Failure to Provide Written Notice and Honor Resident Choice in Room and Roommate Changes
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Notify Residents of Room Changes: The facility did not complete room change notifications for two residents whose rooms were changed, and no documentation of notice was found in the medical record. One resident with BIMS 15 said she was okay with the move but did not know until the day of the change. An LSW confirmed the notifications were not completed and could not show the resident was aware of the room change.
A facility failed to document whether room change notifications were made to residents and their representatives after a plumbing backflow and drainage water backup led to relocation of multiple residents from affected rooms. During record review, 4 of 9 resident charts lacked a completed Notification of Room Change evaluation, and the DON confirmed staff did not document whether the residents and their representatives were notified of the transfer.
A resident with cognitive impairment and Korean as her preferred language was moved multiple times for census needs, but the facility did not document that she received written notice of the room changes in a language she could understand. Records showed verbal approval from the guardian, while staff interviews confirmed the resident did not speak English well and that the SSD relied on the guardian rather than informing the resident directly.
The facility failed to provide written notice before changing the rooms of three residents. One resident had a family member listed as RP, and two residents were their own RPs. Records showed room changes for each resident, including one resident who moved to a different unit and another who had two room changes, but there was no evidence that written notice with the reason for the change was given before the moves. Social services staff confirmed the facility had no evidence of written notice.
Failure to Provide Written Notice Before Room Change: A cognitively intact resident was moved to another room without advance written notice or a documented reason for the change. The SW stated she only followed up after the move and had no documentation of notice, while the resident reported staff began packing her belongings without warning and gave no explanation. The NHA acknowledged the facility did not use its room-change notice form.
Failure to Provide Written Notice for Room and Roommate Changes: The facility did not ensure that two residents received required notice before room or roommate changes. One resident with dementia, schizophrenia, and severe cognitive impairment was given a roommate without advance notice to the family, and the roommate later moved after an altercation. Another resident with severe cognitive impairment and wandering behaviors was moved between rooms multiple times, with staff and family reporting that no prior notice was given and staff giving conflicting accounts of who was responsible for notification.
Failure to Notify Residents of Room Changes
Penalty
Summary
The facility failed to notify residents and their representatives of room changes for 2 of 3 residents reviewed for room change notifications during the complaint survey. Resident #60 had been in one room since admission and was moved to another room on 07/02/25, but no room change notification was found in the medical record. Resident #68 was admitted to one room on 03/10/26, moved to another room on 04/27/26, and then moved again on 06/16/26, and no room change notification was found in the medical record. During interview, a resident with BIMS of 15 stated that she was okay with her room change but did not know she was moving until the day of the move. The LSW stated that the room change notifications were not completed for the two residents and said she had a text conversation with Resident #68’s daughter about it, but could not show that the resident was aware of the room change. The facility policy titled Notification of Change states that the facility must inform the resident and, when applicable, consult with the physician and/or notify the resident’s family member or legal representative when there is a change requiring notification, including a change of room or roommate assignment.
Failure to Document Room Change Notifications
Penalty
Summary
The facility failed to document whether notification of a room change was made to residents and their representatives after 21 residents were relocated from Rooms 111 through 125 on the Magnolia Unit due to a plumbing backflow and drainage water backup. During review of 9 residents' records related to the room transfers, 4 residents did not have a completed Notification of Room Change evaluation in their medical records. The deficiency was identified during a complaint survey after the affected area was observed to be closed off for repairs, with contractors present to replace flooring and clean up the area. Facility documentation showed the residents were moved because of the drainage water backup in the hallway and shower drains affecting Rooms 111 through 125. The DON stated the Social Worker was supposed to ensure the Notification of Room Change was completed for all 21 residents, and also stated the Social Worker was on leave. On interview, the DON confirmed the facility staff failed to document whether the four residents and their representatives were notified of the room change that occurred when the residents were relocated.
Failure to Provide Written Notice of Room Changes
Penalty
Summary
The facility failed to provide written notification of room changes and roommate changes for one resident, who was admitted with diagnoses including anxiety disorder, depressive episodes, muscle weakness, a history of falling, and transient ischemic attack. The resident’s 4/22/26 MDS showed cognitive impairment with a BIMS score of 0 out of 15, and her preferred language was Korean. The communication care plan identified her as at risk for impaired cognitive function/dementia. Record review showed three room change notification forms documenting verbal approval from the resident’s guardian for room changes made for census needs, but there was no documentation in the resident’s EMR that she was provided written notice of the room changes in her preferred language. Staff interviews indicated the resident did not speak English well, that Google Translate was used or intended for communication, and that the SSD relied on the guardian to inform the resident. The SSD acknowledged she did not inform the resident directly of the room changes and said she should have attempted to do so using Google Translate.
Failure to Provide Written Notice Before Room Changes
Penalty
Summary
The facility failed to provide written notice before changing the rooms of three residents. For one resident, the clinical record showed admission to the facility and that a family member was listed as the responsible party. The resident’s room was changed to a different unit, and a progress note documented the resident’s agreement to move the following day; however, there was no evidence that the resident or responsible party received written notification, including the reason for the room change, before the move occurred. For two other residents, the clinical record showed that each was her own responsible party and that each had room changes during the stay. One resident’s room was changed twice, and the other resident’s room was changed once. In each case, there was no evidence that written notification, including the reason for the room change, was provided before the change occurred. Interviews with social services staff confirmed that the facility had no evidence that written notice was provided for the room changes noted above.
Failure to Provide Written Notice Before Room Change
Penalty
Summary
The facility did not ensure that a resident received written notice, including the reason for the change, before her room was changed. The resident, R8, was admitted to the facility and had a most recent MDS dated 6/23/26 showing a BIMS score of 14, indicating she was cognitively intact. On 6/26/26, the facility moved R8 from her room on one side of the building to the other side of the building without providing advance written notice or a documented reason for the move. During interview, the Social Worker stated she followed up with R8 after the move but did not give written notice or advance notice regarding the room change and had no documentation that notice or an explanation was provided. R8 stated that staff came into her room and started packing her belongings without prior notice and that she was given no reason for the move. The facility was unable to provide documentation showing preparation for the move or any written communication to R8 about the room change. The Nursing Home Administrator stated the facility did not provide written notice before room changes and acknowledged that a form existed to explain room changes and the reason for them, but it was not being used.
Failure to Provide Written Notice for Room and Roommate Changes
Penalty
Summary
The facility failed to ensure that residents received written notice, including the reason for the change, before a room or roommate assignment was changed for two residents reviewed for resident rights. The deficiency involved Resident #5 and Resident #24, both of whom were on the secure unit and had significant cognitive impairment and behavioral concerns documented in their records. Resident #5 was an elderly female admitted with diagnoses including unspecified dementia, paranoid schizophrenia, psychotic disorder with delusions, and major depressive disorder. Her quarterly MDS showed a BIMS score of 7, indicating severely impaired cognition, and her care plan noted agitation and anxiety related to dementia and delirium or an acute confusional episode. A family member stated that Resident #5 was given a roommate without advance notice to the family. The family member said she learned of the roommate only after asking CNAs on the hall and overheard staff discussing that the family had not been told. She also stated there was an altercation between Resident #5 and the roommate, during which the roommate pushed Resident #5, and then the roommate was moved to another room. Resident #24 was an elderly male admitted with diagnoses including unspecified dementia, psychotic disorder with delusions, hallucinations, and major depressive disorder. His admission MDS showed a BIMS score of 3, indicating severely impaired cognition, and he had behaviors including disrobing in public, rejecting care, and wandering. Staff observed him sleeping in an extra bed in a room that was not his, and CNA staff stated he often slept there because he did not like his roommate. Staff also reported that he had moved rooms multiple times and became confused about where his room was. His family member stated she was not informed of his room changes and found out only when she visited and he was no longer in the room she expected. Facility staff gave conflicting statements about who was responsible for notifying residents and families, and the DON stated she was unfamiliar with the facility policy on room and roommate changes. The facility policy required prompt written notice for room or roommate changes, including the reason for the change, and stated that notice should be given before a resident is relocated whenever possible.
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