Based on record review, review of facility policy, and staff interview, the facility failed to provide a written notice of room change for 1 of 1 sampled resident (Resident #1) reviewed with a recent room change. Failure to provide the resident and/or resident's representative a written explanation of why a move is required prevents the resident and/or representative from making informed decisions significant to the resident's care. Findings include: Review of the facility policy titled Room/Roommate Change occurred on 07/09/25. This policy, dated 12/12/24, stated, . The resident has the right to receive written notice, including the reason for the change, before the resident's room . location is changed. …
F559 citations in North Dakota
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
North Dakota cites F559 more often than its own record predicts
2.50 times the share F559 takes of citations nationally.
Of every deficiency written in North Dakota 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 North Dakota surveyors wrote
F559 findings written in North Dakota, 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.
What else North Dakota surveyors cite →
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