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F0559
D

Failure to Provide Written Notice for Room Change After Hospital Transfer

Lawndale, California Survey Completed on 09-10-2025

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 with a reason for a room change for one resident. The resident, who had diagnoses including metabolic encephalopathy, pneumonia, type 2 diabetes mellitus, and schizophrenia, was noted to have severely impaired cognitive skills and was dependent on staff for activities of daily living. The resident was transferred to a general acute care hospital due to a change in condition, specifically a persistent cough and increased secretions despite IV antibiotics for pneumonia. Upon review of the facility's census, it was found that the resident's bed was assigned to another individual the day after the hospital transfer, resulting in the resident losing their bed. The DON confirmed that a room change occurred without knowledge of the reason and acknowledged that written notice was not provided as required by facility policy. The facility's policy mandates timely advance written notice with reasons for any room or roommate change, which was not followed in this instance.

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