F656 in West Virginia. Pick another state for the same tag.
Against expectation — 2025
West Virginia cites F656 more often than its own record predicts
Versus expected share1.34×
1.34 times the share F656 takes of citations nationally.
Share of West Virginia citations4.63%
Of every deficiency written in West Virginia in 2025, this is the portion that was F656.
West Virginia4.63%
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 West Virginia surveyors wrote
F656 findings written in West Virginia, 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.
G · Actual harm, isolatedMay 28, 2024
Based on record review, and staff interview, the facility failed to ensure one (1) of three (3) residents had a person-centered comprehensive care plan implemented to meet his/her other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. Failure to implement Resident #72's care plan resulted in her sustaining a burn to her abdomen which required physician intervention. Resident #72 sustained actual harm due to the facility's failure to implement her care plan. Resident identifiers: #27. Facility census: 135.
Findings included:
a) Resident #27
Review of facility documentation during a Facility Reported Incident (FRI) investigation showed a reportable dated 10/30/23. …
E · No harm, potential for more than minimal, patternAugust 20, 2026
Based on staff interview, record review, and resident observation, the facility failed to develop/implement a comprehensive person-centered care plan related to falls and correct age. This is true for Resident's #5, #12, #61. Facility Census 112. Findings included:
a) Resident #61
Review of resident's care plan on pages 24, 25 and 26 revealed the following details:
Focus- Resident is at risk for skin breakdown related to Advanced age (greater than 75 years), decreased activity, frail fragile skin, impaired cognition, impaired sensation, incontinence, informed refusal to aspects of care, limited mobility, moisture/excessive perspiration, nutritional concerns, poor safety awareness, shear/friction risks, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, Hypertension, and Transient… …
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