Health inspection·January 17, 2025

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the rights for one of three sampled residents (Resident 1) when Resident 1 did not receive a written notice of a proposed room change. This failure resulted in Resident 1 experiencing distress, frustration and the feeling of not having control over anything in her life. Findings: A review of the facility's policy titled Room Change/Roommate Assignment revised March 2021, indicated Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., [example] residents and their representatives) is given a notice of change prior to the transfer. A review of Resident 1's admission Record (undated), indicated she was admitted [DATE] with diagnoses that included a fracture of the right leg, history of falling, and pain. A review of Resident 1's admission Minimum Data Set (MDS, a clinical assessment) dated 11/13/24, indicated a Brief Interview for Mental Status (BIMS, an assessment of mental capacity) was conducted and Resident 1 scored a 15 out of 15 indicating her cognition was intact. Resident 1 was her own responsible party (RP, makes her own decisions about health care). During an interview on 1/17/25 at 10:50 am, Resident 1 stated They moved me from my room. I did not want to move. I was crying when I came over here because I did not have my door decorations. There were more drawers and a bigger closet (in the previous room). I am just a line item; it is a business. I did not want to move. They said I did not have a choice (and) it was happening. We have no control over anything in our lives. Resident 1 indicated that she did not receive a written notice indicating the move or the reason why. During an interview on 1/17/25 at 11:30 am, Social Service Director (SSD) indicated that the move for Resident 1 was decided by the admission Department and the Social Service Department because they needed the room for new residents. During an observation and interview on 1/17/25 at 11:51 am, Resident 1 was observed laying in her bed and Resident 1's Personal Therapist (PT) was sitting in a chair next to her bed. There were boxes, papers, clothes and many other items heaped on the floor next to her bed. PT indicated she was present when the facility asked her to move to a new room. PT stated She (Resident 1) was first asked Page 1 of 2 055510 055510 01/17/2025 Redding Post Acute 1836 Gold Street Redding, CA 96001

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few if she wanted to move, and she said no. Then she was told she had to move, and she threw a fit. She did not want to move. She did not agree to move. She has such a short time left (in the facility) and so much stuff to move, now it is in disarray. A review of Resident 1's nursing progress notes dated 1/14/25 at 10:19 am, indicated SSD noted Spoke with resident and requested her to move rooms to 17 A, (Resident 1's name) was not happy about the move but did agree to move rooms. During an interview on 1/17/25 at 12:26 pm, SSD indicated she spoke with Resident 1 about the room change. SSD stated, I did have to work with her, but she did finally agree to try. SSD indicated they needed to do the room change because they needed a room to admit males into and there was no other choice for that situation. During an interview on 1/17/25 at 12:32 pm, Certified Nursing Assistant (CNA) A indicated that the Staffing Coordinator (SC) and herself went into Resident 1's room to talk with her about the move. CNA A indicated that Resident 1 was upset (about having to move) and throwing things and that someone had already come in and asked her about the move. CNA A did not know who that was. CNA A indicated that she then asked for SSD to speak to Resident 1 about the move because Resident 1 was upset. During an interview on 1/17/25 at 12:40 pm, the SSD and Director of Nursing (DON) indicated that they did not give a written notice to Resident 1 about the move and did not know they had to. SSD and DON reviewed the Federal Regulations and confirmed that a written notice was required and that they should have done this, and they did not. 055510 Page 2 of 2