Failure to Provide Advance Notice of Roommate Change
Penalty
Summary
The facility failed to provide advance written notice to a resident or her representative prior to a change in roommate assignment. Review of the clinical record for a resident with dementia and muscle weakness showed that she received a new roommate on October 23, 2025. There was no documentation indicating that the resident or her responsible party was notified before this change occurred. The lack of notification was confirmed during a care plan meeting following a resident-to-resident incident involving the new roommate, where it was documented that the responsible party had not been informed of the new roommate placement. Interviews with facility staff, including the Director of Social Services and the Nursing Home Administrator, confirmed that the usual practice is to notify residents and their representatives of room or roommate changes. However, in this instance, neither the resident nor her representative was notified prior to the new roommate moving in. The deficiency was identified through clinical record review and staff interviews, and it was acknowledged by facility leadership.