Based on observations, record review and interviews, the facility failed to provide written notification of room changes and roommate changes for one (#7) of three residents reviewed for notifications out of 31 sample residents. Specifically, the facility failed to provide timely written and/or verbal notification of room and/or roommate changes to Resident #7 and/or the resident's representatives.Findings include:I. Facility policy and procedureThe Room Change/Roommate Assignment policy, revised November 2025, was provided by the nursing home administrator (NHA) on 8/13/26 at 2:04 p.m. The policy read in pertinent part, Resident room or roommate assignments may change if the facility deems it necessary. Resident preferences are considered when roommate changes are necessary. …
F559 citations in Colorado
Resident Rights Deficiencies
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Colorado cites F559 more often than its own record predicts
3.04 times the share F559 takes of citations nationally.
Of every deficiency written in Colorado in 2025, this is the portion that was F559.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Colorado surveyors wrote
F559 findings written in Colorado, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
The short window
Recent years
| Year | Share of Colorado citations | vs expected |
|---|---|---|
| 2023 | 0.08% | 1.19× |
| 2024 | 0.15% | 1.47× |
| 2025 | 0.34% | 3.04× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Colorado surveyors cite →
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