F655 in Kentucky. Pick another state for the same tag.
Against expectation — 2025
Kentucky cites F655 more often than its own record predicts
Versus expected share1.92×
1.92 times the share F655 takes of citations nationally.
Share of Kentucky citations1.26%
Of every deficiency written in Kentucky in 2025, this is the portion that was F655.
Kentucky1.26%
National0.66%
Share of all citations that were F655.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Kentucky surveyors wrote
F655 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.
J · Immediate jeopardy, isolatedAugust 15, 2025
Based on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' baseline care plan which provided instructions needed to provide effective and person-centered care for each resident was implemented for 1 of 5 (Resident (R) 9) sampled residents reviewed for elopement risk. Resident 9, who had major neurocognitive impairment, was care planned to be monitored frequently for his whereabouts, however, on 07/27/2025, the Resident left the facility by removing his bedroom window and climbing through it without staff knowledge/supervision. The Resident walked approximately 1.3 miles, in the dark. …
Based on interview, record review, and facility policy review, the facility failed to develop and implement a baseline care plan for new residents that included instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for one of 26 sampled residents (Resident (R)425).
R425 required hemodialysis treatments that included parameters for the resident's vital signs and had a known history of falls. However, the facility failed to implement a baseline care plan upon R425's admission to address his hemodialysis needs and risk for falls. …
D · No harm, potential for more than minimal, isolatedApril 2, 2026
Based on observation, interview, record review, and facility policy review, the facility failed to ensure the baseline care plan was developed and implemented with current instructions necessary to provide effective, person-centered care for one of 31 sampled residents Resident(R) 88. Record review revealed a physician order dated 03/24/2026 for a secure care bracelet. However, this intervention was not added to the care plan or Kardex until 04/01/2026. The failure to maintain an accurate and timely baseline care plan had the potential to affect staff awareness of the residents' current risks and needed safety interventions.Review of facility policy dated September 2024 titled, Baseline Care Policy and Protocol, revealed that a baseline care plan would be developed and implemented to… …
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