The moves affected residents with serious medical conditions including dementia, Parkinson's disease, and chronic kidney disease. Federal inspectors discovered the violations during an October complaint investigation at the 50-bed facility.
Resident 110, who had been at the facility since June 2024, requested a room move on December 31, 2024. The resident had dementia, congestive heart failure, and hypertension. Staff processed the move but never provided written notification as required by federal regulations.
Four months later, social services staff discussed a room change with Resident 115, who had Parkinson's disease, chronic obstructive pulmonary disease, and dementia. The resident agreed to the move on April 22, 2025. Again, no written notice was issued.
The most recent case involved Resident 117, a long-term resident who had lived at the facility since July 2021. On May 13, 2025, social services contacted the resident's emergency contact because the facility needed a private room for another resident requiring isolation. The emergency contact agreed to move Resident 117, who had chronic kidney disease, osteoporosis, and atrial fibrillation.
No written notice was provided in that case either.
Social Service Designee 860 told inspectors on October 22 that staff held verbal discussions with residents to get confirmation before room moves. The designee confirmed that none of the three residents received written notice.
"When a resident was set to move rooms, they had a verbal discussion to get confirmation," the social service designee said during the interview.
Regional Nurse 703 revealed a more fundamental problem during a separate interview the same day. The facility had no written policy governing room moves at all.
Federal regulations require nursing homes to provide written notice before changing a resident's room assignment. The rule protects residents' rights to understand and prepare for changes in their living situation, particularly important for residents with cognitive impairments like dementia.
The violation affected residents across different circumstances. One resident initiated the move themselves, another agreed after staff discussion, and a third was moved through their emergency contact when the facility needed their room for medical isolation purposes.
All three moves occurred between December 2024 and May 2025, suggesting the practice was ongoing rather than isolated incidents.
The inspection was prompted by a complaint filed as case number 2642458. Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
East Park Care Center operates as a mid-sized facility with 50 residents. The October inspection focused specifically on room move procedures following the complaint.
The facility's admission dates for the affected residents ranged from 2021 to 2025, indicating both long-term residents and more recent admissions were subject to the same inadequate notification practices.
Resident 110's case was particularly notable because the resident personally requested the room change, yet still did not receive the required written documentation of the move. The resident had been at the facility for over six months when the December move occurred.
Resident 115's situation involved direct staff consultation, with social services discussing the move and confirming the resident's agreement. Despite this interaction, no written follow-up was provided.
The third case highlighted operational pressures that can drive room moves. The facility needed Resident 117's room for another resident requiring isolation, creating a medical necessity for the change. Even in this situation, proper written notification was not provided to the resident's emergency contact.
The absence of any written policy for room moves suggests systemic gaps in the facility's procedures. Without established protocols, staff relied on informal verbal processes that failed to meet federal requirements.
The investigation revealed a pattern of non-compliance spanning five months, from December 2024 through May 2025. During this period, the facility processed room moves for residents with varying levels of cognitive function and medical needs without providing required documentation.
Federal inspectors found no evidence in any of the three medical records that written room move notifications had been issued. The documentation gap was complete across all cases reviewed.
The facility must now develop policies and procedures to ensure residents receive proper written notice before future room changes, addressing both the immediate violations and the underlying policy vacuum that enabled them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for East Park Care Center from 2025-10-28 including all violations, facility responses, and corrective action plans.