F689 in Missouri. Pick another state for the same tag.
Against expectation — 2025
Missouri cites F689 less often than its own record predicts
Versus expected share0.93×
0.93 times the national share — cited less often here than elsewhere.
Share of Missouri citations5.12%
Of every deficiency written in Missouri in 2025, this is the portion that was F689.
Missouri5.12%
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 Missouri surveyors wrote
F689 findings written in Missouri, 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 17, 2026
Based on interview and record review, the facility failed to provide adequate supervision to one sampled resident (Resident #3) who had a known history of chronic suicidal ideations and self-harm. The facility failed to implement the facility policy and physician recommendation to provide one on one (1:1) supervision to a suicidal resident and the physician recommendation to remove all items from the resident space that he/she could self-harm with. On [DATE], 1:1 monitoring was not provided by a designated staff assigned to the resident and at 12:50 P.M., the resident was found in his/her resident room with a call light cord around his/her neck which hung from the ceiling. …
Based on observation, interview, and record review, the facility failed to ensure staff provided appropriate supervision for a cognitively impaired resident (Resident #1) who was at risk of falling when Certified Nursing Assistant (CNA) A, left the resident unattended in a drained whirlpool tub with the whirlpool door open. The lack of supervision resulted in the resident falling, being airlifted to a hospital where Resident #1 was admitted for four days, having pain, and bruising to the right outer hip. The facility census was 20. …
E · No harm, potential for more than minimal, patternAugust 28, 2026
Based on observation, interview and record review, the facility failed to ensure residents were transferred in a safe manner and in accordance with accepted standards of practice, manufacturer guidelines, and facility policy. This failure was evidenced by improper mechanical lift use, unsafe physical assistance without required transfer devices and inadequate care planned direction for one resident (Residents #17). The facility also failed to maintain mechanical lift equipment in safe working condition for one resident (Resident #63). Facility staff failed to apply a gait-belt around the abdomen of a resident who was unbalanced at the time of transfer (Resident #44). The facility staff failed to remove bug spray in a room that housed two residents (Residents #20 and #62). …
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