Based on interviews, record review, observations, and facility policy review, the facility failed to ensure resident-centered comprehensive care plans were developed, implemented, and revised to meet the needs of 13 (Residents #10, #96, #17, #44, #8, #14, #145, #2, #36, #30, #27, #35, and #29) of 29 residents reviewed for comprehensive care plans. The facility failed to develop and implement comprehensive care plans to address residents at risk for falls and residents with a history of multiple falls with injury. …
F656 citations in Missouri
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
Missouri cites F656 less often than its own record predicts
0.48 times the national share — cited less often here than elsewhere.
Of every deficiency written in Missouri 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 Missouri surveyors wrote
F656 findings written in Missouri, 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, facility staff failed to develop and implement a person-centered comprehensive care plan for three (Resident #1, #9 and #58) of five sampled residents. The facility census was 79.1. Review of the facility's policy titled Care Plan Comprehensive, undated, showed an individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental and psychosocial well-being. …
Based on observation, interview, and record review, facility staff failed to develop and implement a comprehensive person-centered care plan to reflect the care needs for three residents (Resident #2, #30, and #41) out of 13 sampled residents. The facility census was 50.1. Review of the facility's policy titled, Care Plan Policy, undated, the care plan is designed to identify each resident's strengths, needs, goals, and preferences and to guide the delivery of quality, coordinated care that promotes the highest practicable physical, mental, and psychosocial well-being. …
The short window
Recent years
| Year | Share of Missouri citations | vs expected |
|---|---|---|
| 2023 | 2.72% | 0.76× |
| 2024 | 2.39% | 0.70× |
| 2025 | 1.65% | 0.48× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Missouri surveyors cite →
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