F658 in North Dakota. Pick another state for the same tag.
Against expectation — 2025
North Dakota cites F658 more often than its own record predicts
Versus expected share4.34×
4.34 times the share F658 takes of citations nationally.
Share of North Dakota citations7.73%
Of every deficiency written in North Dakota in 2025, this is the portion that was F658.
North Dakota7.73%
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 Dakota surveyors wrote
F658 findings written in North Dakota, 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, isolatedFebruary 1, 2022
Based on information provided by the complainant, record review, and staff interview, the facility failed to ensure professional standards of practice 1 of 1 closed record (Resident #1) with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .
Findings Include:
Information provided by the complainant indicated the facility failed to complete hemoglobin blood testing weekly as ordered by the physician
Review of Resident #1's medical record occurred on 02/01/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . …
D · No harm, potential for more than minimal, isolatedJanuary 7, 2026
Based on observation, review of facility policy, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 2 residents (Resident #40) observed for insulin preparation and administration. Failure to properly prepare and prime an insulin pen may result in contamination of the pen and administration of an inaccurate dose of insulin.Findings include:Review of the facility policy titled Medicine: Insulin Administration, Insulin Pens, Insulin Pumps occurred on 01/07/26. This policy, revised 10/31/25, stated, . Insulin Pen. 7. Wipe the tip of the pen where the needle will attach with an alcohol swab or cotton ball moistened with alcohol . 9. Turn the dosage knob to '2' units to prime the pen. 10. …
C · No harm, potential for minimal, widespreadMay 23, 2018
Based on observation, review of facility policy, and staff interview, the facility failed to follow professional standards of practice related to priming insulin pens during 3 of 3 observations of insulin administration, (05/22/18 and 05/23/18). Failure to remove the needle shield prior to priming an insulin pen may result in a resident receiving an inaccurate amount of insulin.
Findings include:
Review of the facility policy titled Insulin Pen occurred on 05/23/18. This policy, dated 02/01/18, stated, . With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until one drop appears.
- Observation on 05/22/18 at 8:50 a.m. showed a nurse (#5) prepared an insulin pen for injection. …
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