F657 in New York. Pick another state for the same tag.
Against expectation — 2025
New York cites F657 more often than its own record predicts
Versus expected share1.25×
1.25 times the share F657 takes of citations nationally.
Share of New York citations2.34%
Of every deficiency written in New York in 2025, this is the portion that was F657.
New York2.34%
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 New York surveyors wrote
F657 findings written in New York, 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.
G · Actual harm, isolatedNovember 21, 2024
Based on record review, interviews, and observations conducted during the Recertification and Complaint (NY00350179) Survey from 11/13/2024 to 11/21/2024 the facility did not ensure that comprehensive care plans were reviewed and revised periodically and after each assessment including both the comprehensive and quarterly review assessments. This was evident for 3 (Resident #84, #118, and #151) of 7 residents reviewed for Catheter Care and Abuse out of 38 total sampled residents. Specifically, 1.) Resident #84's care plan for indwelling catheter/external urinary appliance was not reviewed and revised after the Resident returned from an emergency room visit due to urinary retention and pain at the urinary catheter insertion site. …
D · No harm, potential for more than minimal, isolatedJuly 23, 2026
Based on record review and interviews conducted during a survey, the facility failed to ensure Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after each assessment based on changing goals, preferences, and needs of the resident and in response to current interventions for two (Resident #'s 103 and 110) of 29 reviewed. Specifically, (a.) Resident #103's Comprehensive Care Plan for Falls was not reviewed or revised after they sustained a fall on 05/28/2026; and (b.) Resident #118's Comprehensive Care Plan for Advanced Directives was not revised after their code status changed. …
B · No harm, potential for minimal, patternApril 18, 2019
Based on record review and interview conducted during the recertification survey, the facility did not ensure that 1 of 6 residents (#62) was consistently invited to care plan meetings. Specifically, Resident # 62 stated during an interview that she attended one care plan meeting soon after admission but has not been invited to any further care plan meetings.
Review of the Comprehensive Care Plan (CCP) Policy dated 02/19/2019 revealed that to ensure resident and family participation in the interdisciplinary treatment plan, residents (as they are able to) and families are invited to attend during an initial, annual or significant change CCP meetings.
The findings are:
Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. …
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