F689 in West Virginia. Pick another state for the same tag.
Against expectation — 2025
West Virginia cites F689 less often than its own record predicts
Versus expected share0.80×
0.80 times the national share — cited less often here than elsewhere.
Share of West Virginia citations4.45%
Of every deficiency written in West Virginia in 2025, this is the portion that was F689.
West Virginia4.45%
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 West Virginia surveyors wrote
F689 findings written in West 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, isolatedJuly 17, 2026
Based on observation, record review and staff interviews, the facility failed to provide an environment free from accident hazards because the gap between the side rail and mattress measured 5 3/4 inches, which is one (1) inch greater than the recommended 4 3/4 inch gap. This failure created an immediate jeopardy situation and had the potential to cause fatal entrapment. In addition, the facility failed to provide an environment free from accident hazards by not having fall prevention measures in place for Resident #94 and not ensuring the sharps container was changed at the appropriate level. This failed practice was discovered during the Long-Term Care Survey process. Resident identifiers: #47, #94. Census: 92. …
Based on record review and staff interview, the facility failed to ensure residents were transferred according to their assessed plan of care and/or orders. This was true for one (1) of one (1) residents reviewed for accidents during a complaint survey. Resident identifier: #68. Census: 65. This failed practice let to Resident #68 being transferred by only one staff member which resulted in harm. As a result of the inappropriate transfer, Resident #68 experienced an arterial bleed, was sent out to the hospital, and required orthopedic surgical consultation. Resident #68 ranked her pain as a 10 out of 10 at the time of the incident. …
D · No harm, potential for more than minimal, isolatedAugust 26, 2026
Based on observation and staff interviews, the facility failed to ensure the resident environment remains as free of accident hazards as possible. This failed practice was a random opportunity for discovery. Resident identifier: #5. Facility Census: 74. Findings included:a) Resident #5 During a 100 hall walk through with the nurse manager on 08/25/26 at approximately 12:40 PM, the surveyor and nurse manager both observed in Resident #5's bathroom a putty knife. The putty knife was left lying on the top shelf on the back wall above the toilet. The nurse manager stated she could only imagine it was left there during ongoing repairs. The nurse manager acknowledged he putty knife had sharp edges on the corners and could have caused injury to Resident #5 or anyone else who happened to find it.
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