F689 in Hawaii. Pick another state for the same tag.
Against expectation — 2025
Hawaii cites F689 less often than its own record predicts
Versus expected share0.98×
0.98 times the national share — cited less often here than elsewhere.
Share of Hawaii citations5.42%
Of every deficiency written in Hawaii in 2025, this is the portion that was F689.
Hawaii5.42%
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 Hawaii surveyors wrote
F689 findings written in Hawaii, 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 12, 2026
Based on observation, interview, and record review, the facility failed to provide adequate supervision and interventions resulting in 2 elopement incidents (01/19/26 and 01/28/26) for Resident (R) 36. This deficient practice created the likelihood for a serious adverse outcome (e.g. serious bodily injury and /or death from being hit by a car) due to open access to a busy road from the facility entrance and adjacent parking lot. Findings include:The Office of Health Care Assurance (OHCA) received a facility-reported incident (FRI) Intake #2721134, documenting an incident of elopement that occurred on 01/19/26 at 06:28 PM by R36. …
Based on record review and interview the facility failed to provide adequate supervision to prevent an accident for one of three residents (R) 13 sampled for accidents related to falls resulting in major injury and pain. The deficient practice puts all residents, who are at a high risk for falls, who are informally monitored on one to one for falls prevention, at great risk for a fall with injury and pain.Findings Include:On 08/06/25 at 4:49 PM the Office of Health Care Assurance received an initial report via fax from the facility reporting R13 had an unattended fall on 07/04/25 at 1:00 PM resulting in an Acute comminuted right femoral neck fracture. R13 was transferred to the hospital on [DATE] and underwent surgical repair on 07/05/25. R13 returned to the facility on [DATE] at 1015. …
D · No harm, potential for more than minimal, isolatedJune 12, 2026
Based on interview and record review, the facility failed to do a thorough investigation post-fall for 2 of 5 Residents (Resident (R) 4, R10) sampled. This deficient practice placed the residents at risk for further falls and injury.Findings include:
1) R10 is [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include left femur fracture with repair on 12/28/25 and dementia.
On 06/12/26 at 07:02 AM, a record review was done. A nurse's progress note dated 03/09/26 at 04:18 PM documented that R10 was found on the floor and was first seen by her daughter. R10 complained of left hip pain post-fall and Medical Doctor (MD) 1 was notified. R10 was sent to the emergency room and subsequently admitted to the hospital with a hip fracture. …
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