Based on observation, interview, and record review, it was determined that for two (R1and R2) out of three residents reviewed for accident hazards and falls, the facility failed to ensure that R1 and R2 received adequate assistance and supervision to prevent falls to the extent possible. R1, a cognitively impaired and completely dependent resident, sustained a fall on 6/9/26 at 4:15 PM when a staff member used an incorrect mechanical lift and sling to perform a transfer from the wheelchair to the bed. This fall caused R1 to suffer a hematoma to the front of her head, and she was sent emergently to the hospital. R1 was diagnosed with multiple brain bleeds and skull fractures. Due to this failure, an Immediate Jeopardy (IJ) was called at 9: 00 AM on 6/16/26. …
F689 citations in Delaware
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
Delaware 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 Delaware 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 Delaware surveyors wrote
F689 findings written in Delaware, 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 record review and interview it was determined that for one (R4) out of four residents reviewed for accidents the facility failed to provide assistive devices to prevent an accident. R4 was transported in a facility vehicle without all safety straps secured. The facility driver came to a sudden stop and R4 fell forward and acquired two broken legs causing physical harm. The facility was found to be in past noncompliance with correction completed as of 1/8/26. Findings include:Review of R4's clinical record revealed:12/3/25 - An annual MDS assessment documented that R4 was cognitively intact and required substantial maximum assistance with upper body dressing and weighed 265 pounds.12/7/25 - R4's care plan for self-care deficit included the intervention for staff to provide… …
Based on interviews, record review and review of other facility records, it was determined that for one (R25) of eleven residents reviewed for accidents, the facility failed to provide an accident-free environment. R25 fell from a Hoyer lift onto the floor during a transfer due to improper use of the lift by two staff members. The Hoyer lift fell on R25's right knee. R25 complained of pain and was sent to the hospital for further evaluation and treatment. Due to the facility's corrective measures following this incident, this deficiency is being cited as past non-compliance with a corrected date of 1/9/26, which was verified through interviews and review of facility records. …
The short window
Recent years
| Year | Share of Delaware citations | vs expected |
|---|---|---|
| 2023 | 1.85% | 0.38× |
| 2024 | 4.03% | 0.75× |
| 2025 | 4.47% | 0.81× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Delaware surveyors cite →
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