Based on interview, record review and observation, the facility failed to ensure a resident's Comprehensive Care Plan was updated to include the resident's behavior of parking the wheelchair in the middle of a fall mat for 1 of 20 sampled residents (Resident #91). This deficient practice had the potential to result in an increased risk for falls, injury, or skin tears. Findings include:Resident #91Resident #91 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified dementia, fracture neck left femur, and difficulty in walking.On 08/11/2026 at 8:40 AM, Resident #91 was observed asleep in bed with bilateral fall mats. …
F657 citations in Nevada
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
Nevada cites F657 less often than its own record predicts
0.96 times the national share — cited less often here than elsewhere.
Of every deficiency written in Nevada 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 Nevada surveyors wrote
F657 findings written in Nevada, 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 Nevada citations | vs expected |
|---|---|---|
| 2023 | 1.48% | 0.69× |
| 2024 | 2.43% | 1.27× |
| 2025 | 1.80% | 0.96× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Nevada surveyors cite →
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