F689 in District of Columbia. Pick another state for the same tag.
Against expectation — 2025
District of Columbia cites F689 less often than its own record predicts
Versus expected share0.72×
0.72 times the national share — cited less often here than elsewhere.
Share of District of Columbia citations4.00%
Of every deficiency written in District of Columbia in 2025, this is the portion that was F689.
District of Columbia4.00%
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 District of Columbia surveyors wrote
F689 findings written in District of Columbia, 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, isolatedMarch 24, 2026
Based on observations, record reviews, resident and staff interviews, for one (1) of five (5) sampled residents, facility staff failed to ensure that adequate supervision was provided, in accordance with Resident #1's person-centered plan of care, to prevent her from eloping from a safe area, without authorization. Subsequently, Resident #1 eloped from the secure Memory Care unit on 02/21/26 at 11:45 AM. During this survey, an Immediate Jeopardy (IJ-J) was identified at 42 CFR 483.25, Quality of Care, F689, Free of Accident Hazards/Supervision/Devices on 03/18/26 at 1:12 PM. The facility's Administrator submitted an abatement plan to the Survey Team that was accepted on 03/18/26 at 5:27 PM. …
Number of residents sampled:
Number of residents cited:
Based on record reviews and staff interviews for two (2) of 65 sampled residents, it was determined that the facility's staff failed to ensure residents were provided with adequate monitoring and supervision as evidenced by one resident who sustained a fall with injury when she was left unattended in her room, in a bed that was positioned in the highest raised position and another resident who sustained a fall with injury during an assisted shower. Residents' #95 and #258.
The findings included:
A facility policy titled 'Fall Prevention Program' with a review date of 08/15/2025 documented, in part: Definitions: A fall refers to unintentional change in position coming to rest on the ground, floor.5. Low/Moderate Risk Protocols: a. …
D · No harm, potential for more than minimal, isolatedMay 6, 2026
Number of residents sampled:
Number of residents cited:
Based on record review, staff interview, and family interview, the facility's staff failed to ensure that a resident with a tracheostomy was accompanied by nursing staff during a podiatry appointment for one of the 53 sampled residents. (Resident #43) Resident #43 was admitted to the facility on [DATE] with multiple diagnoses, including Aphasia, Chronic Respiratory Failure, Tracheostomy, and Muscle Weakness.A physician order with a re-order date of 01/31/26 instructed, On Trach collar: FI02:28%, Trach Type: [NAME], Trach Size: XL 7 every shift. …
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