Based on interview and record review, the facility failed to monitor the effectiveness of interventions and revise a resident's comprehensive care plans for a resident with dementia and known behaviors including wandering, entering other resident rooms, physical aggression, inappropriate behaviors towards female residents, and exit seeking, for 1 of 1 residents (Resident #1) reviewed for an elopement out of 3 residents listed in the facility's Adverse Incident log. The resident was able to elope from the facility on April 11, 2020 and was found by police at a nearby shopping center. Upon return to the facility after an evaluation at the hospital, the resident was observed with swelling to the face and knuckles, abrasions, discoloration, and scratches. …
F657 citations in Florida
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
Florida cites F657 less often than its own record predicts
0.47 times the national share — cited less often here than elsewhere.
Of every deficiency written in Florida 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 Florida surveyors wrote
F657 findings written in Florida, 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 interview, and record review, the facility failed to review, revise, and ensure interventions were implemented for a person-centered care plan for falls to address supervision for 1 of 3 residents reviewed for accidents of a total sample of 39 residents, (#1). Findings: Resident #1, a [AGE] year-old female, was admitted to the facility initially on 1/04/21, with her most recent readmission on 4/12/23. Her diagnoses included, Multiple sclerosis, contracture of the left and right knees, history of falls, major depressive disorder, and cognitive communication deficit. …
Based on interview and record review, the facility failed to review and revise, based on changing goals, preferences and needs of the residents, the comprehensive care plans for 3 of 4 residents, Resident #1, #3, and #4, reviewed for ADL (Activities of Daily Living) care needs.Findings include:Review of Resident #1's MDS (Minimal Data Set) assessment dated [DATE] did not document a BIMS (Brief Inventory of Mantal Status) Score. She required partial to moderate assistance for eating and required substantial to maximal assistance or was dependent for all other self-care activities.Review of Resident #1's Care Plan read, Focus - The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) syncope, history of falls, dementia. Date Initiated 6/16/2026. …
The short window
Recent years
| Year | Share of Florida citations | vs expected |
|---|---|---|
| 2023 | 1.35% | 0.63× |
| 2024 | 1.57% | 0.82× |
| 2025 | 0.88% | 0.47× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Florida surveyors cite →
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