F689 in Indiana. Pick another state for the same tag.
Against expectation — 2025
Indiana cites F689 more often than its own record predicts
Versus expected share1.04×
1.04 times the share F689 takes of citations nationally.
Share of Indiana citations5.73%
Of every deficiency written in Indiana in 2025, this is the portion that was F689.
Indiana5.73%
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 Indiana surveyors wrote
F689 findings written in Indiana, 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, isolatedJuly 23, 2026
Based on record review and interview, the facility failed to initiate and update effective resident-specific interventions to prevent the elopement from the facility of a recently admitted resident with a diagnosis of schizophrenia, a court-appointed guardian and history of running away for 1 of 4 residents reviewed for elopement risk. The resident signed out of the building and exited through the main front door entrance. The nursing staff was unaware of the resident's whereabouts. The resident ambulated approximately 1.5 miles from the facility on a highly traveled road that had no sidewalks. The fire department was dispatched to a private residence after the resident knocked on their door and transported the resident to the hospital. …
Based on interviews and record review, the facility failed to prevent a fall of a resident with right-sided paralysis when the resident was turned onto her left side and fell out of bed hitting her head on the ground resulting in actual harm when the resident sustained intercerebral hemorrhaging (where a blood vessel bursts inside the brain tissue, causing bleeding that puts pressure on the brain) and bilateral subdural hematoma (a serious and life-threatening condition where blood collects between the surface of the brain and its outer protective lining usually caused by a head injury) for 1 of 3 residents reviewed for accidents (Resident B). The deficient practice was corrected on 8/6/26, prior to the start of the survey, and was therefore past noncompliance. …
D · No harm, potential for more than minimal, isolatedAugust 27, 2026
Based on record review, interview, and observation, the facility failed to prevent an accident during a transfer for 1 of 3 residents reviewed for accident hazards. (Resident B) Findings include: The clinical record for Resident B was reviewed on 08/27/2026 at 11:00 A.M. An Annual Minimum Data Set (MDS) assessment, dated 06/10/2026, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, morbidly obese (excessive amount of body fat), and depression (mood disorder that causes a persistent feeling of sadness) . The resident was dependent (required a mechanical device to move) with transfers. …
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