F689 in North Carolina. Pick another state for the same tag.
Against expectation — 2025
North Carolina cites F689 less often than its own record predicts
Versus expected share0.98×
0.98 times the national share — cited less often here than elsewhere.
Share of North Carolina citations5.44%
Of every deficiency written in North Carolina in 2025, this is the portion that was F689.
North Carolina5.44%
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 North Carolina surveyors wrote
F689 findings written in North Carolina, 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 31, 2026
Based on observations, general statues, google maps, record review, staff, resident, and physician assistant interviews, the facility failed to safely transport Resident #1 to his medical appointment. On 08/03/26 while being transported to a medical appointment Resident #1 began to slide out of his wheelchair. The Van Driver, who was a Nursing Assistant (NA) pulled the van over, removed Resident #1's seatbelt and attempted to reposition Resident #1 back in his wheelchair and was unsuccessful. The Van Driver then lowered Resident #1 down onto the floor of the van and called NA #1 with his cell phone and reported what had occurred. NA #1 communicated to the Van Driver that she would alert management and to stay where he was. …
Based on observation, record review, staff, resident and Nurse Practitioner interviews, the facility failed to safely transfer a resident from his wheelchair to his bed with the use of a mechanical lift. The unsafe transfer resulted in a residents fall with injuries that included headache, arm pain, neck pain and a cut to his cheek. The resident was transported to the emergency department (ED) on 8/14/26 where he had a laceration repair to his left cheek that required 4 sutures/stitches. This was reviewed for 1 of 3 residents (Resident #48) reviewed for supervision to prevent accidents. …
D · No harm, potential for more than minimal, isolatedAugust 28, 2026
Based on observation, record review, and interviews with the resident and staff, the facility failed to maintain a safe environment free from accident hazards and failed to provide adequate supervision when staff provided a drinking straw to a resident with an active physician order prohibiting straws due to aspiration risk, then left the resident unsupervised while he ate lunch. The deficient practice occurred for 1 of 3 residents reviewed for accidents (Resident #8).Findings included:Resident #8 was admitted to the facility on [DATE] with diagnoses of severe dementia with agitation and dysphagia (difficulty swallowing) following a stroke. The comprehensive Minimum Data Set (MDS) dated [DATE] indicated Resident #8 had severe cognitive impairment. …
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