Based on interview and record review, the facility failed to: 1. Implement the care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial [relating to the interrelation of social factors and individual thought and behavior] and functional needs) for one of four sampled residents (Resident 1) which included interventions related to hemodialysis (a medical treatment that acts as an artificial kidney, filtering waste products and extra fluid from the blood when kidneys are not working well) care that required monitoring of Resident 1's left upper arm arteriovenous fistula (AV fistula or shunt - a surgically created connection between an artery and a vein to provide hemodialysis access where a needle is inserted allowing blood to be… …
F656 citations in California
Comprehensive care plan · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F656 more often than its own record predicts
1.37 times the share F656 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F656.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F656 findings written in California, 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 observation, interview and record review, the facility failed to:Develop and implement an individualized fall prevention care plan, for one of three sampled residents (Resident 1) with interventions including reminding the resident to use a front wheeled walker ([FWW] a mobility aid with two wheels on the front legs and rubber-tipped or sliding legs on the back), and calling for assistance before walking.Implement the facility's Policy and Procedure (P&P) titled Care Planning-Interdisciplinary Team ([IDT]- Residents health care team consisting of variousspecialties), which indicated the Resident's IDT was responsible for the development of an individualized comprehensive care plan for each resident.These failures resulted in Resident 1 falling, sustaining a left femur (thigh bone)… …
Based on observation, interview and record review, the facility failed to develop an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions to meet the resident's behavioral of grabbing things and swinging of arms during care for one (1) of two (2) sampled residents (Resident 1). This deficient practice has the potential to delay in the necessary care and services for Resident 1's behavior and leading to harm to self or others.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of muscle weakness, epilepsy (a chronic… …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 4.50% | 1.25× |
| 2024 | 4.75% | 1.39× |
| 2025 | 4.73% | 1.37× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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