The violation occurred at Countryside Nursing & Rehab Center on September 15, when staff relocated the resident but failed to contact his emergency contact or responsible party. Federal inspectors discovered the oversight during a complaint investigation completed in October.
The resident, identified as R4 in inspection records, is a male with multiple serious conditions including Type 2 diabetes, heart disease, seizures, bipolar disorder, anxiety, and chronic lung disease. His cognitive assessment showed a score of 11 on the Brief Interview of Mental Status, indicating moderately impaired cognition.
According to facility records, R4 was "deemed not responsible for self" and had an assigned emergency contact and responsible party listed in his file.
The room change happened at 9:13 AM on September 15, documented in the facility's electronic system. But the notification that should have followed never occurred.
When inspectors interviewed staff two weeks later, the breakdown in communication became clear. The Restorative Director, identified as V5, told investigators she had suggested the room change to the Assistant Administrator "couple of weeks ago" but said she "didn't initiate the change of R4's room."
The Assistant Administrator, V2, provided more details about what actually happened that morning. She said V5 had notified her that R4 wanted to change rooms, so she went to assist with the move.
"I spoke to R4, she indicated she wanted to be in a different room, I took her then to the new room, R4 liked it, and she stayed there," V2 told inspectors.
Then came the admission of the policy violation.
"Normally, nurses or social service staff would notify the resident's emergency contact about the room change," V2 said. "I didn't notify R4's family that day."
The facility's Administrator, V1, confirmed to inspectors that proper protocol requires notification. "In case of a resident room change, either Director of Nursing or Social Service Director notifies residents' emergency contact of the change," she said.
Social Service Staff member V10 was working the day of the room change but told inspectors she wasn't aware it had happened. She explained the standard procedure: "If a resident has an emergency contact, we call the emergency contact and notify them of change of room. It is documented then in the resident's electronic health record."
No such documentation existed for R4's move.
The facility's written Room Changes policy, dated November 2026, explicitly addresses this requirement. The policy states its purpose is "to make room changes when requested by the resident or as may become necessary to meet the resident's medical and nursing care needs."
Under policy specifications, section 3 is unambiguous: "Prior to the room change, the resident, his or her roommate (if any), and the resident's representative will be provided with information concerning the decision to make the room change."
Federal regulations protecting nursing home residents' rights require facilities to honor residents' choices about roommates and provide written notice before room changes. The regulation exists to ensure families stay informed about their loved ones' care, particularly when cognitive impairment prevents residents from communicating changes themselves.
For R4, whose cognitive assessment indicated he couldn't make fully informed decisions about his care, the family notification wasn't just policy – it was his primary connection to advocacy and oversight of his treatment.
The timing of the room change adds another layer to the violation. Staff moved R4 on a Sunday morning, when fewer administrative personnel typically work and communication systems may be more informal. The Assistant Administrator was "assisting" with what should have been a routine administrative process handled by nursing or social services.
The confusion among staff about who initiated the change and who was responsible for notification suggests systemic problems with the facility's room change procedures. The Restorative Director suggested the move but didn't initiate it. The Assistant Administrator executed the move but didn't follow notification protocols. The Social Service Staff member worked that day but remained unaware of the change entirely.
This breakdown occurred despite multiple staff members knowing the correct procedures. Both the Administrator and Social Service Staff member accurately described the notification requirements to inspectors. The Assistant Administrator acknowledged that notification "normally" happens but admitted she didn't do it.
The violation affected what inspectors classified as "few" residents, suggesting similar notification failures may have occurred with other room changes. The "minimal harm or potential for actual harm" designation indicates R4 wasn't physically injured by the move, but his rights were violated nonetheless.
Countryside Nursing & Rehab Center's failure represents a common problem in nursing home oversight. Facilities often have written policies that meet regulatory requirements, but staff don't consistently follow them. When cognitive impairment prevents residents from self-advocating, these policy failures can leave families completely unaware of significant changes in their loved one's living situation.
The inspection found that R4's room change violated both federal regulations protecting resident rights and the facility's own written procedures. Staff knew what they were supposed to do but didn't do it, leaving a cognitively impaired resident's family uninformed about a major change in his daily environment.
For families with cognitively impaired relatives in nursing homes, the violation highlights the importance of regular contact and explicit arrangements for notification about any changes in care or living situations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Countryside Nursing & Rehab Ctr from 2025-10-01 including all violations, facility responses, and corrective action plans.
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