Based on staff and physician interviews, and facility and hospital record reviews, the facility failed to develop a comprehensive person-centered care plan that accurately reflected the care needs and safety measures required to care for a resident, including the need for two-person assistance with transfers and the assistance required immediately after a transfer 1 of 3 sampled residents reviewed for accidents (Resident #3). Resident #3 experienced a fall from the side of her bed, while being assisted by one staff member which resulted in a fall and the resident experienced an injury to her forehead. Resident #3 was sent to the hospital for evaluation and treatment and passed away later that day from an [MEDICATION NAME] hemorrhage (bleeding around or within the brain itself). …
F656 citations in North Carolina
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
North Carolina cites F656 less often than its own record predicts
0.74 times the national share — cited less often here than elsewhere.
Of every deficiency written in North Carolina 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 North Carolina surveyors wrote
F656 findings written in North Carolina, 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 record review, staff, Nurse Practitioner, and Medical Director interviews, the facility failed to develop and implement effective interventions when the resident manipulated and taped his condom catheter; when the resident refused ADL (activities of daily living) care; when the resident refused full body skin assessments for 1 of 8 residents, (Resident #7). On 3/13/22 Resident #7 arrived at the Emergency Department (ED) with significant swelling of his scrotum and groin and his condom catheter was extensively taped with medical tape. The skin assessment in ED described multiple excoriated [CONDITION(S)] to his foreskin with active bleeding, multiple skin discolorations, two sacral pressure ulcers and abrasions over the body. …
Based on record reviews and staff interviews, the facility failed to develop a person-centered comprehensive care plan in the areas of anticoagulant medication use (Resident #5), and antidepressant medication use (Resident #8) for 2 of 20 residents whose care plans were reviewed.The findings included:1 Resident #5 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation.Resident #5 had a physician order dated 3/3/26 for Eliquis (anticoagulant medication) 5 milligrams (mg) one (1) tablet by mouth twice daily for atrial fibrillation.Review of Resident #5's June's 2026 Medication Administration Record (MAR) for the period of 6/1/26 through 6/30/26 revealed Resident #5 received Eliquis 5mg 1 tablet by mouth twice daily as prescribed.A quarterly Minimum Data Set… …
The short window
Recent years
| Year | Share of North Carolina citations | vs expected |
|---|---|---|
| 2023 | 2.64% | 0.73× |
| 2024 | 2.19% | 0.64× |
| 2025 | 2.55% | 0.74× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else North Carolina surveyors cite →
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