F689 in Utah. Pick another state for the same tag.
Against expectation — 2025
Utah cites F689 more often than its own record predicts
Versus expected share1.17×
1.17 times the share F689 takes of citations nationally.
Share of Utah citations6.46%
Of every deficiency written in Utah in 2025, this is the portion that was F689.
Utah6.46%
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 Utah surveyors wrote
F689 findings written in Utah, 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, isolatedJune 24, 2026
Based on interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 8 sampled residents (Resident 8). Specifically, facility staff failed to respond to a wander guard alarm, failed to communicate with one another, and failed to implement the facility's elopement procedure when Resident 8, a cognitively impaired resident with known exit-seeking behaviors, eloped from the building. Resident 8 was found by police approximately 1.5 hours later near a fast-food restaurant two miles away, having sustained a self-reported fall and facial bruising. …
Based on observation, interview, and record review, the facility did not ensure the residents' environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 3 out of 23 sampled residents, a resident sustained multiple falls with one fall resulting in a head laceration that required staples. This example of non-compliance was cited at a HARM level. Additionally, a resident eloped from the facility and was located by police approximately 3-4 hours after leaving the facility and resident had multiple falls without new interventions identified to prevent future falls. Resident identifiers: 12, 13, and 15.Findings included:HARM1. …
D · No harm, potential for more than minimal, isolatedJuly 30, 2026
Based on interview and record review, the facility failed to ensure that each resident was supervised to prevent accidents. Specifically, for 1 out of 11 sampled residents, a resident who was assessed as being unsafe to leave the facility unsupervised had eloped from the facility. Resident Identifier: 1Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia, altered mental status, and schizophrenia. A Community Risk Assessment, dated 9/11/2025, indicated Resident 1 did not know the facility address/phone number, was unaware of basic traffic laws, and lacked awareness of surroundings and safety concerns (inclement weather, road hazards, emergency vehicles, or bike lanes).An Elopement Risk Assessment identified Resident 1 as At-Risk due to exit-seeking… …
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