What CMS Requires: F656 and F657
Under 42 CFR §483.21, every nursing home must develop and implement a comprehensive, person-centered care plan for each resident within 48 hours of admission (interim) and within 7 days of completing the initial comprehensive MDS assessment (comprehensive).
Two F-tags govern care planning compliance:
| F-Tag | Requirement | Most Cited For |
|---|---|---|
| F656 | Develop a comprehensive, individualized care plan with measurable goals and specific services | Generic plans, missing disciplines, no measurable goals, plan doesn't match MDS findings |
| F657 | Review and revise the care plan after significant change, each assessment, and at least quarterly | Outdated plans, no revision after condition change, goals unchanged despite new diagnoses |
The care plan must be developed by the interdisciplinary team (IDT) — including at minimum a registered nurse, the attending physician, and qualified professionals in the relevant disciplines. The resident and their representative must be offered the opportunity to participate.
CMS expects the plan to be individualized. A plan that reads the same for 15 residents with dementia is not a person-centered care plan. Surveyors know the difference.
Most Common Care Plan Deficiencies
After reviewing thousands of F-tag deficiency citations, here are the patterns that keep showing up under F656 and F657:
1. Goals That Aren't Actually Goals
"Resident will maintain current functional status" is not a measurable goal. Surveyors want to see a baseline ("ambulates 50 feet with rolling walker and standby assist"), a target ("resident will ambulate to dining room independently by 90-day review"), and a timeframe. If there's no way to measure whether the goal was met, you haven't written a goal.
2. Plans That Don't Match the MDS
The MDS is a clinical snapshot. If Section G shows the resident requires extensive assist for bed mobility and the care plan says "encourage independence with ADLs," that's a contradiction surveyors will catch. Care plans must track MDS Section G, I, J, K findings — especially after quarterly and annual assessments.
Citation pattern: Surveyors pull the care plan, pull the MDS, and compare them side by side. Any mismatch between coded status and care plan interventions is a finding. This is one of the fastest ways to pick up a deficiency.
3. No Revision After Significant Change
F657 is specifically about failure to revise. A resident falls and breaks a hip. Nursing notes document the fall, the ER visit, the return with a new hip fracture. But the care plan still says "fall risk: low" with a plan for non-slip socks. That's a deficiency. Any significant change in condition — new diagnosis, hospitalization, major functional decline, new behavioral symptom — requires a care plan revision, not just a note.
4. Missing Disciplines
If a resident is receiving physical therapy, dietary supplementation, and wound care, all three disciplines should be represented in the care plan. A plan that only has nursing entries when the resident is actively in therapy is incomplete. Surveyors will ask the PT what their goals are — and then look for those goals in the care plan.
5. Resident Goals Not Reflected
CMS expects the resident's own stated preferences and goals to be included. "Resident wants to return home to live with daughter" is a goal. The care plan should document it and show how the team is working toward it — or why it's not achievable. Ignoring it entirely is a problem.
Free: SNF State Survey Readiness Checklist
50-point pre-survey audit covering care planning, documentation, F-tag risk areas, and department readiness. Used by DONs to identify gaps before surveyors walk in.
What Surveyors Actually Do
Understanding surveyor methodology helps you self-audit. Surveyors don't just read the care plan in isolation. They triangulate:
- Care plan vs. MDS — do the coded levels match the plan's stated interventions?
- Care plan vs. nursing notes — does the documentation reflect the plan being followed?
- Care plan vs. direct observation — does what they see on the floor match what's written?
- Care plan vs. resident/family interview — does the resident know their care plan goals?
The last one surprises facilities. Surveyors may ask a resident: "What are you working on with therapy?" or "What's the plan for your diet?" If the resident has no idea, that suggests the care planning process isn't actually person-centered — it's a paper exercise.
Surveyors also review the IDT meeting minutes. They want to see who attended, what was discussed, and that the revision documented in the plan actually reflects the meeting. A meeting with no minutes, or minutes that don't match the care plan changes, is a gap.
Care Plan Documentation Checklist
Use this before every survey — or better yet, as part of your monthly mock survey process:
For each active resident, verify:
- Comprehensive care plan completed within 7 days of initial MDS assessment
- All active diagnoses and clinical conditions addressed
- Goals are measurable with specific baselines and timeframes
- Interventions are discipline-specific (not just "monitor and report")
- Care plan reflects current MDS Section G, I, J, K status
- Resident/representative preferences and goals documented
- All active disciplines represented (nursing, therapy, dietary, social services, activities)
- Last revision date documented and within required interval
- Revisions made after any hospitalization or significant change in condition
- IDT meeting attendance documented and matches care plan revision
High-Risk Residents to Prioritize
Not every care plan will be scrutinized equally. Surveyors focus their chart review on residents who have had recent hospitalizations, significant weight loss, new pressure injuries, falls, behavioral changes, or are on the facility's Quality Indicator watch list. Make sure those charts are airtight.
Fixing the Process, Not Just the Plan
Most facilities with recurring care plan deficiencies have a process problem, not a knowledge problem. The DON knows what a good care plan looks like. The issue is a workflow that doesn't reliably produce them.
Build Triggers Into the EMR Workflow
Every significant change event — fall, hospitalization, new diagnosis, therapy discharge — should automatically trigger a care plan review task in your EMR. If the review requires a manual reminder, it will get missed. The process needs to be unavoidable, not aspirational.
Separate the Review Meeting from the Documentation
The care plan meeting is where decisions get made. The documentation is how those decisions get recorded. Many facilities have the meeting but don't update the actual plan until days later — by which time details are fuzzy and the notes don't match. Document the plan changes during or immediately after the meeting.
Audit Before Surveyors Do
Monthly care plan audits — pulling 5–10 charts and checking the 10-point checklist above — will surface most deficiencies before survey. If you're finding the same issues repeatedly (goals not measurable, plans not revised after hospitalizations), that's a systems problem to address in your QAPI plan, not just an in-service topic.
Staff training on care planning documentation belongs in orientation and annually as CMS-required training. If your licensed staff can't write a measurable goal or identify when a revision is required, that gap will show up on survey.
Track Staff Training Completions Automatically
FacilityKit's Staff Training Tracker keeps your care planning in-services, annual certifications, and competency checks current — with automated alerts before anything expires.
Frequently Asked Questions
What is F656 in a nursing home survey?
F656 covers the requirement to develop and implement a comprehensive, person-centered care plan for each resident. Surveyors cite F656 when the care plan is missing required elements, is not individualized, or does not reflect the resident's current needs and goals.
How often must a nursing home update a resident's care plan?
Care plans must be reviewed and revised after each comprehensive MDS assessment (typically quarterly and annually), after a significant change in condition, and whenever the resident's needs or goals change. CMS expects revisions to be timely — not just at scheduled review intervals.
What is the difference between F656 and F657?
F656 covers the initial development of the comprehensive care plan. F657 covers the requirement to review and revise the care plan when conditions change. Facilities often get cited under both when care plans are outdated or don't reflect current interventions.
Who must participate in a nursing home care plan meeting?
The interdisciplinary team (IDT) — including nursing, dietary, therapy, social services, and activities — must participate. The resident and their family or representative must be offered the opportunity to participate. Physician involvement is expected for complex clinical issues.
What documentation do surveyors review for care plan compliance?
Surveyors cross-reference the care plan against MDS assessments, nursing notes, physician orders, therapy evaluations, and direct observation. They look for whether interventions in the care plan are actually being carried out and whether the plan reflects current resident status.