Failure to Provide Required Written Notice of Room Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide written advance notice of room changes to residents or their responsible parties, as required by the facility’s Room/Roommate and Change Notification Policy dated 8/1/24. That policy states residents have the right to receive written notice, including the reason for the change, before a room or roommate change occurs. For one resident admitted in 7/2025 with quadriplegia and aphasia, the admission profile/face sheet identified a family member as the responsible party. The clinical record showed this resident was moved to a different room on 8/21/25, but progress notes from 7/2025 through 9/2025 contained no documentation that written notification of the room change was provided to the responsible family member. During interview, the family member stated she did not receive written notification before the move, and the DNS and Administrator confirmed that no written notification had been provided. A second resident, admitted in 2/2025 with dementia and cognitive communication deficits, was identified as their own responsible party. The census showed this resident had multiple room changes on 12/20/25, 12/22/25, 12/30/25, and 1/3/26. On interview, the resident’s communication was unintelligible and responses unreliable when asked about the room changes. Review of the clinical record revealed no documentation of written notification for any of these room changes. The Administrator reported that residents or their responsible parties should receive written notification of room changes prior to being moved and confirmed that no written notifications were provided for this resident’s room changes.
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