Based on observations, interviews, record review and review of other facility records, it was determined that for two (R137 and R128) out of fifty-seven (57) residents reviewed for care plans, the facility failed to revise care plans for identified changes in care. Findings include:Cross Refer F677 1. R137's clinical record revealed: 7/12/25 – E137 was admitted to the facility. 7/16/26 – A review of an annual MDS assessment revealed R137 was dependent for personal hygiene. 7/21/26, 7/22/26 and 7/23/26 – Observations revealed R137 had visible facial hair growth to the upper lip, chin, cheeks and sideburns. 7/21/26 2:10 PM – R137's care plans were reviewed. …
F657 citations in Delaware
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
Delaware cites F657 more often than its own record predicts
1.82 times the share F657 takes of citations nationally.
Of every deficiency written in Delaware 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 Delaware surveyors wrote
F657 findings written in Delaware, 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.
The short window
Recent years
| Year | Share of Delaware citations | vs expected |
|---|---|---|
| 2023 | 3.70% | 1.73× |
| 2024 | 3.33% | 1.74× |
| 2025 | 3.40% | 1.82× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Delaware surveyors cite →
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