F656 in Pennsylvania. Pick another state for the same tag.
Against expectation — 2025
Pennsylvania cites F656 less often than its own record predicts
Versus expected share0.87×
0.87 times the national share — cited less often here than elsewhere.
Share of Pennsylvania citations3.01%
Of every deficiency written in Pennsylvania in 2025, this is the portion that was F656.
Pennsylvania3.01%
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 Pennsylvania surveyors wrote
F656 findings written in Pennsylvania, 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.
K · Immediate jeopardy, patternSeptember 26, 2024
Based on the review of clinical records, facility policies and interview with staff, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for Resident R135, with a documented history of substance abuse, to prevent relapse and access to illegal substances. This failure resulted in Resident R135, accessing and using illegal substance and experiencing four incidents ([DATE]; [DATE]; [DATE] and [DATE]) of drug overdose which required immediate medical treatment/emergency medical intervention and resulted in an Immediate Jeopardy situation for one of four residents reviewed (Resident R135). …
Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement a comprehensive person-centered care plan for a resident requiring blood sugar monitoring to meet a resident's needs for one of seven residents reviewed (Resident R1) resulting in hospitalization and actual harm of Hyperosmolar Hyperglycemic State (a serious complication of diabetes characterized by extremely high blood sugar levels and severe dehydration, often leading to confusion and other mental status changes requiring immediate medical attention to prevent life-threatening outcomes). …
D · No harm, potential for more than minimal, isolatedSeptember 11, 2026
Based on review of clinical records and staff interview it was determined the facility failed to develop and implement an individualized, person-centered comprehensive care plan that addressed ongoing behaviors and identified interventions to manage wandering and exit seeking behaviors for one of 18 residents reviewed (Resident 11). Findings include: A review of the clinical record revealed Resident 11 was admitted to the facility on [DATE], with diagnoses of Alzheimer's (progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks) and delirium (a sudden and severe change in how the brain works, leading to acute confusion and trouble focusing). …
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