Based on interview and record review, the facility failed to ensure an environment free of accident hazards for 1 of 4 reviewed residents, Resident #1. On 7/24/2026 at 11:45 AM, Resident #1 was seen with her walker heading toward the outside courtyard. At 1:55 PM, Resident #1 was found unresponsive on the bench in the courtyard. Resident #1 was brought to her room. Staff applied packed ice and cool blankets. At 2:55 PM, Emergency Medical Service (EMS) was contacted. Resident #1 was transported to a local hospital, being admitted with diagnoses of heat exhaustion, hyperthermia, and altered mental status.Findings include:Review of Resident #1's admission record showed the resident was admitted on [DATE] with diagnoses to include wedge compression fracture of first lumbar vertebra, history of… …
F689 citations in Florida
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
Florida cites F689 less often than its own record predicts
0.80 times the national share — cited less often here than elsewhere.
Of every deficiency written in Florida 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 Florida surveyors wrote
F689 findings written in Florida, 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, review of facility policy and procedures, record review and staff interviews, the facility failed to provide adequate supervision and implement appropriate resident centered interventions to prevent avoidable accidents for 1 (Resident #999) of 3 residents reviewed who were identified as being at risk for falls and sustained multiple falls at the facility, including falls with injuries.The findings included:Review of the facility provided policy N-1259 Fall Management effective 11/30/14 (revised 7/29/19) documented, Residents are evaluated for fall risk. Patient centered interventions are initiated, based on resident risk . …
Based on observation, interview, and record review the facility failed to ensure an environment that is free from accident hazards in 1 of 2 shower rooms, in a resident therapy room and in 2 of 3 residents' rooms, Resident #36, Resident #70, sampled for accidents and hazards. Findings include: 1) During an observation on 08/3/1/26 at 09:33 AM, a razor was observed in Resident #70's bathroom on the ledge of the sink. During an observation on 09/02/26 at 08:47 AM, a razor was observed in Resident #70's bathroom in a basket on the ledge of the sink. Review of Resident #70's Quarterly Minimum Data Set (MDS) dated [DATE] Section C Cognitive Patterns documented a Brief Interview for Mental Status (BIMS) Summary Score of 3 out of 15. …
The short window
Recent years
| Year | Share of Florida citations | vs expected |
|---|---|---|
| 2023 | 3.35% | 0.68× |
| 2024 | 3.57% | 0.66× |
| 2025 | 4.45% | 0.80× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Florida surveyors cite →
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