F657 in Georgia. Pick another state for the same tag.
Against expectation — 2025
Georgia cites F657 less often than its own record predicts
Versus expected share0.95×
0.95 times the national share — cited less often here than elsewhere.
Share of Georgia citations1.77%
Of every deficiency written in Georgia in 2025, this is the portion that was F657.
Georgia1.77%
National1.87%
Share of all citations that were F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Georgia surveyors wrote
F657 findings written in Georgia, 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.
J · Immediate jeopardy, isolatedAugust 17, 2025
Based on interview, record review, and review of the facility policy titled, Comprehensive Care Plans, the facility failed to revise the resident's care plan with nonpharmacological interventions for inappropriate sexual behavior for one of nine sampled residents (Resident (R) 1). This failure led to multiple residents on the South Pavillion unit being victims of sexual abuse by R1. Cross Reference: F600 Free from Abuse and Neglect.The facility's failure to ensure R1's care plan was revised with interventions protecting residents from sexual abuse had caused or was likely to cause serious injury, harm, impairment, or death to a resident. An Immediate Jeopardy was identified on 8/15/2025 and was determined to exist on 6/20/2025. …
Based on observation, interviews, record reviews, and a review of the policy titled Care Plans - Comprehensive, the facility failed to revise the care plan to include actual skin impairment (bruising) for one resident (R) (R3), from a total sample of 11 residents.
Findings include:
The facility had a policy titled Care Plans - Comprehensive. The policy documented that assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change.
Review of the care plan revealed that R3 was at risk for impairment to skin integrity. …
D · No harm, potential for more than minimal, isolatedJune 7, 2026
Based on staff interviews, record review, and review of the facility policy titled Comprehensive Care Plans, the facility failed to revise the care plan for two of 32 sampled residents (R58 and R49) related to the residents' advance directive. This failure placed residents at risk of not having their end-of-life wishes honored.Findings included:
A review of the facility's policy titled Comprehensive Care Plan with a revision dated of [DATE] documented under the Policy stated it is the policy of the develop and implement a comprehensive person-center care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychological needs and all are identified in the resident's comprehensive… …
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