F659 in North Carolina. Pick another state for the same tag.
Against expectation — 2025
North Carolina cites F659 more often than its own record predicts
Versus expected share1.24×
1.24 times the share F659 takes of citations nationally.
Share of North Carolina citations0.05%
Of every deficiency written in North Carolina in 2025, this is the portion that was F659.
North Carolina0.05%
National0.04%
Share of all citations that were F659.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What North Carolina surveyors wrote
F659 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.
D · No harm, potential for more than minimal, isolatedDecember 19, 2025
Based on record review, observations and staff interviews, the facility failed to ensure a qualified staff member with the necessary skills and licensure inserted a peripheral intravenous (IV) catheter when a Medication Aide used the needle from an IV catheter kit and inserted it into a resident's arm (Resident #78). The deficient practice was identified for 1 of 5 nursing staff reviewed for sufficient and competent nurse staffing (Medication Aide #1). Findings included: Resident #78 was admitted to the facility on [DATE] with diagnoses that included arthritis, dementia, Alzheimer's disease, and diabetes mellitus. Resident #78 was discharged from the facility on 11/16/25. …
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction