F689 in Ohio. Pick another state for the same tag.
Against expectation — 2025
Ohio cites F689 less often than its own record predicts
Versus expected share1.00×
1.00 times the national share — cited less often here than elsewhere.
Share of Ohio citations5.51%
Of every deficiency written in Ohio in 2025, this is the portion that was F689.
Ohio5.51%
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 Ohio surveyors wrote
F689 findings written in Ohio, 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 27, 2026
Based on medical record review, staff interviews, and review of facility policies, the facilityfailed to provide supervision during a meal for Resident #81. This resulted in ImmediateJeopardy when Resident #81 was provided a meal tray and consumed food items without staffsupervision resulting in the resident being found unresponsive with blue fingers, food in hermouth, and deceased . This affected one (Resident #81) of three residents (#4, #23, and #81)reviewed for meal assistance. …
Based on record review, staff and resident interview, observation, and policy review, the facility failed to ensure a resident was provided adequate supervision during incontinence care resulting in a fall from the bed. This resulted in Actual Harm to Resident #20 when Certified Nursing Assistant (CNA) #224 rolled the resident on her side and left the bedside to gather incontinence supplies. Resident #20 fell out of bed resulting in a laceration to her forehead and one broken toe. This affected one (Resident #20) of three residents reviewed for falls. The facility census was 152.Findings include: Record review revealed Resident #20 was admitted to the facility on [DATE]. Diagnoses included muscular dystrophy, chronic obstructive pulmonary disease (COPD) and spinal stenosis. …
D · No harm, potential for more than minimal, isolatedAugust 31, 2026
Based on medical record review, staff interview, and policy review, the facility failed to ensure physician orders for safe resident transfers were followed. This affected one (Resident #6) of 15 facility-identified residents who required a mechanical lift for transfers. The facility census was 85 residents. Findings include:Review of the medical record for Resident #6 revealed an admission date of 11/13/13 with diagnoses including cerebral infarction, hemiplegia and hemiparesis, peripheral vascular disease, epilepsy, and osteoporosis. Review of the care plan for Resident #6 dated 10/09/25 revealed the resident should be transferred with the use of a Hoyer lift with the assistance of two staff. …
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