F656 in Maryland. Pick another state for the same tag.
Against expectation — 2025
Maryland cites F656 less often than its own record predicts
Versus expected share0.89×
0.89 times the national share — cited less often here than elsewhere.
Share of Maryland citations3.06%
Of every deficiency written in Maryland in 2025, this is the portion that was F656.
Maryland3.06%
National3.44%
Share of all citations that were F656.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Maryland surveyors wrote
F656 findings written in Maryland, 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.
G · Actual harm, isolatedFebruary 8, 2019
Based on medical record review and interview, it was determined the facility staff failed to follow the resident's interdisciplinary care plan and put additional safeguards in place to prevent the resident from obtaining lighting materials and setting a fire (Resident #1). This was evident for 1 of 11 residents reviewed during a complaint survey. This failure resulted in a fire at the facility on 2/2/19 that resulted in smoke inhalation to a second resident (Resident #2).
A care plan is a guide that addresses the unique needs of each resident. …
D · No harm, potential for more than minimal, isolatedAugust 28, 2026
Based on a review of complaint 3167646, interviews, and medical record review, it was determined that facility staff failed to develop a comprehensive person-centered care plan for a resident with glaucoma. This was evident for 1 (Resident #5) of 8 residents during a complaint survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care.Glaucoma is a group of eye diseases that damage the optic nerve, often due to high fluid pressure inside the eye called the intraocular pressure. …
B · No harm, potential for minimal, patternMay 14, 2018
Based on surveyor review of the clinical records, observation of resident and staff practice and interview of the facility staff, it was determined that the facility staff failed to develop a person-centered care plan for an individual. This finding was evident for 2 of 16 residents reviewed for comprehensive care plans (#11 and #122). The findings include:
1. On 05-08-18 at 10:30 AM, resident #11 was observed wearing a left hand splint during lunch on 05-08-18. The resident was alert and oriented to name only.
On 05-11-18 at 10 AM, interview of staff #1 revealed resident #11 required total assistance with all activities of daily living. …
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