Based on interview, record review, review of facility's policies, and review of the Kentucky Board of Nursing's (KBN), Advisory Opinion Statements (AOS), review of the American Nurse's Association, Nursing Scope and Standards of Practice 3rd Edition, and review of the American Heart Association Journal, Ethical Issues Around Out of Hospital Resuscitation, Withholding Cardiopulmonary Resuscitation (CPR) at the Start versus Withdrawing CPR at the End, it was determined the facility failed to have an effective system to ensure services provided met professional standards of quality for one (1) of eight (8) sampled residents (Resident #1). …
F658 citations in Kentucky
Professional standards of care · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Kentucky cites F658 less often than its own record predicts
0.63 times the national share — cited less often here than elsewhere.
Of every deficiency written in Kentucky in 2025, this is the portion that was F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Kentucky surveyors wrote
F658 findings written in Kentucky, 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.
Based on interview, record review, facility policy review, facility Event Report review, and Hospital Record review, it was determined the facility failed to ensure services provided or arranged by the facility met professional standards of quality for one (1) of three (3) sampled residents, (Resident #1). On 04/17/2020, Licensed Practical Nurse (LPN) #1 failed to obtain vital signs, and assess for pain and injury per facility care standards after Resident #1 was found on the floor. In addition, licensed staff failed to assess the resident each shift on 04/18/2020 and 04/19/2020, per facility care standards to determine the resident's status after the incident. …
Based on interview, record review, and review of the facility's documentation and policy, the facility failed to ensure professional standards of nursing practice were maintained regarding the storage, tracking, and reconciliation of scheduled controlled substances for 1 of 1 residents sampled for narcotic medication out of the total sample of 10 (Resident (R)43). The findings include: Review of the facility's policy titled, Medication Administration Standards of Practice, last revised 03/2026, revealed the policy did not specifically address new narcotic medication security after delivery from the pharmacy. Review of the admission Face Sheet for R43 revealed the facility admitted the resident on 07/07/2026. …
The short window
Recent years
| Year | Share of Kentucky citations | vs expected |
|---|---|---|
| 2023 | 0.62% | 0.39× |
| 2024 | 1.05% | 0.64× |
| 2025 | 1.12% | 0.63× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Kentucky surveyors cite →
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