F657 in Pennsylvania. Pick another state for the same tag.
Against expectation — 2025
Pennsylvania cites F657 more often than its own record predicts
Versus expected share1.09×
1.09 times the share F657 takes of citations nationally.
Share of Pennsylvania citations2.04%
Of every deficiency written in Pennsylvania in 2025, this is the portion that was F657.
Pennsylvania2.04%
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 Pennsylvania surveyors wrote
F657 findings written in Pennsylvania, 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, isolatedJune 11, 2026
Based on facility policy review, clinical record reviews, review of select facility documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to revise a resident's care plan to provide adequate supervision with eating for one of four residents reviewed (Resident 4), which resulted in actual harm as evidenced by Resident 4 choking and suffering death.Findings include: Review of facility policy titled OPS416 Person-Centered Care Plan, dated September 15, 2025, revealed, in part, 6. …
E · No harm, potential for more than minimal, patternSeptember 10, 2026
Based on policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 22 residents reviewed (Residents 2, 3, and 8).Findings Include:Review of facility policy, titled MDS Assessment Completion and Care Planning; reviewed January 2026, revealed, Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. …
C · No harm, potential for minimal, widespreadDecember 2, 2025
Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to revise/update care plans for two of eighteen residents to accurately reflect the current status of the resident (Resident R7 and R32). Finding include:Review of the facility policy Care Plans, Comprehensive Person-Centered dated 8/13/25, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Review of the clinical record indicated Resident R7 was admitted on [DATE], and readmitted on [DATE].Review of Resident R7s Minimum Data Set (MDS-a periodic assessment of care needs) dated 9/10/25, indicated diagnoses of… …
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