Based on clinical record reviews, observations, review of facility documentation, and interviews for one of three sampled residents (Resident #1) who was reviewed for a comprehensive plan of care, the facility failed to revise the resident's plan of care and implement a level of supervision to protect the resident when the resident consistently expressed a desire for discharge against the wishes of the conservator. The finding includes: Resident (R) #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R#1's clinical record identified Person #1 as R#1's conservator. A Resident Care Plan (RCP) dated [DATE] identified R#1's desire to be discharged from the facility to community-based living. …
F657 citations in Connecticut
Care plan timing and revision · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Connecticut cites F657 more often than its own record predicts
1.87 times the share F657 takes of citations nationally.
Of every deficiency written in Connecticut in 2025, this is the portion that was F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Connecticut surveyors wrote
F657 findings written in Connecticut, 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 review of clinical records, review of facility policy/procedures and interviews for one sampled resident (Resident #5) with a significant change MDS assessment, the facility failed to ensure that the comprehensive care plan was revised to reflect that the resident was not receiving intravenous medications and for two of twelve sampled residents (Residents #91 and #105) reviewed facility acquired pressure injuries, the facility failed to ensure that the care plan contained measures to prevent the occurrence or reoccurrence of a pressure injury. …
Based on interviews, review of the clinical record, and facility policy for the only sampled resident (Resident #25) reviewed for care planning, the facility failed to conduct and invite Resident #25 to care plan meetings. The findings include: Resident #25's diagnoses included major depressive disorder and mild cognitive impairment. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 was moderately cognitively impaired.The Resident Care Plan (RCP) in effect from 8/7/25 to 4/27/26 identified Resident #25 was admitted to the facility for short term rehabilitation. …
The short window
Recent years
| Year | Share of Connecticut citations | vs expected |
|---|---|---|
| 2023 | 2.76% | 1.29× |
| 2024 | 2.92% | 1.53× |
| 2025 | 3.49% | 1.87× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Connecticut surveyors cite →
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