F0559

E

Failure to Provide Written Notice and Honor Resident Choice in Room and Roommate Changes

Saint Peters, Missouri Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to honor residents’ rights related to room changes, including the right to receive written notice of a room or roommate change, the right to share a room with a roommate of choice, and the right to refuse a room move unless necessary for health or safety reasons. The facility’s own undated policy stated that room or roommate changes may occur when the facility deems it necessary or when requested by the resident, that resident preferences are to be considered, and that residents have the right to share a room with a spouse, domestic partner, or friend. The policy also required that all parties receive verbal or written notice prior to a room or roommate change, that written notice include the reason for the change and information to help the new roommates become acquainted, and that residents have the right to refuse a room move without affecting Medicare or Medicaid eligibility. Despite this, multiple residents were moved without written notice, without being offered choices of rooms or roommates, and without being informed they could refuse the move.

One cognitively intact resident with quadriplegia, anxiety, and depression had been in a private room for over two years and was moved to a semi‑private room. A progress note documented that the ADON and social worker (SW) called the resident’s POA about the move and that the POA was agreeable, and that the resident was told he/she would be moving the next day. The note did not document any written notice or explanation of the reason for the move. The resident later reported being very upset about losing the long‑standing private room, stated that he/she was not given an option and was simply told by the SW and ADON that the move would occur the next day, and described staff coming in the next morning and moving him/her. The resident and family reported that many decorations and belongings had to be taken home due to lack of space, and that staff “shoved” belongings into boxes and did not offer to put them away. The POA stated that the SW had emailed that the resident was being moved to make room for potential isolation patients, that no choice of rooms was given, and that neither the POA nor the resident were told they could refuse the move.

Another resident with cognitive impairment, heart disease, hypertension, diabetes, and a history of stroke was also moved from a private room. A progress note by the SW documented a call to two family members about a room change and that “consent” was obtained, but did not specify what the consent covered or provide any written notice. The family members reported being told by the SW that the resident would be moved to another room to create a quarantine room for potential hospital admissions and that the move had been approved by the Administrator. They stated they were told they had three days to move the resident, were not offered any alternative rooms, and were not introduced to the new roommate until after the move into a semi‑private room. There was no documentation that the resident or family were informed of a right to refuse the move or that written notice explaining the reason for the move was provided.

A third resident with cognitive impairment, heart failure, hypertension, heart disease, a fractured hip, and dementia was moved from a rehab hall room to a LTC room. The SW’s progress notes documented a phone call to the resident’s family member with “verbal consent” and a late entry stating that consent was obtained from the spouse to move from the rehab hall to a LTC room that became available, but did not specify the content of the consent or any written notice. The family member reported being told by the SW that the resident was being moved because a new administrator was changing things and moving residents, and that when the family member asked if the move could wait, the SW said no. The family member also reported speaking with a person identifying himself as the Administrator, who stated the current room was meant for rehab and that the resident was moving to the LTC section that day, and that the resident was not the only one being moved. The family member stated the resident was not given a choice of room or roommate, and that staff moved the resident the next day.

A fourth resident, cognitively able to make decisions and dependent on staff for ADLs, was admitted to a private room and later moved. The resident’s family member reported receiving a phone call from a person identifying himself as the Administrator, who said the resident was being moved to another room to create an isolation room for potential COVID patients. The family member stated that the SW later said the move had to occur and that the new roommate did not want a camera in the room. The family member reported that the resident was not offered a choice of rooms and was not introduced to the new roommate before the move. There was no documentation of written notice explaining the reason for the move or of any opportunity for the resident to see the new location, meet the new roommate, or ask questions prior to the move.

Interviews with staff further clarified the circumstances leading to these deficiencies. The SW stated she had been told by a person identifying himself as the Administrator that residents needed to be moved off the rehab unit to free up rooms for potential rehab residents, and that she was to find rooms on the LTC side or discharge the residents. She reported she was not aware that residents had a choice to move or not, or that they had a choice of roommates, and that she was following instructions. The Administrator interviewed stated he had recently come to the facility, that his temporary license had not yet been approved, and that he needed to move residents to better align acuity for staffing and to keep rehab and LTC residents grouped together. He stated they had obtained permission for the residents to move and that he was not aware residents had the right to decline a room move, although he would expect staff to give residents a choice when able. Across these cases, there was no evidence that residents received written notice of room or roommate changes, were informed of their right to refuse, or were given the opportunity to see the new room, meet the new roommate, and ask questions as required by facility policy and resident rights.

The facility also failed to ensure residents’ right to share a room with a roommate of choice. The policy stated that residents have the right to share a room with a spouse, domestic partner, or friend, and that resident preferences are considered when room or roommate changes are proposed. In the described room moves, residents and families reported that no choices of rooms or roommates were offered, and there was no documentation that roommate preferences were solicited or honored. The moves were driven by facility needs such as creating isolation or rehab rooms and redistributing residents by acuity, rather than by resident choice or preference, and were implemented without the written notices and pre‑move opportunities outlined in the facility’s own policy.