F658 in Colorado. Pick another state for the same tag.
Against expectation — 2025
Colorado cites F658 more often than its own record predicts
Versus expected share1.26×
1.26 times the share F658 takes of citations nationally.
Share of Colorado citations2.24%
Of every deficiency written in Colorado in 2025, this is the portion that was F658.
Colorado2.24%
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 Colorado surveyors wrote
F658 findings written in Colorado, 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.
G · Actual harm, isolatedJanuary 16, 2020
Based on observations, record review, and interviews, the facility failed to ensure seven (#35, #45, #[AGE], #9, #68, #38 and #61) of 45 sample residents received quality care in accordance with professional nursing standards of care.
The facility failed to ensure Resident #35 was assessed by a registered nurse (RN) after a fall with major injury. Additionally, the resident did not receive timely treatment after she fell and expressed pain and discomfort in her ankle. The resident did not get an x-ray ordered until over 24 hours after she fell . …
D · No harm, potential for more than minimal, isolatedJuly 21, 2026
Based on observations, record review and interviews, the facility failed to follow physician orders and appropriately administer medication for one (#64) of one resident out of 35 total sample residents. Specifically, the facility failed to follow the Resident #64's physician's order for the correct order of administering heparin (anticoagulant), saline flush and intravenous (IV) antibiotics.Findings include: I. Facility policy and procedure The Central Venous Catheter Flushing and Locking policy, revised March 2022, was received by regional clinical resource #1 on 7/21/26 at 6:42 p.m. …
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