Based on interview and record review, the facility failed to provide advanced written notice for room changes, to include the reason for the move, for 2 (Residents 2 and 3) of 3 residents reviewed for room changes. These failures placed the residents at risk for feelings of powerlessness and decreased quality of life. In addition, failure to properly conduct and address continued complaints of a room move, caused Resident 2 psychological harm the night of the room move, and continued physical and mood stressors. Findings included . Review of a 10/20/2017 policy titled Change of Room or Roommate showed the facility would conduct room changes or roommate assignments when considered to be necessary by the facility and/or when requested by the resident or their representative. …
F559 citations in Washington
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
Washington cites F559 less often than its own record predicts
0.63 times the national share — cited less often here than elsewhere.
Of every deficiency written in Washington 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 Washington surveyors wrote
F559 findings written in Washington, 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 interview and record review, the facility failed to provide written notice of room changes that included the reason for the room change for 3 of 3 residents (Resident 1, 2, and 3) reviewed for notification of room changes. This failure prevented the residents from having the necessary information needed to make an informed decision regarding their living situation, placing them at risk for frustration, dissatisfaction, and psychosocial decline. Findings included. <Resident 1>Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including broken heart syndrome (temporary heart damage caused by severe emotional or physical stress), spina bifida (a birth defect where the spinal cord fails to develop properly) and weakness. …
The short window
Recent years
| Year | Share of Washington citations | vs expected |
|---|---|---|
| 2023 | 0.11% | 1.51× |
| 2024 | 0.15% | 1.49× |
| 2025 | 0.07% | 0.63× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Washington surveyors cite →
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