Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #1) of 14 residents, reviewed for care plans. The facility failed to address Resident #1's required off-loading of heels and repositioning every two hours, as these orders were not reflected in Resident #1's Comprehensive Care Plan. Resident #1 developed a Stage 4 Pressure Wound. On 03/25/2026 at 6:22 p.m. an Immediate Jeopardy (IJ) was identified. The IJ template was provided to the facility on [DATE] at 6:22 PM. …
F656 citations in Texas
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
Texas cites F656 more often than its own record predicts
1.67 times the share F656 takes of citations nationally.
Of every deficiency written in Texas 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 Texas surveyors wrote
F656 findings written in Texas, 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 observations, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included describing the services to be furnished to attain or maintain measurable objectives to meet the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 7 residents reviewed for care plans. The facility failed to follow Resident #1's care plan to have staff near him during meals to ensure he did not take other residents' food when resident #1 choked and vomited on 05/07/26 resulting in staff performing the Heimlich.This failure could place residents at risk of not receiving individualized care and services to meet their needs.Findings included:Record review of Resident #1's Care… …
Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #20) reviewed for care plans.The facility failed to ensure Resident #20's comprehensive care plan was updated to reflect that resident had an indwelling urinary catheter.These failures could place residents at risk for not having their needs met.The findings were:A record review of Resident #20's Face Sheet, dated 09/10/2026, revealed the resident was a [AGE] year-old male, initially admitted to the facility… …
The short window
Recent years
| Year | Share of Texas citations | vs expected |
|---|---|---|
| 2023 | 5.60% | 1.56× |
| 2024 | 5.24% | 1.54× |
| 2025 | 5.76% | 1.67× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Texas surveyors cite →
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