F657 in Tennessee. Pick another state for the same tag.
Against expectation — 2025
Tennessee cites F657 more often than its own record predicts
Versus expected share2.22×
2.22 times the share F657 takes of citations nationally.
Share of Tennessee citations4.14%
Of every deficiency written in Tennessee in 2025, this is the portion that was F657.
Tennessee4.14%
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 Tennessee surveyors wrote
F657 findings written in Tennessee, 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, isolatedOctober 11, 2023
Based on interview, record review, review of the Hospitalists Discharge Summary, and review of the facility's policy, the facility failed to revise the Comprehensive Care Plan with newly identified problem areas and with new interventions for one of 35 sampled residents (Resident (R) 7). On 07/30/23, R7 was transferred to the hospital after he was discovered entrapped between his mattress and a grab bar attached to his bed. When R7 was readmitted to the facility on [DATE], his care plan was not revised to include updated interventions related to his entrapment. Additionally, while being treated at the hospital for the entrapment incident, it was discovered that R7 had a fecal impaction. …
Based on facility policy review, medical record review, facility post fall investigation review, and interviews, the facility failed to revise the comprehensive care plan related to falls for 3 residents (Resident #14, #15, and #17) of 3 residents reviewed for falls which resulted in actual harm to Resident #14 when the resident fell and sustained a laceration to the left eye and required the area to have steri strips (wound closure tape) placed to close the wound, failed to revise the comprehensive care plan related to a wound for Resident #14 of 2 residents reviewed for wounds, failed to revise the comprehensive care plan related to a wander guard (a safety device used for high elopement risk) for 2 residents (Resident #15 and #17), failed to revise the comprehensive care plan for new… …
E · No harm, potential for more than minimal, patternAugust 7, 2026
Based on facility policy review, medical record review, observation, and interview, the facility failed to revise the care plans for 5 residents (Residents #9, #33, #74, #75, and #85) of 21 residents sampled and failed to conduct interdisciplinary team (IDT) care conferences including the resident and resident representatives for 2 residents (Residents #53, and #54) of 21 residents and resident representatives interviewed.
The findings include:
Review of the facility policy titled, Care Plan Revision guidelines, revised on 9/2025, revealed .resident care plans will .be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review .The IDT .will also review and revise a resident's comprehensive care plan as necessary, when a… …
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