of F689 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 20255,993
Every F689 citation surveyors wrote nationally that year.
Facilities cited4,704
Distinct nursing homes with at least one F689 finding.
The harm level
How severely F689 is cited
32.5% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J2,33410.4%
K3711.6%
L800.4%
Actual harm
G4,47619.9%
H540.2%
I—
No harm, potential for more than minimal
D12,25654.5%
E2,87912.8%
F420.2%
No harm, potential for minimal
A—
B90.0%
C20.0%
Every recorded F689 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F689 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedAugust 31, 2026
Based on observations, general statues, google maps, record review, staff, resident, and physician assistant interviews, the facility failed to safely transport Resident #1 to his medical appointment. On 08/03/26 while being transported to a medical appointment Resident #1 began to slide out of his wheelchair. The Van Driver, who was a Nursing Assistant (NA) pulled the van over, removed Resident #1's seatbelt and attempted to reposition Resident #1 back in his wheelchair and was unsuccessful. The Van Driver then lowered Resident #1 down onto the floor of the van and called NA #1 with his cell phone and reported what had occurred. NA #1 communicated to the Van Driver that she would alert management and to stay where he was. …
Based on record review, staff interview, and facility policy, it was determined the facility failed to ensure residents were free from accidents. This was true for 1 of 1 resident (Resident #2) whose record was reviewed for avoidable falls. This failure resulted in harm to Resident #2 when the facility did not provide care in accordance with the plan of care and failed to maintain his safety. Findings include:A request was made for the facility's incident and accident policy; however, the facility provided a Resident Incident Report and a Resident Incident/Accident Report Procedure Guide.Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including displaced fracture of the second cervical vertebra, vertigo, and dementia.A review of Resident… …
D · No harm, potential for more than minimal, isolatedSeptember 23, 2026
Based on observation, interview and record review, the facility failed to implement interventions to prevent falls for 1 of 1 residents (R2 ) investigated for fall safety.Findings Include:R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment with diagnoses which included: Alzheimer's disease, arthritis, repeated falls and fracture. R2's MDS identified R2 required substantial maximal assistance with transfers, walking and dressing. R2 had one fall with no injury since admission. R2's Care Area assessment dated [DATE], identified R2 was at risk for falls due to history of falls, Alzheimer's disease and R2 did not realize his limitations. R2 was adjusting to new environment. …
B · No harm, potential for minimal, patternApril 1, 2026
Based on observation, record review, and interviews conducted during the survey, the facility failed to ensure that residents were free of accident or hazards according to professional standards for three (3) (Resident #94, 132, and 231) of eight (8) residents reviewed. Specifically, Resident #94 had an over-the-counter nasal spray on their bedside table, Resident #132 had a can of unopened beer on their personal storage shelf as well as an unopened single shot of liquor on their dresser, and Resident #231 had a clear plastic bag of prescription medication in their chair located next to the doorway in their room. …
Observe each nurse aide's job performance and give regular training.
Cited in the same inspection, not caused by one another.
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