F689 in Kansas. Pick another state for the same tag.
Against expectation — 2025
Kansas cites F689 more often than its own record predicts
Versus expected share1.24×
1.24 times the share F689 takes of citations nationally.
Share of Kansas citations6.87%
Of every deficiency written in Kansas in 2025, this is the portion that was F689.
Kansas6.87%
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 Kansas surveyors wrote
F689 findings written in Kansas, 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, isolatedJune 17, 2026
Based on observation, record review, and interviews, the facility failed to provide adequate supervision for Resident (R) 1, who took medications to prevent alcohol relapses and was at risk for self-harm, to prevent an elopement and the staff did not identify the resident was missing for over nine hours. On 06/14/2026 at approximately 04:18 AM staff observed R1 wandering in the facility and this was the last time staff knew R1's whereabouts. On 06/14/2026 at approximately 02:00 PM, staff identified R1 was not in her room, and it appeared she had not been there all day. …
Based on observations, record review, and interviews, the facility failed to ensure an environment free from accident hazards when Certified Nurse Aide (CNA) O did not use a gait belt during a transfer for Resident (R) 2 resulting in a fall where R2 sustained a fracture. The facility further failed to ensure interventions to prevent falls were implemented for R14 and failed to ensure staff used a full body lift safely for R9.Findings included:- R2 admitted to the facility on [DATE], discharged to the hospital on [DATE], and readmitted to the facility on [DATE].
R2's Electronic Medical Record (EMR) documented diagnoses of a need for assistance with personal care and lack of coordination. …
D · No harm, potential for more than minimal, isolatedAugust 31, 2026
Based on observation, record review, and interview, the facility failed to provide an environment free from accident hazards when staff failed to use the Hoyer (total body mechanical lift) lift for Resident (R) 1, per her plan of care, resulting in a non-injury fall.Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of dementia and anxiety.R1's 07/20/2026 Annual Change Minimum Data Set (MDS) documented that R2 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated severely impaired cognition. R1's MDS documented that she was a total assist for transfers.R1's 07/23/2026 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R1 was dependent on staff to make decisions regarding activities of daily living (ADLs). …
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