Based on interview, record review, and review of facility policy it was determined the facility failed to implement the care plan for one of three (3) sampled residents (Resident #1). The facility care planned to monitor Resident #1 for increased shortness of breath (SOB), dyspnea (difficulty in breathing), cyanosis or other signs/symptoms (s/s) of respiratory distress or cardiac distress. On [DATE] at 5:50 AM, the resident was found to be sweaty, had shortness of air (SOA) and the resident's vital signs were abnormal; however, the licensed staff failed to monitor the resident according to the resident's care plan. At 6:20 AM, Emergency Medical Services (EMS) arrived, and Resident #1 was found to be unresponsive, not breathing, with no pulse, and pupils fixed and dilated. …
F659 citations in Kentucky
Resident Assessment and Care Planning Deficiencies
Provide care by qualified persons according to each resident's written plan of care.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
No F659 citations were recorded in Kentucky for 2025. That means none appear in the CMS file for that year — not that the requirement does not apply.
In the surveyor’s words
What Kentucky surveyors wrote
F659 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 interview, record review, review of facility policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure services were provided in accordance with each resident's Comprehensive Care Plan for one (1) of nineteen (19) sampled residents (Resident #70). Resident #70's Comprehensive Care Plan initiated 01/12/16, revealed the resident required extensive assist of two (2) staff for transfers and toileting. However, on 03/28/18, per staff interviews, Resident #70's Care Plan was not implemented and the resident was transferred to the toilet with the assist of one (1) staff member and then was left on the toilet unsupervised. …
Based on interview and record review it was determined the facility failed to follow the plan of care for one (1) of twenty-five (25) sampled residents (Resident #203). Resident #203 was a new admission to the facility, was continent of bowel and bladder, and assessed to require assistance with transfers and toileting. However, on 04/22/19, the facility failed to provide the resident with assistance to the toilet, and the resident had an incontinence episode in bed. The findings include: Interview with the Nurse Consultant on 04/25/19 at 3:15 PM revealed the facility did not have a policy for following the resident's plan of care. A review of the medical record for Resident #203 revealed the facility admitted the resident on 04/12/19 with [DIAGNOSES REDACTED]. …
What else Kentucky surveyors cite →
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