Based on interviews, record review, review of a Facility Reported Incident (FRI's), review of the facility's investigative files, review of facility's policies titled, Elopement Prevention, Visitors Screening and Accidents and Incidents, and a facility document titled, Lifting Machine, Using a Mechanical, the facility failed to provide adequate supervision to prevent elopement for Resident Identifier (RI) # 68 a resident with a known history of wandering daily and attempting to leave the facility and failed ensure that resident environment remained free from accident hazardsSpecifically:1) On 06/18/2026, RI #68 was assessed by the facility for elopement risk and identified as at risk for elopement. On 06/24/2026, RI #68 attempted to follow a visitor out of the front door. …
F689 citations in Alabama
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Alabama cites F689 less often than its own record predicts
0.81 times the national share — cited less often here than elsewhere.
Of every deficiency written in Alabama in 2025, this is the portion that was F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Alabama surveyors wrote
F689 findings written in Alabama, 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.
Based on observation, interview, record review, and document review, the facility failed to ensure staff transferred a resident, who was at risk for falls, with the use of a mechanical lift and two-person staff assistance. Specifically, on 06/11/2024, failed to follow the resident's care plan and daily care guide when she assisted the resident with a transfer from their wheelchair to the bed. During the transfer, Resident #6 fell to the floor and sustained a right femur fracture. This deficient practice affected 1 (Resident #6) of 4 sampled residents reviewed for accidents. Findings included: An admission Record revealed the facility admitted Resident #6 on 04/10/2024. …
Based on interview, record review, and facility document and policy review, the facility failed to assess a resident after a fall for 1 (Resident #9) of 8 residents reviewed for accidents.Findings included: A facility policy titled Fall, effective 11/01/2001, revealed, Purpose: To provide emergency care after a fall and prevent further injury if a facture has occurred. A Resident Face Sheet revealed the facility admitted Resident #9 on 05/12/2016. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of intractable epileptic spasms, unspecified intellectual disabilities, lack of coordination, muscle weakness (generalized), unspecified lack of coordination, difficulty in walking, and unsteadiness on feet. …
The short window
Recent years
| Year | Share of Alabama citations | vs expected |
|---|---|---|
| 2023 | 3.11% | 0.63× |
| 2024 | 3.28% | 0.61× |
| 2025 | 4.48% | 0.81× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Alabama surveyors cite →
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