Countryside Nursing & Rehab Ctr

According to R4's face sheet, R1 is deemed not responsible for self and has assigned emergency contact/responsible party.

According to facility census, R4's room was documented on 09/15/2025 at 9:13 AM. On 09/30/2025 at 12:45 PM V5 (Restorative Director) said, couple of weeks ago, I spoke to V2 (Assistant Administrator) and mentioned that R4 should be moved to another room. I didn't initiate the change of R4's room though.On 09/30/2025 at 1:15 PM V1 (Administrator/Abuse Prevention Coordinator) said, in case of a resident room change, either Director of Nursing or Social Service Director notifies residents' emergency contact of the change. On 09/30/2025 at 2:03 PM V10 (Social Service Staff) said, I worked on 09/15/2025 but I'm not aware of R4's change of room. 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.On 09/30/2025 at 2:22 PM V2 (Assistant Administrator) said, I changed R4's room in the system on 09/15/2025 at 9:13 AM as I was notified by V5 (Restorative Director) that R4 wanted to change the room. I was assisting with change of room. 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.

Normally, nurses or social service staff would notify the resident's emergency contact about the room change. I didn't notify R4's family that day.The facility Room Changes policy dated November 2026 reads in part, Policy: To make room changes when requested by the resident or as may become necessary to meet the resident's medical and nursing care needs.

Policy specifications:

• 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.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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