F689 is the fourth most cited deficiency in standard surveys and the first most cited in complaint surveys so far during the 2022 Fiscal Year according to CASPER data as of 4/17/22.

F689 has been cited a total of 2,010 times during standard and complaint surveys

      • 7% cited at Severity Level 4 (Immediate Jeopardy)
      • 3% cited at Severity Level 3 (Actual Harm that is Not Immediate Jeopardy)
      • 9% cited at Severity Level 2 (No Actual Harm w/Potential for More than Minimal Harm)
      • < 1% cited at Severity Level 1 (No Actual Harm w/Potential for Minimal Harm)

F689 Accidents

The facility must ensure that (1) the resident environment remains as free of accident hazards as is possible; and (2) each resident receives adequate supervision and assistance devices to prevent accidents.

CMS definitions:

      • “Free of accident hazards as is possible” refers to being free of accident hazards over which the facility has control.
      • “Adequate Supervision” refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident’s assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident.
      • “Assistive Device” refers to any item (e.g., fixtures such as handrails, grab bars, and mechanical devices/equipment such as stand- alone or overhead transfer lifts, canes, wheelchairs, and walkers, etc.) that is used by, or in the care of a resident to promote, supplement, or enhance the resident’s function and/or safety.


The intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes:

      • Identifying hazard(s) and risk(s);
      • Evaluating and analyzing hazard(s) and risk(s);
      • Implementing interventions to reduce hazard(s) and risk(s); and
      • Monitoring for effectiveness and modifying interventions when necessary


Survey Process

During the survey initial pool process resident/representative interviews, the Accident Critical Element Pathway (CMS 20127) may be triggered. This pathway involves reviews of the following:

      • Smoking
      • Wandering/Elopement
      • Resident to Resident Altercations
      • Falls
      • Entrapment/Safety
      • Environmental Hazards

Key Elements of Noncompliance

To cite deficient practice at F689, the surveyor’s investigation will generally show that the facility failed to do one or more of the following:

      • Identify and eliminate all known and foreseeable accident hazards in the resident’s environment, to the extent possible; or
      • To the extent possible, reduce the risk of all known or foreseeable accident hazards that cannot be eliminated; or
      • Provide appropriate and sufficient supervision to each resident to prevent an avoidable accident; or
      • Provide assistance devices necessary to prevent an avoidable accident from occurring

 F689 can be cited in conjunction with other deficiencies:

      • F584 Safe Environment.
      • F600 Freedom from Abuse, Neglect, and Exploitation
      • F604 Respect and Dignity. Physical Restraint
      • F926 Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents.

 To learn more about how to avoid this and other top citations register to join us on Tuesday, May 3, 2022 for the next session in the Survey Top Citations Webinar Series: F689 Free of Accident Hazards/Supervision/Devices . Each session in this series emphasizes understanding and applying the Interpretive guidance to avoid the top tags.  Attendees will:

      • Learn from actual citation examples including IJ tag reviews
      • Gain insights into successfully managing the survey process & understanding the critical element pathways used to guide surveyor investigations
      • Implement survey preparedness best practices
      • Review steps for developing an effective plan of correction & disputing cited deficiencies through the Informal Dispute Resolution (IDR) process





Angie Hamer, RN, RAC-CT
Clinical Consultant

Learn more about the rest of the Proactive team.