F656 in New York. Pick another state for the same tag.
Against expectation — 2025
New York cites F656 more often than its own record predicts
Versus expected share1.14×
1.14 times the share F656 takes of citations nationally.
Share of New York citations3.92%
Of every deficiency written in New York in 2025, this is the portion that was F656.
New York3.92%
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 New York surveyors wrote
F656 findings written in New York, 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.
J · Immediate jeopardy, isolatedMarch 4, 2026
Based on record review and interview during the survey the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, for one (1) of one (1) resident (Resident #1) reviewed. Specifically, Resident #1's care plan documented the resident was to have no male caregivers. During the night shift (11:00 PM-7:00 AM) on 02/03/2026, male Certified Nurse Aide #2 was assigned to provide 1:1 supervision for Resident #1. On 02/04/2026 at 7:00 AM Certified Nurse Aide #2 was witnessed by Certified Nurse Aide #1 abusing Resident #1. …
Based on record reviews and interviews during an abbreviated survey (Case # NY00271568), the facility did not ensure it implemented the comprehensive care plan consistent with resident rights for 1 (Resident #2) of 8 residents reviewed. Specifically, the facility did not ensure the intervention for the use of floor mats as documented on Resident #2's comprehensive care plan (CCP) for At Risk to Fall was implemented by facility staff resulting in a fractured right upper arm from a fall out of bed. This resulted in actual harm to Resident #2 that was not immediate jeopardy.
This is evidenced by:
The Policy and Procedure titled, Care Plans- Comprehensive documented a comprehensive, person-centered care plan is developed and implemented for each resident. …
D · No harm, potential for more than minimal, isolatedAugust 25, 2026
Based on record review, and staff interviews, the facility did not have a person-centered comprehensive care plan developed to address the residents' medical, physical, mental, and psychosocial needs. This was evident for one of five residents (Resident #15) reviewed for pain. Specifically, a pain care plan was not developed and implemented for Resident #15 who had a medical order for narcotic pain medication as well as multiple diagnoses that indicated resident would benefit from pain management and treatment.The findings are:Review of the facility policy titled Pain Management last revised 1/2026 found that it is the policy of the facility to assess and treat each resident for pain on a continuing basis and to afford the resident pain relief to the extent feasible and medically… …
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