F657 in Texas. Pick another state for the same tag.
Against expectation — 2025
Texas cites F657 less often than its own record predicts
Versus expected share0.59×
0.59 times the national share — cited less often here than elsewhere.
Share of Texas citations1.10%
Of every deficiency written in Texas in 2025, this is the portion that was F657.
Texas1.10%
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 Texas surveyors wrote
F657 findings written in Texas, 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, isolatedJune 11, 2024
Based on observation, interview, and record review the facility failed to review and revise the person-centered care planning for one (Resident #2) of eight residents reviewed for care plan revision in that:
1. Resident #2's care plan was not updated when he had a decline in health and did not have the strength to sit upright.
2. Resident #2 was placed into his wheelchair and left unattenededunattended after a decline in his health caused him unsteady trunk balance and support. He fell out of the wheelchair, hit his face, and was transferred to the emergency room .
An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 032:50 pm. …
Based on the interviews and record review, the facility failed to review and revise Resident Care Plans after each assessment for 1 of 3 Residents (Resident # 1) whose records were reviewed for care plan revision/timing,
The kardex of Resident # 1 was not updated to reflect the required extensive assistance with 2 persons for transfers via mechanical lift .
These deficient practices could affect any resident and contribute to the Residents not receiving the care and services they need. …
D · No harm, potential for more than minimal, isolatedSeptember 12, 2026
Based on interview and record review the facility failed to ensure comprehensive care plans were prepared by an interdisciplinary team, to the extent practicable, the participation of the resident and the resident's representative(s), and reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 3 of 8 (Residents #7, #12, and #69) residents reviewed for care plans in that: 1. Resident #7 did not have a care plan conference in her chart for his care needed at the facility.2. Resident #12 did not have a care plan conference in her chart for his care needed at the facility.3. Resident #69 did not have a care plan conference in her chart for his care needed at the facility. …
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