Based on staff interview and record review the facility failed to timely revise and implement a comprehensive, person-centered care plan for one (1) of eight (8) residents at risk for aspiration and choking risk. Resident #1. The facility's failure to revise the care plan and provide supervision on [DATE] at 11:20 AM, resulted in serious injury and death for Resident #1, who had a documented aspiration/choking risk. Resident #1 was not provided supervision while eating when staff served his lunch meal and stepped away from the table. Resident #1 began choking and required transfer to the emergency department where he was intubated and air lifted to another hospital for a higher level of care. Resident #1 expired after being taken off the ventilator on [DATE]. …
F657 citations in Mississippi
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
Mississippi cites F657 less often than its own record predicts
0.57 times the national share — cited less often here than elsewhere.
Of every deficiency written in Mississippi 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 Mississippi surveyors wrote
F657 findings written in Mississippi, 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, record review and facility policy review, the facility failed to update a care plan after a residents falls for one (1) of three (3) resident care plans reviewed. Resident #1 Findings Include A review of the facility policy titled, “Fall Prevention Program,” revealed “All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter…The resident's plan of care will be updated to reflect risk for falls and appropriate interventions… If a fall occurs… the plan of care will be updated to reflect interventions.” A record review of the “Care Plan Report” for Resident #1 revealed a focus of “The resident is at risk for falls related to Hemiplegia and hemiparesis following unspecified… …
Based on observation, facility policy review, record review and interviews, the facility failed to update the resident's care plan after a fall to prevent recurrence for one (1) of four (4) sampled residents. Resident #3.Findings Included: Record review of the facility policy, Falls Standard with a revision date of May 2026, revealed, POST FALL STANDARD.Revise/update intervention on the Plan of Care and included FALLS: DECISION TREE.Step 3 Has the resident just fallen? ->Step 4 Evaluate the factors associated with the fall. ->Step 5 Identify the resident's actual and potential complications of falls. -> Step 6 Develop a plan for managing falls and fall risks.Record review of the facility policy, COMPREHENSIVE CARE PLAN with a revision date of July 2026 revealed, . 3. …
The short window
Recent years
| Year | Share of Mississippi citations | vs expected |
|---|---|---|
| 2023 | 0.40% | 0.19× |
| 2024 | 1.01% | 0.53× |
| 2025 | 1.06% | 0.57× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Mississippi surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction