Based on observation, interview, and record review conducted during survey, the facility failed to ensure each resident received adequate supervision and to prevent accidents for three (Resident #'s 30, 110, and 129) of 103 residents reviewed. Specifically, Resident #30, who required supervision and touch assistance for eating, was observed alone in their room, lying flat on their bed while eating; Resident #110, who required supervision or assistance with eating, was observed in a dining room reclined at a fifteen-degree angle in a lounge chair with a food tray on a table next to them, while staff was noted to hand the resident bowls of food and walk away while resident was making audible gurgling sounds; Resident #129, who required supervision while eating and was on aspiration… …
F689 citations in New York
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
New York cites F689 less often than its own record predicts
0.86 times the national share — cited less often here than elsewhere.
Of every deficiency written in New York 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 New York surveyors wrote
F689 findings written in New York, 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 observations, interviews, and record review, the facility failed to ensure the resident environment remained as free from accident hazards as possible for one of one resident reviewed (Resident #1). Specifically, the facility failed to identify and correct an unsafe third-floor resident room window which opened approximately 15 inches and failed to have a system to routinely inspect resident room windows for safety. Subsequently, on [DATE], the resident was able to exit the window and fell to their death. …
Based on observations, record review, and interviews conducted during an Abbreviated Survey, the facility did not ensure the resident environment remained as free from accident hazards as possible and did not ensure residents received adequate supervision to prevent accidents for two residents (Residents #4 and #6) of five residents reviewed for accidents. Specifically, 1. On 06/26/2026, Licensed Practical Nurse #7 reported to Registered Nurse Supervisor #2 that Licensed Practical Nurse #8 left their medication cart opened and Resident #4 with moderately impaired cognition with documented wandering behaviors, accessed the cart and was found by Certified Nurse Aides #5 and #6 in the day room with medications in their lap. …
The short window
Recent years
| Year | Share of New York citations | vs expected |
|---|---|---|
| 2023 | 5.52% | 1.12× |
| 2024 | 5.15% | 0.96× |
| 2025 | 4.76% | 0.86× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New York surveyors cite →
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