F689 in Virginia. Pick another state for the same tag.
Against expectation — 2025
Virginia cites F689 less often than its own record predicts
Versus expected share0.68×
0.68 times the national share — cited less often here than elsewhere.
Share of Virginia citations3.75%
Of every deficiency written in Virginia in 2025, this is the portion that was F689.
Virginia3.75%
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 Virginia surveyors wrote
F689 findings written in Virginia, 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 20, 2026
Based on record review, interviews, and policy review, the facility failed to: 1.) appropriately assess a resident and identify and implement interventions related to wandering and elopement risk for one of two residents (Resident (R) 10) reviewed for elopement out of a total sample of 47. As a result, R10, who had been assessed as an elopement risk prior to a hospital discharge but was not assessed at risk on readmission, exited the facility without staff knowledge 12 days after readmission and sustained a subarachnoid hemorrhage, a severe head injury. …
Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the resident environment remained free of accident hazards as is possible for (1) one of (15) fifteen current sampled residents, Resident #24. Resident #24's bariatric mattress measured 46 (forty-six) inches and was placed on a bed frame that extended to only 42 (forty-two) inches, resulting in an overlay. While being provided with incontinence care on 03/13/2026, Resident #24 fell out of bed landing face down between the bed and the wall. Resident #24 sustained a hematoma to the forehead and a laceration to the bridge of the nose, resulting in transfer to a higher level of care, thus constituting harm. …
D · No harm, potential for more than minimal, isolatedJuly 2, 2026
Based on observation, staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide adequate supervision to prevent accidents for 1 of 8 residents (Resident #2), in the survey sample.The findings included: The facility staff failed to provide supervision to prevent Resident #1 from pushing Resident #2 out of a chair and onto the floor as well as attempting to hit Resident #2 with a chair. 1. Resident #1 was originally admitted to the facility 2/21/26. …
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