LANCASTER, CA - Federal inspectors cited Desert Canyon Post Acute for failing to follow proper procedures when moving residents to different rooms, a violation that left multiple residents feeling their rights were disregarded.
The April 25, 2025 inspection found that the facility moved three residents without providing required written notifications or proper orientations to their new accommodations, violating federal regulations designed to protect residents' autonomy and dignity.
Blind Resident Faced Additional Challenges
The most concerning case involved a blind resident with diabetes who had lived in her room for over a year before being relocated. The resident told inspectors that staff informed her she needed to move because her room would become an isolation room, but provided no written documentation of the change.
"The facility did not orient her in her new room and Resident 1 was having a hard time to maneuver in the bathroom, room, and keep bumping to her extra dresser because her closet was too small," according to the inspection report. The resident expressed feeling that the facility didn't care about her by placing her in the farthest room at the back of the building, knowing she was blind.
This lack of proper orientation poses significant safety risks for residents with visual impairments. Federal regulations require nursing homes to help residents adapt to room changes, particularly when residents have physical limitations that affect mobility and navigation.
Pattern of Inadequate Communication
A second resident, who had experienced a stroke, described feeling "thrown in the other room like garbage" when staff announced the move without consultation. The resident told inspectors that facility staff "did not even ask me anything" and provided no documentation explaining the reasons for the room change.
A third resident was moved after complaining about a noisy roommate. When her family contacted the facility, staff informed her that "whoever is the complainant they are the one who needs to be moved." The resident reported feeling forced to relocate and said she was left with no choice in the matter.
Required Procedures Not Followed
Federal regulations mandate that nursing homes provide written notice when changing a resident's room assignment. This notice must include the specific reasons for the change and give residents the opportunity to understand and respond to the decision.
The facility's own policy, last reviewed in October 2024, clearly states that "notice of a change in room or roommate assignment will be in writing and will include the reason for such change." The policy also requires social services staff to orient residents to new rooms and provide opportunities to meet new roommates and ask questions about the move.
During the inspection, the Social Service Director acknowledged that no written notifications were provided to any of the affected residents or their responsible parties, directly contradicting established procedures.
Regulatory Requirements for Room Changes
Nursing home regulations exist to protect residents' rights to participate in decisions affecting their care and living arrangements. When facilities move residents without proper notice or consent, they violate fundamental principles of resident autonomy and dignity.
Proper room change procedures serve multiple purposes: they ensure residents understand why moves are necessary, provide time to mentally prepare for transitions, and maintain trust between residents and staff. For vulnerable populations, including those with visual impairments or cognitive challenges, these protections become even more critical.
The orientation process helps residents safely navigate new environments and establishes relationships with new roommates. Without this support, residents may experience increased anxiety, confusion, and safety risks.
Facility Response Required
The citation requires Desert Canyon Post Acute to develop corrective actions addressing these procedural failures. The facility must demonstrate how it will ensure future room changes comply with federal requirements and its own policies.
Residents and families affected by improper room changes have the right to file complaints with state survey agencies or contact the facility's administration directly. The inspection findings highlight the importance of advocating for proper procedures when nursing homes propose room changes.
These violations underscore ongoing challenges in nursing home oversight and the need for facilities to consistently follow established procedures protecting resident rights. When basic communication requirements are not met, residents lose their voice in decisions that significantly impact their daily lives and wellbeing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Desert Canyon Post Acute, LLC from 2025-04-25 including all violations, facility responses, and corrective action plans.
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