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F657: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals

F657 is one of the federal requirements every Medicare and Medicaid certified nursing home must meet. CMS describes it as: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. It sits in CMS's resident assessment and care planning category.

8,500citations in the CMS files
6,003homes cited at least once
1,671in the 12 months to September 2026
0.7%rated actual harm or immediate jeopardy

CMS Health Deficiencies file, data as of September 1, 2026. The files hold each home's last three standard inspections and three years of complaint visits.

How seriously inspectors rate it

Every citation gets a letter for how much harm inspectors found and how many residents it touched (how to read the letters). 23.1% of F657 citations came from a complaint visit rather than a routine inspection.

  • Immediate jeopardy (J, K, L)20 (0.2%)
  • Actual harm (G, H, I)40 (0.5%)
  • Potential for more than minimal harm (D, E, F)8,343 (98.2%)
  • Potential for minimal harm (A, B, C)97 (1.1%)

By letter: B 90, C 7, D 6,705, E 1,605, F 33, G 37, H 3, J 18, K 2.

What inspectors wrote

Three recent F657 citations from different states, quoted from the inspectors' statements of deficiencies (CMS form 2567). Names are removed by CMS.

Inspectors wrote, August 13, 2026, scope and severity DBased on interview and document review, the facility failed to ensure quarterly care conferences were provided or offered for 1 of 1 resident (R61) reviewed for care planning.

Good Samaritan Society - Maplewood, Saint Paul, MN

Inspectors wrote, August 5, 2026, scope and severity DBased on interview and record review, the facility failed to ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 18 residents (Resident #2) reviewed for comprehensive resident centered care plans. The facility failed to ensure Resident #2's comprehensive care plan was reviewed and revised with having PASRR positive status for mental illness. This failure could place residents at risk of not receiving the care and services to meet their needs. [...]

Spindletop Hill Nursing and Rehabilitation Center, Beaumont, TX

Inspectors wrote, August 5, 2026, scope and severity DBased on record review, observation, and interviews, the facility failed to update the plan of care for Resident (R) 36 when the resident began using insulin and required blood sugar monitoring.

North Point Skilled Nursing Center, Paola, KS

Most recent F657 citations at the harm or jeopardy level

Newest first, the latest 40 in the current files. Each home's page shows the citation in full context, with its correction status.

InspectionHomeTownLetterVisit
June 11, 2026Gettysburg CenterGettysburg, PA GComplaint
May 27, 2026Pioneer Trace Group LLCFlemingsburg, KY JComplaint
May 13, 2026Noxubee County Nursing HomeMacon, MS JComplaint
April 1, 2026Bel Aire CenterNewport, VT GComplaint
December 16, 2025Center for Living & RehabilitationBennington, VT GComplaint
September 16, 2025Yazoo City Rehabilitation and Healthcare CenterYazoo City, MS GComplaint
August 17, 2025Fountainview Ctr for AlzheimerAtlanta, GA JComplaint
June 12, 2025Franciscan Post-Acute Care CenterMerced, CA GComplaint
May 15, 2025Trenton Gardens Rehabilitation and Nursing CenterTrenton, NJ JComplaint
May 14, 2025Sunrise Post AcuteBanning, CA GComplaint
May 8, 2025La Vida Serena Nursing and RehabilitationDel Rio, TX GComplaint
April 11, 2025Brookside Nursing CenterMadill, OK JComplaint
April 4, 2025Hillcrest Manor Nursing CenterBlackwell, OK GStandard
April 2, 2025Lawrence Co Nursing CenterMonticello, MS GStandard
March 17, 2025Community Health Care of GoreGore, OK GStandard
March 15, 2025Carmel ManorFort Thomas, KY GComplaint
February 3, 2025Parkway Health & Rehab LLCCanton, MS GComplaint
November 22, 2024Bourbon Heights Nursing HomeParis, KY GStandard
November 21, 2024Grand Manor Nursing & Rehabilitation CenterBronx, NY GComplaint
November 21, 2024The Laurels of FultonPerrinton, MI GStandard
September 30, 2024Barbourville Health and Rehabilitation CenterBarbourville, KY HComplaint
June 14, 2024Liberty Care & Rehabilitation CenterLiberty, KY GComplaint
May 31, 2024Ruleville Community Care CenterRuleville, MS JComplaint
April 16, 2024Complete Care at Prospect Heights LLCHackensack, NJ GComplaint
April 5, 2024Yazoo City Rehabilitation and Healthcare CenterYazoo City, MS JComplaint
February 28, 2024The Manor of Farmington HillsFarmington Hills, MI GComplaint
February 19, 2024Avir at Arden WoodHouston, TX KComplaint
January 31, 2024Shenandoah Valley Health and RehabBuena Vista, VA GComplaint
January 31, 2024West Chicago Living and Rehab CenterWest Chicago, IL GComplaint
January 23, 2024Klondike Nursing and Rehabilitation CenterLouisville, KY GComplaint
January 11, 2024Harrison Nursing and Rehabilitation CenterCynthiana, KY GStandard
December 5, 2023Pine Forest Health and RehabilitationJackson, MS JComplaint
November 29, 2023Pikes Peak Post AcuteColorado Springs, CO GComplaint
October 14, 2023Mills Nursing & RehabilitationMayfield, KY JComplaint
October 11, 2023Ascension Living Alexian Village TennesseeSignal Mountain, TN JComplaint
October 5, 2023Laughlin Health Care CenterGreeneville, TN GComplaint
September 29, 2023Henson Park Health & RehabilitationDanville, KY JComplaint
September 22, 2023Diversicare of Oak RidgeOak Ridge, TN JComplaint
September 18, 2023Hopkins CenterWyncote, PA GComplaint
July 27, 2023Edgewood Health & RehabilitationByram, MS GStandard

Most recent F657 citations

InspectionHomeTownLetter
August 14, 2026Maple Springs of PalmerPalmer, AK D
August 13, 2026Good Samaritan Society - MaplewoodSaint Paul, MN D
August 5, 2026Spindletop Hill Nursing and Rehabilitation CenterBeaumont, TX D
August 5, 2026North Point Skilled Nursing CenterPaola, KS D
August 5, 2026Mini-Cassia Care CenterBurley, ID D
August 3, 2026Wauneta Care and Therapy CenterWauneta, NE E
July 31, 2026Heritage ManorChisholm, MN E
July 31, 2026South Coast Post AcuteSanta Ana, CA D
July 31, 2026Vernon Healthcare CenterLos Angeles, CA D
July 30, 2026Williamsburg Village Healthcare CampusDesoto, TX D
July 30, 2026Mountains Community Hosp Dp/SNFLake Arrowhead, CA D
July 30, 2026Sage Creek Post-AcuteLas Vegas, NV D
July 30, 2026Kittson HealthcareHallock, MN D
July 30, 2026Ocean Grove Post AcuteMillsboro, DE D
July 30, 2026Tempe Post AcuteTempe, AZ D
July 29, 2026Magnolia Place Health CareLiberty, TX E
July 29, 2026New Orange HillsOrange, CA D
July 29, 2026Morgantown Healthcare CenterMorgantown, WV D
July 29, 2026Hopkins Restorative Care CenterHopkins, MN D
July 28, 2026Mission Valley Nursing and Transitional CareMission, TX D
July 28, 2026Pheasant Ridge Nursing and RehabilitationRoanoke, VA D
July 28, 2026Countryside Nursing & Rehab CtrDolton, IL D
July 28, 2026Kit Carson Nursing & Rehabilitation CenterJackson, CA D
July 27, 2026Texoma Healthcare CenterSherman, TX D
July 27, 2026Suburban Healthcare and RehabilitationNorth Randall, OH D

F657 citations by state

Counts depend on how many homes a state has and how often its inspectors visit, so a larger number is not by itself a worse record.

StateCitations
California901
Ohio581
Texas455
Pennsylvania418
Virginia397
Maryland392
New York349
Kansas285
Indiana273
Michigan272
Missouri254
Iowa240
Illinois238
Washington231
Oklahoma226
Connecticut190
West Virginia180
Minnesota176
Florida174
Tennessee164
New Mexico145
New Jersey140
North Carolina129
Wisconsin121
Massachusetts119
Kentucky104
Georgia96
Maine94
Louisiana93
Arkansas89
Oregon88
Montana87
Idaho86
Nebraska68
South Dakota68
North Dakota64
Hawaii59
Delaware57
Mississippi48
Nevada46
Arizona45
South Carolina45
District of Columbia43
Vermont38
Colorado32
Alabama24
Alaska19
New Hampshire17
Rhode Island17
Utah12
Wyoming8
Puerto Rico2
Guam1

By inspection year: 2017 2, 2018 54, 2019 357, 2020 106, 2021 271, 2022 622, 2023 1,537, 2024 2,317, 2025 2,025, 2026 1,209.

Common questions

What is F657 in a nursing home inspection?
F657 is the federal requirement to "develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals". CMS files it under resident assessment and care planning. A home cited under F657 did not meet that requirement at the inspection.
How often is F657 cited?
The CMS files as of September 1, 2026 list 8,500 F657 citations at 6,003 nursing homes, 1,671 of them in the 12 months to that date. 0.7% were rated as actual harm or immediate jeopardy.
Is a F657 citation serious?
It depends on the letter. Most F657 citations (98.2%) were rated as potential for more than minimal harm, D to F. 20 were immediate jeopardy, the most serious level.

The interpretive guidance inspectors use for each F-tag is CMS's State Operations Manual, Appendix PP. NursingHomeClear reports the citations as CMS records them and is not affiliated with CMS. All F-tags · Methodology

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