F689 in Wisconsin. Pick another state for the same tag.
Against expectation — 2025
Wisconsin cites F689 more often than its own record predicts
Versus expected share1.25×
1.25 times the share F689 takes of citations nationally.
Share of Wisconsin citations6.92%
Of every deficiency written in Wisconsin in 2025, this is the portion that was F689.
Wisconsin6.92%
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 Wisconsin surveyors wrote
F689 findings written in Wisconsin, 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 27, 2026
Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 3 of 3 residents (R6, R2 & R11) reviewed for supervision.R6, who is cognitively impaired, was at risk for elopement, exited the facility unsupervised, and was found 2.5 hours later about 2 miles from the facility.The facility's failure to provide adequate supervision for a resident who is at risk for elopement, created a finding of immediate jeopardy that began on 8/9/26. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on 8/18/26 at 3:30 PM. …
Based on observation, interview, and record review, the facility did not ensure 3 (R20, R67, R37) of 6 residents reviewed for accidents had adequate supervision to prevent accidents.
*R20 fell out of the wheelchair while staff was pushing the wheelchair and sustained multiple right knee fractures.
*R67 was assessed to require two staff to assist with bed mobility tasks and sustained a fall out of bed when being assisted by one staff member.
*R37 is a smoker and did not have evidence of smoking assessments.
Findings include:
The facility policy titled Fall Prevention and Management Guidelines with revised date 7/18/24 documents: . …
D · No harm, potential for more than minimal, isolatedAugust 25, 2026
Based on interview and record review, the facility did not ensure that 2 of 3 residents (R1 and R5) reviewed for falls received adequate supervision and assistive devices to prevent accidents.* R1 had a fall on 7/7/26, R1 was found by the van driver on the floor of the transport vehicle. The facility did not adequately evaluate and analyze the circumstances of R1's fall on 7/7/26 to identify the factors contributing to the falls and determine whether additional interventions were necessary to reduce the risk of future falls or accidents. Additionally, R1's fall interventions were observed not to be in place.* R5 was found in the bathroom in the fetal position on the floor on 8/17/26. …
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