Based on medical record review, interviews, review of facility investigation documents, and policy review, the facility failed to implement person-centered care planned interventions. This resulted in Actual Harm when Resident #97 was being bathed by one staff member, had a spasm in one leg, fell out of the bed, and sustained fractures in both legs. This affected one (Resident #97) of three residents reviewed for falls. The facility census was 92.Findings Included: Review of the medical record revealed the facility admitted Resident #97 on 07/04/19. Diagnoses included absolute glaucoma, binge eating disorder, abnormal posture, bariatric surgery status, muscle weakness, difficulty in walking, and the need for assistance with personal care. …
F656 citations in Ohio
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
Ohio cites F656 less often than its own record predicts
0.59 times the national share — cited less often here than elsewhere.
Of every deficiency written in Ohio 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 Ohio surveyors wrote
F656 findings written in Ohio, 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, the facility failed to ensure resident care plans were developed to address individual resident needs. This affected three (#03, #08, and #63) of 23 residents reviewed for care planning. The facility census was 101.Findings include: 1. Review of Resident #08's medical record revealed the resident admitted to the facility on [DATE] with diagnoses including gangrene, diabetes mellitus due to underlying condition with foot ulcer, other chronic osteomyelitis of the right ankle and foot, chronic respiratory failure with hypoxia, non-pressure chronic ulcer of other part of the right foot with unspecified severity, end stage renal disease (ESRD) and dependence on renal dialysis. …
The short window
Recent years
| Year | Share of Ohio citations | vs expected |
|---|---|---|
| 2023 | 1.84% | 0.51× |
| 2024 | 1.83% | 0.54× |
| 2025 | 2.05% | 0.59× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Ohio surveyors cite →
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