Failure to Notify Correct Responsible Party of Room Change
Summary
The facility failed to ensure that the correct responsible party (RP) for a resident was accurately documented in the medical record and failed to notify the correct RP of a room change. The resident in question was admitted with diagnoses including cerebral palsy, altered mental status, and quadriplegia, and was determined to lack the capacity to make decisions. The resident required total assistance with activities of daily living and was dependent on staff for care. When the resident tested positive for COVID-19, a room change to the COVID-19 unit was required. Documentation showed that the facility notified an RP listed on the admission record, but did not verify that this was the correct RP. Interviews with facility staff confirmed that the standard procedure is to notify the resident or their RP of any room change, complete the necessary documentation, and inform the ombudsman. However, in this instance, the DON acknowledged that although a listed RP was contacted, staff did not confirm that this was the correct RP as documented in the admission record. The facility's policy requires advance written notice to all involved parties prior to a room or roommate change, but this was not properly followed in this case.
Plan Of Correction
F 559 CHOOSE/BE NOTIFIED OF ROOM/ROOMMATE CHANGE CFR(s): 483.10(e)(4)-(6) IMMEDIATE CORRECTIVE ACTION: Resident 1 was discharged on 1/3/25. ACTION TAKEN TO IDENTIFY ALL OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE AND CORRECTIVE ACTION TAKEN: All residents had the potential to be affected by this deficient practice. The Medical Records Director (MRD) reviewed five (5) residents with room change requests in the last 30 days, to check if written notice of room change was provided to the resident and/or resident's RP. No other residents were affected by this deficient practice. PROCESS AND ACTION TAKEN TO ENSURE DEFICIENT PRACTICE DOES NOT RECUR: The Director of Nursing Services (DON) conducted an in-service education with the licensed staff on 6/30/25, regarding facility policy on Room Change, ensuring that advance notice is provided to the resident and/or RP prior to room change. The Administrator conducted an in-service with Social Services department staff on 7/7/25, regarding facility policy on Room Change, ensuring that advance notice is provided to the resident and/or resident's RP prior to room change. Effective 7/7/25, the MRD or her designee will review weekly room change requests to ensure completion of the advance notice and notification of resident and/or resident's RP. The Social Services Director or the Social Services Designee will immediately correct any deficient practice identified in the audit. The DON and/or her designee and the MRD will randomly review five (5) resident charts weekly for the next 30 days to ensure residents' RPs were notified and documentation completed regarding room changes. MONITORING PERFORMANCE TO ENSURE THAT CORRECTION IS ACHIEVED AND SUSTAINED: As part of the facility's Continuous Quality Improvement (CQI) program, the DON will report findings to the Quality Assessment and Assurance Committee (QAA) regarding weekly random reviews for the next 30 days. The MRD will also report findings to the QAA regarding weekly random reviews for the next 30 days. The Administrator will monitor compliance through review of DON and MRD reports. CORRECTIVE ACTION COMPLETION: July 7, 2025 This page intentionally left blank
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with intact cognition and significant visual impairment was threatened by a roommate, who had dementia and mental health diagnoses, when the roommate placed a plastic knife to the resident’s neck after the resident called out for assistance. Following the incident, the DON instructed an LPN to move the victim rather than the aggressor, and the resident was relocated to a room at the end of a corridor four rooms away, with no alternate route of access, requiring the resident to pass the aggressor’s room to reach common areas. The resident reported feeling they had no real choice but to move and later expressed anger and ongoing nervousness about the situation. Interviews and census review showed that private rooms on another unit had been available for the aggressor, and facility leadership acknowledged that the victim was not offered the option to remain in the original room, despite resident rights policies guaranteeing notice and choice regarding roommate changes.
A cognitively intact resident with cerebral ischemia, anxiety, and depression was moved to a different room after continuing to receive informal assistance with ADLs from a cognitively intact roommate with anemia, anxiety, and depression, despite prior counseling to stop this practice. The facility’s own policies require at least 30 days’ written notice, inclusion of the reason and new room assignment, and consultation with the resident and representative, as well as honoring the right to share a room with a chosen roommate when practicable. In this case, the resident was only verbally informed of the move, was not given written notice or an opportunity to refuse, and the representative was not notified in advance, while leadership staff later reported they were unaware of the move and that such changes are generally discussed and not carried out if a resident objects.
The facility failed to provide and document required written notice, including reasons, before changing a resident’s room and assigning new roommates for four cognitively intact residents. One resident with multiple chronic conditions, including DM2, major depressive disorder, delusional disorder, and COPD, had a room change without any documented notification to her POA, and she reported not signing any room-change document. Three other residents with conditions such as schizophrenia, COPD, asthma, hypertension, low back pain, and obesity had new roommates without documented family notification or written notice. During interviews, residents reported not recalling written notifications, and facility leadership and psychiatric rehab staff acknowledged that neither written notices nor progress note documentation of these room and roommate changes were completed, contrary to facility policy and stated resident rights.
A resident with dementia, stroke history, seizures, CKD, and a gastrostomy was hospitalized for a brain bleed, during which time her room was changed without prior notification to her legal representative. On return, the family member and POA found the resident’s belongings had been moved without being informed. Interviews with the DON, Social Service Director, and Administrator revealed uncertainty about who is responsible for room change notification, absence of a room change notification policy, and lack of required documentation of such notifications, and records contained no evidence that the resident, guardian, or representative had been notified.
A resident with intact cognition was moved to a new room after returning from a brief hospitalization, but staff did not give advance written notice or explain the reason for the change. The resident and her daughter reported that she was awakened to find staff packing her belongings, was not told where she was going or who she would room with, and was not given a chance to tour the room or meet the roommate. The record showed no documentation that her rooming preferences were considered or that written notice was provided before the transfer.
A resident with intact cognition was moved into another resident's room without a clear explanation, consent, or documentation of the reason for the transfer. Staff and leadership confirmed there was no record that either resident or the responsible party was notified, and the room change assessment and transfer form were not completed.
Failure to Honor Resident Room Choice After Resident-to-Resident Threat
Penalty
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.
Failure to Provide Required Notice and Consultation Before Resident Room Change
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive written notice and be consulted before a room change, as required by facility policy and resident rights regulations. The facility’s Room Changes policy states that residents must receive at least 30 days’ notice before any planned room change, except in emergencies, and that the notice must include the reason for the change and the new room assignment. The policy also requires consultation with the resident and their representative, and affirms the resident’s right to refuse a room change made for staff convenience or that moves them outside a distinct part of the nursing home. The Resident Rights policy further states that residents have the right to share a room with a roommate of choice when practicable, if both live in the same facility and agree. Resident #43, who was cognitively intact per the MDS and had diagnoses including cerebral ischemia, anxiety, and depression, had been rooming with Resident #129, who was also cognitively intact and had diagnoses including anemia, anxiety, and depression. A social worker note documented that on 07/24/2025, Resident #43 was counseled about maintaining appropriate boundaries and reminded that their roommate should not provide or assist with any aspects of care, including physical assistance or hygiene tasks, and Resident #43 agreed to refrain from asking or accepting such help. Despite this, a subsequent social worker note on 08/07/2025 documented that a room change occurred that day due to safety concerns related to Resident #43’s non-compliance with seeking physical assistance from their roommate. Interviews and documentation showed that the room change was carried out without written notice to Resident #43 or their representative, and without offering the opportunity to disagree or decline the move. Resident #43 reported being verbally informed of the room change because the roommate was helping with activities such as putting on shoes and retrieving items from the closet, and was observed to be tearful about being separated. Resident #129 stated they were helping with tasks like getting items from the closet but were never asked about the move and that the residents were “just separated.” Resident Representative #1 stated they were never informed of the room change by facility staff and only learned of it when the resident called them in distress. RN #6 confirmed the residents were separated after both had been educated not to assist with care and stated that the social worker notified families, but could not specify when, while the Director of Social Work and DON both reported they were unaware of the move and indicated that, in general, moves are discussed in meetings and not done if a resident objects. No written notice or documented consultation consistent with policy was evident prior to the room change.
Failure to Provide and Document Required Written Notice of Room and Roommate Changes
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to receive written notice, including the reason, before a room or roommate change, and to document notification to residents and their representatives. Four cognitively intact residents were affected. One resident with Type 2 diabetes mellitus, major depressive disorder, delusional disorder, and COPD had a documented room change, but there was no progress note between 03/20/2026 and 03/28/2026 showing that her POA was notified of the room change. This resident stated she had a room change a couple of weeks prior, identified her POA, and reported she did not know if the facility had spoken to the POA and that she did not sign any document regarding the room change. Another resident with schizophrenia, low back pain, and myalgia, who was responsible for her own decisions and had been in her current room since 10/07/2022, had no documentation in her progress notes during the same review period that her family was notified of a new roommate. A third resident with COPD, asthma, and hypertension, and a fourth resident with hypertension, low back pain, and obesity, both cognitively intact and responsible for themselves, had been in their current rooms since 12/31/2023 and 08/22/2023 respectively. For both of these residents, there was no documentation in the progress notes that family members were notified of new roommates during the review period. During interviews, one resident stated she observed staff showing the new roommate the room but said she was not presented with written notification of the roommate change, while another resident could not recall being introduced to the new roommate or receiving written notification. Staff interviews confirmed that required notifications and documentation did not occur. The Assistant Administrator stated she relies on Social Services to contact the POA regarding room changes and acknowledged that residents were verbally notified of a new roommate but that these notifications were not documented. The Psychiatric Rehabilitation Services Director and Assistant Director both stated they did not notify the POA of the room change and did not notify or document notification to the families of the other affected residents regarding roommate changes. The Assistant Administrator further confirmed that no written notice was provided to residents or the POA regarding the room and roommate changes prior to the move, despite facility policy and the facility’s Statement of Resident Rights requiring residents to receive written notice, including the reason for the change, before their room or roommate is changed.
Failure to Notify Resident Representative of Room Change
Penalty
Summary
The facility failed to honor a resident’s right to receive appropriate notification before a room change. The resident, an older adult with diagnoses including cerebral infarction (stroke), seizures, chronic kidney disease, dementia, and gastrostomy status, had a cognitive assessment indicating staff were unable to examine cognitive patterns due to dementia and that the resident was rarely or never understood. The resident became lethargic and was sent to the hospital for further evaluation, where she was admitted for a brain bleed and remained hospitalized for four days. During this hospitalization, the facility changed her room. Upon the resident’s return from the hospital, her family member and power of attorney for care reported that the resident’s belongings had been packed and moved to another room without any prior notification to the family. Record review showed no documentation that the resident, her state guardian, or her family member/power of attorney had been notified of the room change. When interviewed, the DON stated uncertainty about who was responsible for informing residents or representatives of room changes and indicated there was no policy for room change notification. The Social Service Director was also unsure of responsibility, and the Administrator acknowledged that any staff performing the room change should notify the resident or representative, but confirmed there was no written policy and that documentation of such notification was not required. No policy on room change notification was provided during the investigation.
Failure to Provide Written Notice and Honor Room Preference Before Room Change
Penalty
Summary
The facility failed to honor a resident’s rooming preferences and failed to provide written notice, including the reason for the room change, before a facility-initiated transfer for one resident. The resident was admitted to the facility and initially lived on B Hall, then was moved to a room on A Hall after returning from a five-day hospitalization. The resident was cognitively intact with a BIMS score of 15 and stated that she awoke to staff packing her belongings, was not told where she was going or who she would room with, and was not given the opportunity to tour the new room or meet the new roommate. She reported that staff told her only that her current room was being renovated and that the move was temporary, and she was upset that she had no advance notice to prepare for the move. The resident’s daughter, who served as the resident representative, reported that she was not notified in advance or in writing about the room change. She stated that Social Services called her on the morning of the move and said the resident would be transferred that afternoon, and that the resident would be assigned to a window bed despite her preference for a bed closer to the door and bathroom. The clinical record contained no documentation that written notice, including the reason for the room change, was provided before the relocation, and there was no documented evidence that the resident’s preferences were considered or that she was offered a chance to view the new room or meet the roommate prior to the move. Social Services provided a Room Change Request Letter indicating verbal notification was given, but the facility could not produce evidence of prior written notification.
Failure to Notify Residents and Complete Room Transfer Assessment
Penalty
Summary
The facility failed to notify two residents of a room change and failed to complete a room transfer assessment after moving Resident 127 into Resident 32's room. Resident 127 was admitted with diagnoses including Type II diabetes with neuropathy and asthma, and her record showed she had capacity to understand choices and make health care decisions, with a BIMS score of 14 out of 15 indicating intact cognition. During interview, Resident 127 stated she was moved from her previous room without a clear explanation, was told only that the room needed cleaning and she would return afterward, and said she did not want to move. She also stated nursing staff and CNAs did not provide additional information, and she was later told the room had been reassigned for short-term residents. The ADON stated residents must consent before being moved and must be informed of the reason for any transfer, but she was unaware of the reason for Resident 127's room change. The SSD confirmed Resident 127 was relocated and that the room change assessment section was not completed, with no documentation of the reason for the transfer or evidence of consent, and she could not identify who initiated the move. Resident 32, who had diagnoses including epilepsy and Type II diabetes, stated she remembered Resident 127 moving into her room and was not informed by staff. The SSD verified there was no documentation that Resident 32's RP was notified, no record that Resident 32 was informed of the transfer, and the transfer form had not been initiated. The ADM confirmed the transfer occurred but could not provide who authorized it or why it happened.
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