F658 in North Carolina. Pick another state for the same tag.
Against expectation — 2025
North Carolina cites F658 more often than its own record predicts
Versus expected share1.27×
1.27 times the share F658 takes of citations nationally.
Share of North Carolina citations2.26%
Of every deficiency written in North Carolina in 2025, this is the portion that was F658.
North Carolina2.26%
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 North Carolina surveyors wrote
F658 findings written in North Carolina, 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 5, 2018
Based on observation, record review, resident, and staff interviews, the facility failed to follow physician orders [REDACTED].#110) reviewed for wound care. The resident experienced pain during the removal of the incorrect dressing that was applied to a wound.
Findings included:
Resident #110 was admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED].
Review of Resident #110's most recent quarterly minimum data set ((MDS) dated [DATE] revealed she was cognitively intact and had some behavioral symptoms not directed toward others. The resident required extensive assistance of 1 staff with dressing, toileting, personal hygiene and bathing. …
D · No harm, potential for more than minimal, isolatedAugust 21, 2026
Based on staff interviews, Nurse Practitioner interview, Resident Representative interview and record review, the facility failed to enter a provider's verbal order in the medical record for a nicotine patch (adhesive skin patch that delivers a controlled dose of nicotine through the skin to help people quit smoking) for a resident who expressed a desire to quit smoking tobacco. This occurred for 1 of 3 residents reviewed for smoking (Resident #10). Findings included: Resident #10 was admitted to the facility on [DATE] with diagnoses that included hemiplegia affective left dominant side.Review of the smoking assessment completed by Unit Manger #2 on 6/19/26 indicated Resident #10 was assessed to be a safe smoker.Review of the most recent quarterly Minimum Data Set assessment dated [DATE]… …
B · No harm, potential for minimal, patternSeptember 1, 2023
Based on record reviews, observation, and staff interviews, the facility failed to clarify a consultation note and discontinue an order to flush an abscess drain (Resident #25). This was for 1 of 1 resident reviewed for well-being.
The findings included:
Resident #25 was originally admitted to the facility on [DATE]. He was recently readmitted from the hospital on 8/2/23 with a diagnosis of a liver abscess with a drain present.
A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 had severely impaired decision-making skills and was coded with surgical wounds.
A review of Resident #25's active physician orders included an order dated 8/9/23 to use 5 milliliters (ml) of sterile saline solution via irrigation twice a day for the abscess tube for six weeks. …
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