalty
Summary
The facility failed to ensure residents had a choice in room assignments and were notified in a timely manner before room changes were made. Resident #63, who had a BIMS score of 14, was moved from room A3 B to room D32 A. A review of the facility’s room moves for the prior month showed that eight residents had room changes listed as clinical need. During interview, Resident #63 stated she was not told the reason for the room change and said she would have stayed in her old room because she liked that hallway better. She also reported that when she went to her room, another resident was in her bed and staff then told her she was in a different room. The AD stated room changes were part of his responsibility, said he told her of the room change that morning, and acknowledged that more notice would be a good idea.
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