F689 in Pennsylvania. Pick another state for the same tag.
Against expectation — 2025
Pennsylvania cites F689 less often than its own record predicts
Versus expected share0.86×
0.86 times the national share — cited less often here than elsewhere.
Share of Pennsylvania citations4.78%
Of every deficiency written in Pennsylvania in 2025, this is the portion that was F689.
Pennsylvania4.78%
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 Pennsylvania surveyors wrote
F689 findings written in Pennsylvania, 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.
K · Immediate jeopardy, patternAugust 25, 2026
Based on facility policy review, clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide adequate supervision to monitor a resident's whereabouts to prevent an elopement (an unauthorized departure from the facility) for one of two sampled residents (Resident 1) at risk for elopement. In addition, the facility failed to clarify physicians' orders and adequately assess residents who were permitted to leave the facility for six of eight residents reviewed (Residents 1, 2, 3, 4, 5, 8). These failures resulted in an immediate jeopardy situation. …
Based on review of facility policy, facility documents, clinical record review, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance while preparing for a transfer from the wheelchair to the bed, which resulted in actual harm of a skin tear (a traumatic wound where the outer layers of skin are partially or completely separated from underlying tissue, usually caused by mechanical forces such as friction, shearing, or adhesive removal) for one of four residents (Resident R1).Findings include: Review of facility policy Accident/Incident Reports, Residents dated 11/10/25, indicated an accident is defined as an event that results in bodily injury or potential injury and/or causes a change in resident status. …
D · No harm, potential for more than minimal, isolatedSeptember 3, 2026
Based on review of facility documents, record review, and resident and staff interviews it was determined that the facility failed to provide a resident environment free of accidental hazards for one of two residents (Resident R33).Findings include. Review of the facility's admission Agreement indicated that residents have the right to a safe, clean, comfortable and homelike environment including but not limited to receiving treatment and supports for daily living safely, and ensuring that the physical layout of the facility maximizes resident independence and does not pose a resident safety risk. Review of Resident 33's clinical record indicated that he was admitted to the facility on [DATE]. …
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