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F0559
E

Failure to Notify Residents of New Roommates

Visalia, California Survey Completed on 12-03-2025

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 prior written notification to three residents or their legal representatives before assigning new roommates to their rooms. Record reviews showed that after one resident was placed on comfort care and moved to a private room, a new admission was placed in the same room without informing the family. Additionally, documentation for other residents did not show evidence that they or their representatives were notified in advance of new roommates being assigned to their rooms. During interviews, the Director of Nursing confirmed the absence of documentation regarding advance notice for the affected residents. The facility's own policy requires that residents' families or legal representatives be informed prior to any in-room transfers, but this procedure was not followed in these cases. The lack of notification resulted in a violation of the residents' rights to be informed and to have a choice regarding their roommates.

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