F689 in California. Pick another state for the same tag.
Against expectation — 2025
California cites F689 less often than its own record predicts
Versus expected share0.84×
0.84 times the national share — cited less often here than elsewhere.
Share of California citations4.62%
Of every deficiency written in California in 2025, this is the portion that was F689.
California4.62%
National5.53%
Share of all citations that were F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F689 findings written in California, 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.
J · Immediate jeopardy, isolatedApril 24, 2026
Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement effective interventions to prevent elopement (when a resident leaves the facility grounds or a designated safe area without the staff knowing and/or without the supervision the resident needs) for one of three sampled residents (Resident 1) who was assessed at risk for wandering (walking around without a clear purpose) and elopement by failing to: 1. Accurately assess and identify elopement risk. The facility's Wandering & Elopement assessment dated [DATE] indicated a Low Probable Risk even though Resident 1 demonstrated repeated exit seeking, wandering, and attempts to elope on [DATE]. …
Based on interview and record review, the facility failed to:Follow their policy and procedure (P&P) titled, WanderGaurd [sic](device used as safety protocol used to assist staff in monitoring people at risk for wandering near exits) Policy and Procedure for one of three sampled residents (Resident 1) when Respiratory Therapist (RT) responded to Resident 1's wanderguard alarm but did not check outside the surrounding area to ensure Resident 1 did not exit the facility premises.Ensure the every 30-minute monitoring log were completed for one of three sampled residents (Resident 1) with a history of elopement (occurs when a resident leaves the facility without authorization and/or any necessary supervision).These failures resulted in Resident 1 leaving the facility unaccompanied, missing for… …
D · No harm, potential for more than minimal, isolatedAugust 31, 2026
Based on observation , interview, and record review, the facility failed to provide adequate assistance and supervision to prevent a fall for one of three sampled residents ( Resident 1), who was identified as being at risk for falls and assessed as requiring moderate to maximum assistance with lower- body dressing. This deficient practice resulted in Resident 1 falling and sustaining a right - sided occipital condyle fracture ( right sided break of the bone at the lower right side of skull, connecting to the neck/ spine) and placed other residents with similar assistance needs at risk for falls and injury. …
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