F689 in Wyoming. Pick another state for the same tag.
Against expectation — 2025
Wyoming cites F689 more often than its own record predicts
Versus expected share1.11×
1.11 times the share F689 takes of citations nationally.
Share of Wyoming citations6.15%
Of every deficiency written in Wyoming in 2025, this is the portion that was F689.
Wyoming6.15%
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 Wyoming surveyors wrote
F689 findings written in Wyoming, 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.
K · Immediate jeopardy, patternJuly 16, 2026
Based on medical record review, observation, staff and resident interview, facility incident review, and policy and procedure review, the facility failed to ensure hot liquids were at a consumable temperature to prevent accident hazards for 1 of 5 sample residents (#59) reviewed for accident hazards. This failure resulted in actual harm to resident # 59 who received a burn from hot liquid that was provided by staff. The failure resulted in a determination of immediate jeopardy due to a lack of implementation of preventative measures. The census was 70. The findings were: 1. …
Based on staff interview, medical record review, policy review, and facility incident investigation review, the facility failed to ensure adequate supervision was provided for 2 of 8 sample residents (#2, #14) reviewed for accident hazards. The failure resulted in actual harm to resident #2. The findings were:1.Review of the quarterly MDS dated [DATE] showed resident #2 had a BIMS score of 6 out of 15, which indicated severe cognitive impairment, and had diagnoses of traumatic brain injury, non-Alzheimer's dementia, hemiplegia, and chronic lung disease. …
E · No harm, potential for more than minimal, patternAugust 21, 2026
Based on observation, resident and staff interview, medical record review, facility incident review, and policy and procedure review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 3 of 3 sample residents (#4, #6, #7) reviewed for accident hazards. The findings were:
1. Review of the comprehensive MDS assessment dated [DATE] showed resident #7 had a BIMS score of 11 out of 15, which indicated moderate cognitive impairment, and diagnoses which included dementia, seizure disorder, anxiety, nontraumatic intracerebral hemorrhage, fracture of nasal bones, and restlessness and agitation. The following concerns were identified:
a. …
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