of F657 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20252,025
Every F657 citation surveyors wrote nationally that year.
Facilities cited1,934
Distinct nursing homes with at least one F657 finding.
The harm level
How severely F657 is cited
0.7% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J200.2%
K20.0%
L—
Actual harm
G410.5%
H30.0%
I—
No harm, potential for more than minimal
D7,06378.7%
E1,71419.1%
F340.4%
No harm, potential for minimal
A—
B961.1%
C70.1%
Every recorded F657 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F657 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedMay 27, 2026
Based on interview, record review, review of the facility's investigation, and review of the facility's policy, the facility failed to ensure residents' care plans were revised to include interventions needed to provide person-centered care related to supervision and monitoring to ensure safety for 1 of 28 sampled residents, Resident (R) 5.Interviews with staff revealed that on 05/02/2026 at approximately 5:55 PM, staff observed the resident exiting the facility and they were able to intervene and return the resident back to the facility. However, the facility failed to revise the resident's care plan to include interventions that would increase the resident's supervision and/or monitoring. …
Based on facility policy review, clinical record reviews, review of select facility documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to revise a resident's care plan to provide adequate supervision with eating for one of four residents reviewed (Resident 4), which resulted in actual harm as evidenced by Resident 4 choking and suffering death.Findings include: Review of facility policy titled OPS416 Person-Centered Care Plan, dated September 15, 2025, revealed, in part, 6. …
D · No harm, potential for more than minimal, isolatedSeptember 17, 2026
Based on observation, interview, and document review the facility failed to ensure the care plan was updated timely and accurately and failed to monitor effectiveness of interventions and modify the care plan as needed for 1 of 1 resident (R151) reviewed for falls.Findings include:R151's significant change in status minimum data set (MDS) dated [DATE], indicated R151 had impaired cognitive status, required assist from staff for transfers, and had a history of multiple falls. R151's diagnoses included osteoarthritis, weakness, history of falling with fractures, generalized anxiety disorder, major depressive disorder, and age-related physical debility.R151's care plan dated 8/25/26, indicated R151 was at risk for and had a history of falling. …
B · No harm, potential for minimal, patternMay 14, 2026
Based on record review and interview the facility failed to ensure the comprehensive care plans for 2 of 22 sampled residents were developed by the interdisciplinary team (IDT), including the resident and resident representative, as evidenced by the failure to ensure care plan meetings for Resident #9 and Resident #42.The findings included:1. Record review revealed Resident #9 was admitted to the facility on [DATE]. Review of the current Annual Minimum Data Set (MDS) assessment had an Assessment Reference Date (ARD) of 03/31/26. …
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Cited in the same inspection, not caused by one another.
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