Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure residents received written notice, including the reason for the room change/transfer, for eight (8) of fifty-three (53) sampled residents (Residents #6, #50, #72, #49, #3, #40, #60, and #82. The facility transferred Resident #6's personal belongings to another room, but when Resident #6 refused the transfer, the facility did not return the belongings for four (4) days. Resident #6 was upset and cried for four (4) days. The facility transferred Resident #50 out of a room the resident had shared with his/her spouse who had died in the room. The facility transferred Resident #72 several times who is a fall risk and has limited vision. …
F559 citations in Kentucky
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
Kentucky cites F559 more often than its own record predicts
1.26 times the share F559 takes of citations nationally.
Of every deficiency written in Kentucky 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 Kentucky surveyors wrote
F559 findings written in Kentucky, 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.
Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents were permitted to share a room with their spouse when both residents resided in the facility and both consented, for 2 of 2 sampled residents reviewed for roommate change, Resident (R)2 and R77.Although R2 and R77 had been married for 66 years and expressed the desire to reside together, there was no documented evidence the facility made reasonable efforts to accommodate the married couple's request prior to the Surveyor's intervention. This failure resulted in prolonged separation and psychosocial distress for both residents. …
Based on interview, record review, and facility policy review, the facility failed to provide written notification of a room change, including the reason for the change for 1 of 40 residents (Resident #3) sampled for room change, prior to relocating the resident to another room in the facility. The findings include: Review of the facility's policy titled, Room/Roommate Change Notification Policy, revised 01/31/2025, revealed a POLICY STATEMENT noting the facility would provide notice to the resident prior to changing the resident's room or roommate. Per policy review, the interdisciplinary team (IDT) was to participate in making all resident room relocation decisions. The policy specified, 2. Notice of intra-facility transfers will be made before the relocation except when: a. …
The short window
Recent years
| Year | Share of Kentucky citations | vs expected |
|---|---|---|
| 2024 | 0.15% | 1.47× |
| 2025 | 0.14% | 1.26× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Kentucky surveyors cite →
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