Based on observation, interview and record review the facility failed to ensure residents who engaged in smoking had adequate supervision to protect residents and/or staff from potential fire hazards for 2 of 3 residents (Resident 51 and 32) reviewed for smoking. This failure placed all residents at serious risk for injury related to unsafe smoking practices and constituted an Immediate Jeopardy (IJ).The failed practice resulted in an IJ on 04/26/2026 when the facility failed to ensure the residents' environment was safe from burns and fire. The IJ was removed on 04/28/2026 after the facility provided a safe receptacle for properly disposing of cigarette butts, reassessed and educated staff and residents of the facility's no smoking policy and confiscated residents smoking paraphernalia. …
F689 citations in Washington
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Washington cites F689 less often than its own record predicts
0.71 times the national share — cited less often here than elsewhere.
Of every deficiency written in Washington in 2025, this is the portion that was F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Washington surveyors wrote
F689 findings written in Washington, 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.
Based on interview and record review, the facility failed to provide the required care planned supervision to prevent accidents for 2 of 4 sample residents (Resident 2 & 5) reviewed for accidents/hazards. The facility failed to assess safety risks, provide adequate resident supervision, and implement fall and elopement care plans (CP). Resident 2, who had a history of falling, experienced harm when they fell out of bed and fractured their nose, requiring hospitalization, due to fall prevention interventions not being implemented. These failures placed the residents at a potential risk of harm related to avoidable incidents. Findings included .Review of the facility's Fall Management policy, dated 05/26/2021 showed residents would be assessed for fall risk upon admission to the facility. …
Based on observation, interview and record review, the facility failed to follow the accident protocols for 1 of 3 residents (Resident 1), reviewed for elopement and suicidal ideation risk. This failure placed residents at risk for additional elopements, injury, and diminished quality of life.Findings included.Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 1 had moderate cognitive impairment and was independent with most activities of daily living (ADLs). The MDS mood score showed the resident had moderately severe depression. …
The short window
Recent years
| Year | Share of Washington citations | vs expected |
|---|---|---|
| 2023 | 3.72% | 0.75× |
| 2024 | 3.95% | 0.73× |
| 2025 | 3.95% | 0.71× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Washington surveyors cite →
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