Based on record review, Incident and Accident (I&A) report review, resident, family, and staff interview, it was determined the facility failed to ensure residents received the level of supervision necessary to prevent residents with diminished cognitive ability from elopement from the facility and to prevent falls. This was true for 2 of 6 residents (#6 and #12) reviewed for supervision and accidents. The facility's failure to implement and maintain supervision measures to prevent elopement placed Resident #12 in immediate jeopardy of serious harm, impairment, or death. …
F689 citations in Idaho
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
Idaho cites F689 less often than its own record predicts
0.51 times the national share — cited less often here than elsewhere.
Of every deficiency written in Idaho 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 Idaho surveyors wrote
F689 findings written in Idaho, 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, staff interview, and facility policy, it was determined the facility failed to ensure residents were free from accidents. This was true for 1 of 1 resident (Resident #2) whose record was reviewed for avoidable falls. This failure resulted in harm to Resident #2 when the facility did not provide care in accordance with the plan of care and failed to maintain his safety. Findings include:A request was made for the facility's incident and accident policy; however, the facility provided a Resident Incident Report and a Resident Incident/Accident Report Procedure Guide.Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including displaced fracture of the second cervical vertebra, vertigo, and dementia.A review of Resident… …
Based on observation, staff interview, policy review, and Occupational Safety and Health Administration (OSHA) Standard, it was determined the facility failed to ensure residents were free from accident hazards for 2 of 18 Residents (#15 and #41) whose room was observed for environmental safety. This deficient practice had the potential to cause physical harm if a power strip cord were to overheat and cause a fire. Findings include:The facility's Electrical Safety for Residents policy, reviewed date 8/2026, documented 8. Power strips shall not be used with medical devices in resident care areas. …
The short window
Recent years
| Year | Share of Idaho citations | vs expected |
|---|---|---|
| 2023 | 3.33% | 0.67× |
| 2024 | 3.10% | 0.58× |
| 2025 | 2.82% | 0.51× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Idaho surveyors cite →
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