F658 in Georgia. Pick another state for the same tag.
Against expectation — 2025
Georgia cites F658 less often than its own record predicts
Versus expected share0.61×
0.61 times the national share — cited less often here than elsewhere.
Share of Georgia citations1.09%
Of every deficiency written in Georgia in 2025, this is the portion that was F658.
Georgia1.09%
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 Georgia surveyors wrote
F658 findings written in Georgia, 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, isolatedMarch 30, 2025
Based on interviews, record review, and review of the facility's policy titled Change in a Resident's Condition or Status, the facility failed to ensure the nursing staff used their clinical skills and judgement to identify and notify the resident's medical provider of the worsening of skin condition for one of three sampled residents (R) (R159). On [DATE] and [DATE], R159 had a change in condition when pedal pulses were unpalpable; however, nursing staff did not identify this as a change in condition, and the resident's medical provider was not notified. …
Based on observation, interviews, record review, and a review of the facility policies titled Admissions and Medication Orders, the facility failed to protect one of 33 sampled residents (R) (R4) with allergies. Harm was identified to have occurred on 9/24/2025 when R4 was administered Bactrim DS (an antibiotic medication) that was listed as a known allergy for the resident, resulting in an allergic reaction to the medication (flushing (feeling hot), redness, and rash).Findings included:A review of the facility's policy titled Admissions, reviewed and updated in October 2016, revealed that it is the intent of the facility for the charge nurse to record information, including but not limited to the following, in the designated place (nurses' notes, admission nurse assessment, etc) . …
D · No harm, potential for more than minimal, isolatedAugust 13, 2026
Based on observations, staff and resident interviews, record review, and review of the facility's policy titled, Medication Orders, the facility failed to transcribe a physician order following an approved psychoactive medication gradual dose reduction (GDR) recommendation for one of five residents (R) (R16) reviewed for unnecessary medications. This deficient practice had the potential to contribute unnecessary medication side effects and chemical restraint for R16.Findings include:Review of the facility policy titled, Medication Orders reviewed on February 14, 2024, documented in sections 4: .c: Enter the order on the medication order and receipt record. …
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