F689 in Minnesota. Pick another state for the same tag.
Against expectation — 2025
Minnesota cites F689 more often than its own record predicts
Versus expected share1.18×
1.18 times the share F689 takes of citations nationally.
Share of Minnesota citations6.52%
Of every deficiency written in Minnesota in 2025, this is the portion that was F689.
Minnesota6.52%
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 Minnesota surveyors wrote
F689 findings written in Minnesota, 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, isolatedAugust 28, 2026
Based on observation, interview and document review, the facility failed to provide adequate supervision and appropriately secure an exit door to prevent an elopement for 1 of 3 resident (R1) reviewed for elopement. This resulted in immediate jeopardy (IJ) when R1 left the facility without staff knowledge and was not located for approximately three hours.The immediate jeopardy began on [DATE] at 10:41 p.m., when R1 exited the facility through the north assisted living door. At 1:40 a.m., R1 was located laying in a row of trees across the road approximately 288 yards away from the facility. The administrator and director of nursing (DON) were notified of the immediate jeopardy on [DATE] at 5:10 p.m. …
Based on observation, interview and document review, the facility failed to ensure a safe transfer using a mechanical lift was completed for 1 of 1 resident (R1) reviewed. R1 was resistive to care and did not want to get up from the bed, however, two staff members proceeded to place a hoyer sling underneath her and began to transfer her from the bed to a shower chair despite R1 being resistive. R1 became more physically behavioral while in the device (i.e., wiggling around, moving) which caused her shoulder to nudge free from the sling mid-air and resulted in an avoidable fall from the lift. R1 sustained a scalp hematoma (i.e., goose egg) with bleeding, bruising on her left side, increased pain, and mental anguish (i.e., tearfulness) from the event which constituted actual harm. …
D · No harm, potential for more than minimal, isolatedSeptember 23, 2026
Based on observation, interview and record review, the facility failed to implement interventions to prevent falls for 1 of 1 residents (R2 ) investigated for fall safety.Findings Include:R2's admission Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment with diagnoses which included: Alzheimer's disease, arthritis, repeated falls and fracture. R2's MDS identified R2 required substantial maximal assistance with transfers, walking and dressing. R2 had one fall with no injury since admission. R2's Care Area assessment dated [DATE], identified R2 was at risk for falls due to history of falls, Alzheimer's disease and R2 did not realize his limitations. R2 was adjusting to new environment. …
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