Based on observation record review and staff interview, for two (2) of 53 sampled residents, the facility staff failed to fully implement the care plan interventions for a Resident who had an unwitnessed fall and failed to develop a care plan to manage an unstageable pressure ulcer for one resident. Residents #146 and #150. 1. Resident #150 was admitted to the facility on [DATE] with multiple diagnoses including Fracture of First Lumbar Vertebra, Abnormalities of Gait Mobility, Generalized Muscle Weakness, Severe Protein-Calorie Malnutrition, and Need for Assistance with Personal Care. A Skin Evaluation Form dated 04/23/26 at 7:25 PM documented in part, Left Buttocks DTI (Deep Tissue Injury) unstageable 30% skin, 20% slough, 50% dermis. …
F656 citations in District of Columbia
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
District of Columbia cites F656 more often than its own record predicts
2.56 times the share F656 takes of citations nationally.
Of every deficiency written in District of Columbia 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 District of Columbia surveyors wrote
F656 findings written in District of Columbia, 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.
The short window
Recent years
| Year | Share of District of Columbia citations | vs expected |
|---|---|---|
| 2023 | 5.45% | 1.52× |
| 2024 | 5.10% | 1.50× |
| 2025 | 8.80% | 2.56× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else District of Columbia surveyors cite →
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