F559

Based on observation, interview and record review, the facility failed to ensure residents' right to receive written notice, including the reason for the change, before the resident's room or roommate was changed, was not supported for 16 of 26 sampled residents (Resident 1,2,3,4,5,7,8,9,11,12,13,14,15,16,18,22) when Resident 1, Resident 2, Resident 3, Resident, 4, Resident 5, Resident 7, Resident 8, Resident 9, Resident 11, Resident 12, Resident 13, Resident 14, Resident 15, Resident 16, Resident 18 and Resident 22 were moved from their assigned room to another room in the facility without first receiving written notice. …

Keystone Post-Acute · California

Based on observations, interviews, and record review conducted during a survey, the facility failed to ensure the resident's right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. This was evident for two (Residents #5 and #15) of three residents reviewed for resident rights. Specifically, 1) Resident #5 and their designated representative were not provided with notification nor an opportunity to meet their new roommate prior to receiving one on 02/13/2026, and 2) Resident #15 was cognitively impaired and had their room changed on 02/13/2026 without a documented explanation or plan to address the resident's potential adjustment needs. …

The Grand Rehabilitation and Nursing At Pawling · New York

Based on complaint, reviews of a closed clinical record and all other pertinent administrative documents, and interviews with a resident and the facility staff, it was determined that the facility staff failed to notify the resident of a proposed room change in writing before the staff moved the resident's belongings to a new room without his/her knowledge. This was evident for 1 (Resident #4) of 5 residents reviewed during a complaint survey. The findings include: On 6/18/26 at 10:46 am the Office of Health Care Quality received a complaint (3048023) from another State agency that indicated Resident #4 was inappropriately discharge from the facility. …

Shady Grove Nursing and Rehabilitation Center · Maryland

Based on review of the clinical record, facility documentation, facility policy and interviews for 6 of 8 residents (Resident #59, Resident #67, Resident #89 and Resident #93, Resident #129, and Resident #155) reviewed for choices, the facility failed to allow the residents the right to see the room, meet the roommates, or ask questions about the room prior to the room change, failed to provide a written notice of a change in room prior to or following the room change, and failed to ensure residents were aware of their right to return to their previous room due to being moved emergently. The findings include:1. …

Silver Springs Care Center · Connecticut