F658 in Tennessee. Pick another state for the same tag.
Against expectation — 2025
Tennessee cites F658 less often than its own record predicts
Versus expected share0.13×
0.13 times the national share — cited less often here than elsewhere.
Share of Tennessee citations0.23%
Of every deficiency written in Tennessee in 2025, this is the portion that was F658.
Tennessee0.23%
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 Tennessee surveyors wrote
F658 findings written in Tennessee, 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.
L · Immediate jeopardy, widespreadOctober 11, 2023
Based on observation, interview, record review, and review of a facility document, the facility failed to ensure services were provided to meet acceptable professional standards for six out of six sampled residents (Resident (R) 4, R7, R8, R20, R21, and R22) reviewed for accidents, bowel monitoring, and supplemental oxygen therapy, out of a total sample of 35.
On 07/30/23, R7 was found entrapped between the grab bar and mattress and sustained multiple fractures to his ribs. The nurse on duty assigned to R7 failed to complete a thorough assessment of R7 and failed to accurately report the incident to the resident's physician. Additionally, the facility failed to ensure R7 received supplemental oxygen therapy per the physician orders. …
Based on medical record review, facility documentation review and interview, the facility failed to follow a care plan while caring for 1 (Resident #1) of 2 residents reviewed for following a comprehensive care plan.
This failure resulted in a fracture of the surgical neck (a [MEDICATION(S)] below the tubercles [rounded projection] of the greater and lesser tubercles of the humerus [large bone in upper arm]) and greater tuberosity causing Harm to Resident #1.
The findings include:
Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . …
D · No harm, potential for more than minimal, isolatedJuly 29, 2026
Based on the facility policy review, Lippincott Nursing Center website review, medical record review, and interviews, the facility failed to ensure basic nursing standards for the rights of medication administration were followed for 1 resident (Resident #6) of 7 residents reviewed for medication administration. The findings include: Review of the facility policy titled, Administration of Medications, dated 9/9/2025, revealed .the facility must ensure .its residents are free of any significant medication errors .Medication Error .the observed or identified preparation or administration of medication .which is not in accordance with the prescriber's order .Accepted professional standards and principles which apply to professional services. …
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