F658 in Indiana. Pick another state for the same tag.
Against expectation — 2025
Indiana cites F658 less often than its own record predicts
Versus expected share0.46×
0.46 times the national share — cited less often here than elsewhere.
Share of Indiana citations0.81%
Of every deficiency written in Indiana in 2025, this is the portion that was F658.
Indiana0.81%
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 Indiana surveyors wrote
F658 findings written in Indiana, 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, isolatedSeptember 13, 2018
Based on interview, observation and record review, the facility failed to ensure a comprehensive assessment and care plan reflected a safe transfer process for 1 of 4 residents reviewed for transfers. This deficiency resulted in 1 resident sustaining a tibia/fibula fracture on her right leg during a transfer. (Resident D)
Finding includes:
On 9/12/18, during the initial tour, Resident D was observed in the activity room. She was sitting in a Broda chair with a green cast to her right foot/ankle. Her toes were exposed and had no discolorization and were not observed to be swollen.
On 9/12/18 at 11:16 A.M., a review of the clinical record for Resident D was conducted. …
D · No harm, potential for more than minimal, isolatedAugust 13, 2026
Based on interview, observation, and record review, the facility failed to ensure professional standards for administering medications ordered by a physician were met for 1 of 3 residents reviewed for medication administration. (Resident B) Resident B was not administered physician ordered medication, the facility documented the medication as administered when it was not, and did not notify the physician the resident had not received the medication for consecutive days. Findings include: On 8/12/26 at 10:21 A.M., Resident B indicated he had not received eye drops in several days. On 8/12/26 at 10:37 A.M., Nurse 6 indicated Resident B had been out of eyedrops for several days, showed that there were none in the medication cart, and provided a reorder for the eyedrops on 8/9/26. …
B · No harm, potential for minimal, patternJanuary 15, 2019
Based on observation, interview and record review, the facility failed to ensure Certified Nurse Aides (CNA's) were knowledgeable of gait belt usage for 4 of 7 residents reviewed for assisted transfer. (Resident D, Resident P, Resident S and Resident Q)
Findings include:
During the initial tour, on 1/14/18 at 10:20 A.M., CNA (Certified Nurses Aide) 5 indicated some residents had gait belts in their rooms and others did not. She thought therapy would place them there. CNA 5 indicated if a resident was a one assist with transfers they should probably should use a gait belt. During the tour, day shift CNA's 2, 6, 7, 8, 5, 9 and 2 were observed not to have a gait belt on their person.
On 1/14/19 at from 3:00 P.M. …
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