F689 in Nebraska. Pick another state for the same tag.
Against expectation — 2025
Nebraska cites F689 more often than its own record predicts
Versus expected share1.00×
1.00 times the share F689 takes of citations nationally.
Share of Nebraska citations5.55%
Of every deficiency written in Nebraska in 2025, this is the portion that was F689.
Nebraska5.55%
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 Nebraska surveyors wrote
F689 findings written in Nebraska, 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 9, 2026
Licensure Reference Number 175 NAC 12-006.09(I) and 12-006.09(I)(i)(1,2,3 and 4). Based on observation, record reviews and interviews; the facility failed to ensure residents that were identified as an elopement risk were supervised when leaving the facility for 1 (Resident 1) of 3 residents sampled, failed to ensure prompt follow-up after a resident's whereabouts were unknown for 1 (Resident 2) of 3 residents sampled, failed to identify and implement interventions to prevent elopements and falls and failed to monitor for neurological changes after unwitnessed falls or falls with head injuries for 1 (Resident 1) of 3 residents on sample. …
Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review, the facility failed to implement intervention to prevent the potential for hot liquid burns on 2 (Residents 1 and 2) of 3 sampled residents. The facility census was 156. Findings are:A record review of the facility's undated Precautions for Handling Hot Beverages education prior to this incident revealed staff shall monitor, serve, and hold hot beverages in a safe manner to prevent burns. The temperature (temp) of any hot beverage would be allowed to cool to 130 degrees Fahrenheit (F). Additional precautions may be implemented based on the needs and make-up of the residents served. …
D · No harm, potential for more than minimal, isolatedAugust 31, 2026
Licensure Reference Number 175 NAC 12-006.09(I)Based on observations, record review and interviews, the facility failed to investigate falls and implement interventions based on root causes for 2 (Residents 65 and 67) of 5 sampled residents. The facility identified a census of 90. Findings are:A record review of the facility policy Falls and Fall Risk, Managing with a revision date of March 2018 revealed a Policy Statement, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. …
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