F689 in Michigan. Pick another state for the same tag.
Against expectation — 2025
Michigan cites F689 more often than its own record predicts
Versus expected share1.17×
1.17 times the share F689 takes of citations nationally.
Share of Michigan citations6.47%
Of every deficiency written in Michigan in 2025, this is the portion that was F689.
Michigan6.47%
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 Michigan surveyors wrote
F689 findings written in Michigan, 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 25, 2026
This citation pertains to intake 3027558.Based on observation, interview, and record review the facility failed to provide adequate supervision and follow elopement protocol resulting in R101 leaving the facility unknown to staff and sustaining a fall out of a wheelchair resulting in a facial hematoma, an abrasion to the left hand and right toes for one resident (R101) at risk for immediate jeopardy out of six residents reviewed for supervision.Further investigation of the incident revealed facility staff failed to supervise a severely cognitively impaired resident (R101) with a high elopement risk and respond appropriately to a door alarm (Emergency Door) on the Ridge Unit. …
This deficient practice pertains to Intake #3158817.Based on observation, interview, and record review, the facility failed to provide adequate supervision resulting in a fall with injuries for one Resident (#2) of three residents reviewed for accident hazards and supervision. This deficient practice resulted in facial lacerations and broken dentition for Resident #2.Findings include:Resident #2 (R2)Review of R2's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/20/23 with diagnoses including dementia, Alzheimer's disease, and a cognitive communication deficit. …
D · No harm, potential for more than minimal, isolatedAugust 28, 2026
This citation pertains to intake 3171936.Based on observation, interview, and record review, the facility failed to provide two staff members during care for one (R101) of three residents reviewed for safety resulting in R101 falling off the bed onto the floor and sustaining an abrasion to their right kneecap. Findings include: The State Agency (SA) received a complaint that R101 rolled off the bed onto the floor when only one staff member was providing care. On 8/28/26 at 10:40 AM, R101 was observed seated in a wheelchair in the therapy department. During interview R101 said, I was getting cleaned up. I'm unable to move my legs and need a total of two people to assist me with getting changed. I only had the one girl. I told her I needed two. She said she could do it. …
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