Failure to Honor Resident Room Choice After Resident-to-Resident Threat
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose whether to remain in their room and to receive appropriate notice before a room change following a resident‑to‑resident altercation. One resident with intact cognition, muscle weakness, type II diabetes mellitus, and absolute glaucoma was dependent on staff for bed mobility and required assistance with transfers and ambulation. This resident ambulated independently with a rolling walker in the room and throughout the facility and enjoyed walking out of the room, socializing with friends, and going to the dining room for meals. Another resident, who had Alzheimer’s disease, major depressive disorder with psychotic symptoms, generalized anxiety disorder, and moderately impaired cognition, had a care plan identifying poor impulse control, lack of safety awareness, potential for manipulative behaviors, and a history of making accusatory statements, with interventions including the use of plastic utensils and staff support for coping and behavior. On the date of the incident, the cognitively intact resident reported that the dinner cart was outside the room and began calling out “hello” for help. The roommate became aggravated, approached the resident’s side of the room, told the resident to use the call bell, and then placed a plastic knife to the resident’s neck and moved it across. The victim reported that the roommate cursed, called names, and threatened that if the resident did not “shut up” it would be worse next time. Staff documentation and interviews confirmed that the victim was removed from the room to the hallway, assessed with no acute injury noted, and that the aggressor was placed on one‑to‑one observation and sent to the ED for evaluation. The victim was described as calm but slightly anxious and later expressed being upset and worried about the aggressor returning. Following the altercation, the DON directed staff to move the victim to a different room, despite the aggressor being the one who initiated the threatening behavior. The LPN asked the victim if they were agreeable to the move and proceeded with the room change without offering the option to remain in the original room. The new room was located at the end of a hallway four rooms away from the aggressor’s room, with no alternate route of exit or access, requiring the victim to routinely pass the aggressor’s room to reach common areas and the dining room. The victim later reported feeling they had no real choice but to move in order to feel safe, expressed anger that the aggressor ended up with a private room, and continued to feel nervous about having to walk past the aggressor’s room. Interviews with facility leadership acknowledged that the victim should have been offered the choice to remain in the original room, that the aggressor should have been moved instead, and that private rooms on another unit had been available at the time. The facility’s Residents’ Bill of Rights policy stated that residents have the right to notice before a roommate is changed, to be treated equally with other residents, and to be free from abuse, but there was no specific policy available for room transfers following resident‑to‑resident altercations.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Provide Written Notice for Room and Roommate Changes: The facility did not provide written notice, including the reason, before room or roommate changes for six residents. Residents with intact cognition, as well as residents with dementia or other cognitive impairment, and several resident representatives reported they were not notified in writing. The DON acknowledged the facility did not give written notification when room or roommate changes occurred.
Failure to Notify Responsible Party Before Room Change: A resident with Alzheimer's disease and dementia was moved to another room after reporting fear of her roommate following a roommate-on-resident incident. Facility records showed the resident's son was contacted about the incident, but the DON later confirmed staff did not notify the responsible party before the room move, despite policy requiring prior notice.
Failure to Provide Written Notice and Consent Opportunity for Room Change: A resident with hemiplegia, hemiparesis, and impaired cognition was moved to another room for a new admission without advance written notice, without documentation that he was told he could refuse, and without being given the notice to sign or a copy of it. The SSD and DON stated residents had the right to refuse room changes and that alert residents should sign the consent, but the record showed no documentation that the resident was informed in advance or agreed to the move, and the resident and FM reported he was moved abruptly and felt frustrated and disappointed.
Failure to provide written notice before a room and roommate change: A resident with moderate cognitive impairment and a spinal hardware-related diagnosis returned from the hospital and was upset to find the room changed and a new roommate assigned. The record lacked evidence that the resident was informed beforehand or given written notice with the reason for the change, and the DON could not produce documentation showing prior notification.
Two residents were moved to different rooms after only verbal notice from the SSD, with no written notice provided before the change. One resident was moved from the first floor to the second floor and said she was angry and upset, while the other was told immediately before dinner that she had to move because a new admission needed an isolation room. The SSD and DON confirmed the facility gave only oral notice, despite the residents being their own RP and having no memory impairment.
A resident with dementia, immunodeficiency, SLE, and RA was moved from a Medicare bed to an LTC room without prior written notice or explanation. The resident said she was not told why she was moved and learned of it only when it happened, and her family member reported receiving no written or verbal notice. The DON said the family was not notified because she forgot and the move occurred when a Medicaid bed became available.
Failure to Provide Written Notice for Room and Roommate Changes
Penalty
Summary
The facility failed to provide written notification, including the reason for a room change, before residents’ rooms or roommate assignments were changed for 6 of 6 residents reviewed. The facility policy titled Room Change stated that when a room change occurs, the resident being moved and the resident receiving a new roommate will be notified verbally and in writing, including the reason for the change, and that staff should complete a room change notice and place it in the medical record. Resident ID #45, admitted with type 2 diabetes and with a BIMS score of 15/15, was moved from the room on 4/1/2026, and the record did not show written notification of the room change or the reason for it. Resident ID #147, admitted with pneumonia and a BIMS score of 8/15, was moved to another floor on 6/9/2026; the record did not show written notification, and the resident stated s/he was not initially happy with the transfer because s/he had made friends on the second floor. Resident ID #66, admitted with anxiety and depression and with a BIMS score of 15/15, reported being awakened by staff and told the room would be changed, denied having a choice, and denied receiving written notice; the record also lacked evidence of written notification. Resident ID #93, with heart failure and a BIMS score of 15/15, stated s/he was not notified before receiving a roommate, and the record did not show written notice. Resident ID #99, with dementia and obsessive-compulsive disorder and a BIMS score of 0/15, had been moved three times between December 2024 and June 2026; the resident’s representative stated no written notifications were provided, and the record lacked evidence of written notice. Resident ID #101, with dementia and a BIMS score of 0/15, had been moved three times between January 2026 and June 2026; the representative also stated no written notifications were provided, and the record lacked evidence of written notice. The Social Worker stated that the facility completes an assessment in the record when a room change or roommate change occurs but does not give written notification to the resident or resident representative, and the DON acknowledged the facility failed to provide the required written notification for all six residents.
Failure to Notify Responsible Party Before Room Change
Penalty
Summary
The facility failed to provide written notice to a resident's responsible party before changing the resident's room. The resident had diagnoses of Alzheimer's disease and dementia and lived on the secured nursing unit for residents with dementia-type diagnoses. Facility policy stated that when a room change occurs, the patient will be notified prior to the move, and the facility form included signature lines for the resident or responsible party. After a roommate incident in which staff found the roommate on top of the resident in bed, assessed a bite mark on the resident's left hand without broken skin, and documented the resident's report that her hair had been pulled and she had been slapped in the face, the resident's son was contacted about the incident and the roommate was placed on one-to-one supervision. Later documentation showed the resident stated she was scared of the roommate and did not want to remain in the room with her because of the recent incidents. The facility then moved the resident to another room on the A nursing unit without notifying the responsible party beforehand, and the responsible party later expressed being very upset about the move and requested that the resident be returned to the previous room.
Failure to Provide Written Notice and Consent Opportunity for Room Change
Penalty
Summary
The facility failed to ensure a resident who was moved to another room received advance written notice of the room change, was informed of the reason for the move in a way he could understand, was given the opportunity to refuse the move, was offered the chance to sign the room-change notice, and was provided a copy of the notice. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, and the H&P indicated he did not have capacity to make medical decisions, while the MDS described his cognition as moderately impaired. The room-change notice stated the move was needed for a new admission and was not medically necessary, and it also indicated the resident preferred to give verbal consent instead of a signature. The record contained no documentation in the progress notes or social services notes showing the resident was informed in advance, told he could refuse the room change, or given the notice to sign. During interview, the family member stated staff came into the resident’s room and told him he was going to be moved without advance notice, and that neither she nor the resident had received prior notice. She also stated the resident became frustrated and disappointed after the move and that the new room did not provide the same view or stimulation as the prior room. The resident stated staff woke him and told him he would be moved, then returned within an hour and began moving him, and he stated he did not receive written notification or a copy of the notice. The SSD stated she was responsible for notifying residents of room changes and that staff were required to obtain consent before moving a resident. She stated the resident had capacity to sign the notice, but she did not provide it for signature, did not provide a copy, and did not document that he was informed of his right to refuse the room change. The DON stated residents had the right to refuse a room change and that alert residents should sign the room-change consent so it was mutually understood they knew about, agreed to, and understood the move. Facility policy stated residents had the right to refuse a room change unless necessary for health or safety reasons, and that staff were to orient the resident to the transfer and document the move in the medical record.
Failure to Provide Written Notice Before Room and Roommate Change
Penalty
Summary
The facility failed to provide written notification, including the reason for a room change, before changing a resident's room and roommate assignment. Resident ID #1, who was admitted in May 2026 with a diagnosis including infection or inflammatory reaction due to internal fixation device of the spine, had a Brief Interview for Mental Status score of 11 out of 15 on 5/15/2026, indicating moderate cognitive impairment. After the resident was transferred to the hospital on 5/27/2026 for an elevated temperature and returned the next day, a progress note dated 5/28/2026 at 2:19 PM documented that the resident was upset because the room had been changed and a new roommate assigned. Record review did not show evidence that the resident was informed of the room change before it occurred, and there was no evidence that written notice of the room change, including the reason for the change, was provided as required by facility policy. The facility policy stated that when a room change occurs, the resident being moved and the resident receiving a new roommate will be notified verbally and in writing, and that a room change notice should be completed and placed in the medical record. During interview, the DON acknowledged that the resident's room assignment had been changed and that a new roommate had been assigned, but she was unable to provide evidence of prior written notification.
Failure to Provide Written Notice Before Room Changes
Penalty
Summary
The facility failed to protect two residents’ right to receive written notice before a room change. Resident 1 was admitted with a diagnosis of fracture of the neck of the right femur and was her own responsible party; her MDS dated 3/20/26 indicated no memory impairment. Resident 2 was last admitted with a diagnosis of peripheral autonomic neuropathy and was also her own responsible party; her MDS indicated no memory impairment. Both residents stated they were told verbally that their rooms were being changed, but they were not given written notice before the move. Resident 1 stated she was informed in person by the SSD that her room was being changed from the first floor to the second floor on 6/4/26, and she said she was angry and upset and was not given an opportunity to discuss the move until after she had been moved. Resident 2 stated she was told right before dinner that her room was changing immediately because a new resident needed isolation, and she said she felt like luggage when staff placed her clothes in garbage bags for the move. The SSD stated residents were verbally given notice an hour or two before room changes and that written notice was not provided, and the DON confirmed residents were notified verbally and no written notice was given. The facility policy stated residents and their representatives would be given advance notice of room or roommate assignment changes and that notice may be oral or in writing.
Failure to Provide Written Notice Before Room Change
Penalty
Summary
The facility failed to ensure Resident #2, who had diagnoses including dementia, immunodeficiency, systemic lupus erythematosus, and rheumatoid arthritis, received written notice before her room was changed. Her MDS 5-day assessment dated 04/28/26 showed a BIMS score of 15, indicating intact cognition, and her care plan noted she required assistance with functional abilities in self-care and mobility. Record review and interviews showed Resident #2 was moved from a Medicare bed to a room on the long-term care side on 05/07/26. The resident stated she was moved to a different room, was not told why, was not given written notice, and did not learn of the move until the day it occurred. Her family member said she was not notified before the move and did not receive written or verbal notice from facility staff. The DON stated the family member was not notified because she forgot, and that the move occurred because a Medicaid bed was already available.
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