F659: Provide care by qualified persons according to each resident's written plan of care
F659 is one of the federal requirements every Medicare and Medicaid certified nursing home must meet. CMS describes it as: Provide care by qualified persons according to each resident's written plan of care.
It sits in CMS's resident assessment and care planning category.
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). 42.5% of F659 citations came from a complaint visit rather than a routine inspection.
By letter: D 117, E 26, F 6, G 1, J 2, K 1.
What inspectors wrote
Three recent F659 citations from different states, quoted from the inspectors' statements of deficiencies (CMS form 2567). Names are removed by CMS.
Inspectors wrote, July 28, 2026, scope and severity DBased on interview and record review, the facility failed to have services provided by qualified persons in accordance with each resident's written plan of care for 1 of 1 resident (Resident #26) reviewed for care plan in that: CNA D administered liquid cough medication to Resident #26 on 7/23/26, which was not in her scope of practice. This failure could place residents who received medication at risk for improper care.
Weslaco Nursing and Rehabilitation Center, Weslaco, TX
Inspectors wrote, June 29, 2026, scope and severity DBased on record review and interviews, the facility failed to ensure the services provided or arranged by the facility were provided by qualified persons for three of three licensed nurses reviewed (Licensed Practical Nurses #5, #11 and #12) reviewed. Specifically, Licensed Practical Nurses #5, #11 and #12 performed cardiopulmonary resuscitation on Resident #1 without having valid cardiopulmonary resuscitation certification.
Charles T Sitrin Health Care Center Inc, New Hartford, NY
Inspectors wrote, April 22, 2026, scope and severity DBased on observation, interview, and record review, the facility did not ensure unlicensed staff would not administer medications to 1 resident (R27) for 5 residents reviewed for medication administration in a sample of 23 residents. Certified Nursing Assistant (CNA) D was observed by Surveyor applying a Lidocaine external patch 4% to R27's back.
Friendly Village Nursing and Rehab Center, Rhinelander, WI
Most recent F659 citations at the harm or jeopardy level
Newest first, all 4 in the current files. Each home's page shows the citation in full context, with its correction status.
| Inspection | Home | Town | Letter | Visit |
|---|---|---|---|---|
| April 13, 2026 | Allure of Pinecrest | Mount Morris, IL | G | Complaint |
| November 20, 2025 | Bria of Woodriver | Wood River, IL | J | Complaint |
| October 3, 2025 | Bria of Woodriver | Wood River, IL | K | Complaint |
| May 31, 2024 | Winnie L Nursing & Rehabilitation | Cameron, TX | J | Complaint |
Most recent F659 citations
F659 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.
By inspection year: 2018 2, 2019 14, 2020 1, 2021 3, 2022 3, 2023 26, 2024 36, 2025 42, 2026 26.
Common questions
- What is F659 in a nursing home inspection?
- F659 is the federal requirement to "provide care by qualified persons according to each resident's written plan of care". CMS files it under resident assessment and care planning. A home cited under F659 did not meet that requirement at the inspection.
- How often is F659 cited?
- The CMS files as of September 1, 2026 list 153 F659 citations at 146 nursing homes, 41 of them in the 12 months to that date. 2.6% were rated as actual harm or immediate jeopardy.
- Is a F659 citation serious?
- It depends on the letter. Most F659 citations (97.4%) were rated as potential for more than minimal harm, D to F. 3 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