F658 in Alabama. Pick another state for the same tag.
Against expectation — 2025
Alabama cites F658 more often than its own record predicts
Versus expected share1.67×
1.67 times the share F658 takes of citations nationally.
Share of Alabama citations2.99%
Of every deficiency written in Alabama in 2025, this is the portion that was F658.
Alabama2.99%
National1.78%
Share of all citations that were F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Alabama surveyors wrote
F658 findings written in Alabama, 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 5, 2025
Based on interviews, resident record review, and review of a facility policy titled, Medication Administration General Guidelines, and review of ALABAMA BOARD OF NURSING ADMINISTRATIVE CODE CHAPTER 610-X-6 STANDARDS OF NURSING PRACTICE the facility failed to ensure licensed staff implemented physician orders and followed standards of practice when they documented administration of Resident Identifier (RI) #9's intravenous (IV) medications.
Specifically, on 05/14/2025 the facility submitted a plan to remove the immediacy of jeopardy that included . On 5/14/25, the DON [Director of Nursing (Former DON #2)] and/or designee reviewed Medication Administration Records for the last 60 days and no additional concerns were identified. …
Based on interviews, review of Resident Identifier (RI) #81's medical record, the facility's POSITION DESCRIPTION and the FUNDAMENTALS OF NURSING, the facility failed to ensure Employee Identifier (EI) #4, the Health Information Management Coordinator (HIMC) transcribed RI #81's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The failure to transcribe the order resulted in RI #81's suprapubic catheter not being changed as ordered by the physician for three months. On 5/22/2021, RI #81 was sent to the local hospital's emergency room after complaining of abdominal pain and sediment being noted in the suprapubic catheter tubing. …
D · No harm, potential for more than minimal, isolatedDecember 11, 2025
Based on observations, interviews, record review, and facility policy, the facility failed to follow professional standards of practice when a Licensed Practical (LPN) Nurse prepared a resident's medications, and then another nurse administered the medications to the resident. administered medications that he/she did not personally prepare Additionally, the LPN documented on the medication administration record (MAR) the administration of the medications even though the LPN was not the nurse who administered the medications. …
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