Based on complaint, reviews of a closed clinical record and all other pertinent administrative documents, and interviews with a resident and the facility staff, it was determined that the facility staff failed to notify the resident of a proposed room change in writing before the staff moved the resident's belongings to a new room without his/her knowledge. This was evident for 1 (Resident #4) of 5 residents reviewed during a complaint survey. The findings include: On 6/18/26 at 10:46 am the Office of Health Care Quality received a complaint (3048023) from another State agency that indicated Resident #4 was inappropriately discharge from the facility. …
F559 citations in Maryland
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
Maryland cites F559 more often than its own record predicts
1.19 times the share F559 takes of citations nationally.
Of every deficiency written in Maryland 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 Maryland surveyors wrote
F559 findings written in Maryland, 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 medical record review and staff interview it was determined the facility failed to provide a resident and/or the resident's responsible party with a written notice before the resident received a roommate. This was evident for 4 (#3, #5, #4, #6) of 17 residents reviewed during a revisit survey, however it had the potential to affect all residents as the facility staff were not aware of the regulation. The findings include: 1) On 5/22/23 at 1:53 PM a review of Resident #3's medical record revealed a 5/3/23 social service note that documented Resident #3 was receiving a roommate and the resident's representative was notified. Further review of the medical record failed to produce documentation that the resident's representative (RP) was notified in writing of the roommate. …
The short window
Recent years
| Year | Share of Maryland citations | vs expected |
|---|---|---|
| 2023 | 0.25% | 3.56× |
| 2024 | 0.05% | 0.52× |
| 2025 | 0.13% | 1.19× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maryland surveyors cite →
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