Based on interview, record review, and observation, the facility failed to ensure three of three residents sampled for accidents (Resident 14, 34, and 116) had interventions implemented to identify hazards and risks associated with smoking. The facility failed to ensure: 1) Resident 14 with a lighter and cigarettes did not attempt to put a used cigarette in a trash can within the resident's room, 2) Resident 34 was a documented smoker with an Oxygen Concentrator (a device delivering up to 95 percent Oxygen, Oxygen when in contact with flammable materials through heat can cause severe burns) in the resident's room, and 3) a non-smoking policy and procedure was enforced when Resident 116 (R116) took out a black lighter from the left chest pocket. …
F689 citations in Nevada
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
Nevada cites F689 less often than its own record predicts
0.56 times the national share — cited less often here than elsewhere.
Of every deficiency written in Nevada 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 Nevada surveyors wrote
F689 findings written in Nevada, 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 observation, interview, clinical record review, and document review, the facility failed to ensure a resident with a history of falls and deemed a high fall risk per assessments completed by the Physical Therapist (PT) received interventions during activities of daily living (ADL) care to mitigate the resident's risk of fall resulting in the resident sustaining a fall with injury for 1 of 5 residents reviewed for facility reported incidents (FRI) (Resident #2). This deficient practice resulted in the resident sustaining a fracture to resident's left lower extremity with the potential to result in the resident experiencing increased levels of pain and difficulty with ADLs causing the resident to experience a decrease in quality of life. …
Based on interview, record review, and observation, the facility failed to ensure a resident's behavior to park a wheelchair in the middle of a fall mat was addressed through adequate supervision and environmental safeguards for 1 of 20 sampled residents (Resident #91). This deficient practice had the potential to result in an increased risk for falls, injury, or skin tears.Findings include:Resident #91Resident #91 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified dementia, fracture neck left femur, and difficulty in walking.On 08/11/2026 at 8:40 AM, Resident #91 was observed asleep in bed with bilateral fall mats. …
The short window
Recent years
| Year | Share of Nevada citations | vs expected |
|---|---|---|
| 2023 | 5.00% | 1.01× |
| 2024 | 2.94% | 0.55× |
| 2025 | 3.11% | 0.56× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Nevada surveyors cite →
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