Based on record review, observations and interviews the facility failed to ensure residents received adequate supervision to prevent elopement for 1 (#1) of 3 (#1, #2, #3) residents reviewed for elopement. The facility failed to provide adequate supervision for Resident #1 who was a known elopement risk. This deficient practice resulted in an immediate jeopardy situation for Resident #1 on 04/03/2026 at 5:31p.m., when he eloped from the facility through the front door unnoticed by staff while following visitors out of the building. Resident #1 had a history of exit seeking behaviors, had been identified as an elopement risk, and wore a wander guard ankle bracelet. Resident #1 was picked up by a local police officer about 0.9 miles from the facility on the interstate highway. …
F689 citations in Louisiana
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
Louisiana cites F689 less often than its own record predicts
0.61 times the national share — cited less often here than elsewhere.
Of every deficiency written in Louisiana 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 Louisiana surveyors wrote
F689 findings written in Louisiana, 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 interviews and record reviews, the facility failed to ensure a resident received the required two-person assistance during a transfer for 1 (Resident #2) of 5 residents investigated for accident hazards.This deficient practice resulted in an actual harm on 07/25/2026 at 5:05AM when S2Certified Nursing Assistant (CNA) transferred Resident #2 from her bed to the wheelchair unassisted. Resident #2's legs gave out and Resident #2 slid to the ground during the transfer as documented by S2CNA, which resulted in a left leg oblique moderately displaced comminuted fracture of the distal diaphysis of the femur (a break in the lower shaft of the thighbone near the knee). …
Based on observations, record reviews, and interviews the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (#64) of 3 (#55, #64, and #85) residents investigated for elopement risk.The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be past noncompliance citation.Findings: Review of the facility's Elopement, Risk Reduction Strategies, and Management of Missing Residents policy (latest review date 03/05/2026) revealed in part:The facility maintains a process to assess all residents for risk of elopement, implement risk reduction strategies for those identified as an elopement risk, institute measures for resident identification at the time of admission, and conduct a… …
The short window
Recent years
| Year | Share of Louisiana citations | vs expected |
|---|---|---|
| 2023 | 4.06% | 0.82× |
| 2024 | 4.24% | 0.79× |
| 2025 | 3.39% | 0.61× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Louisiana surveyors cite →
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