Failure to Provide Written Notice Before Roommate Assignment
Penalty
Summary
The facility failed to provide written notice, including the reason for the change, to a resident and/or his representative before assigning him a new roommate. The resident had diagnoses of generalized muscle weakness and dementia with behavioral disturbances, but his most recent MDS documented a BIMS score of 15, indicating intact cognition, and his CAA noted he was highly active in his ADLs and preferred to do what he could for himself. His care plan identified a behavior problem and directed staff to administer medications as ordered and monitor behavior episodes. A social service note documented that on 02/11/26, staff verbally notified the resident that he would be getting a roommate in the next couple of days, and the resident verbalized understanding and agreement. The facility produced a general notice, dated 11/26/24, addressed to the resident and his representative, stating that effective 01/01/25 the facility would be transitioning some private rooms to semi-private accommodations and that if the resident received the letter, his room was one being converted. This notice did not specify when he would actually receive a roommate. The resident received a roommate when another resident was admitted on 02/13/26, but the facility was unable to provide any written notice specific to that roommate assignment. During interviews, the resident stated he never received written notice prior to the roommate moving in and was only told verbally. Social Services staff confirmed she verbally informed the resident and documented a note but did not provide written notice, and administrative staff confirmed residents were told at least the day before they were getting a roommate but not in writing. The facility’s Room Moves policy directed Social Services to inform residents and families of room moves but did not address written notice of room or roommate changes.
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