F689 Free of Accident Hazards/Supervision/Devices has been the third most frequently cited F tag so far in the 2021 fiscal year per Casper data (9/5/21).  3,466 citations have been issued nationally for the  16.6% of providers surveyed. Scope and Severity has ranged from B to L, with the majority (1,858) cited at the D level (few residents/no actual harm).

According to the SOM Appendix PP, the intent of F689 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:

  1. Identifying hazard(s) and risk(s);
  2. Evaluating and analyzing hazard(s) and risk(s);
  3. Implementing interventions to reduce hazard(s) and risk(s); and
  4. Monitoring for effectiveness and modifying interventions when necessary


We often think of Falls and Elopement when discussing F689, but there are several types of Accident Hazards included with this regulation including: Smoking, Assistive Devices, Resident-to-Resident Altercations, Vulnerability, Environmental Hazards, and Electrical Safety.


      • Smoking – The facility is responsible not only for the safety of the resident that smokes, but also the safety of others. Smoking policy(s) should address:
        • when and where residents may smoke,
        • supervision while smoking – as indicated, based on assessment and care plans,
        • proper storage/security of smoking materials – based on assessment and care plans, and
        • prohibiting smoking while oxygen or other flammable substances are nearby.
      • Assistive Devices – Assistive and mechanical devices must be properly maintained and assessed for safe use, and staff must know how to properly use them.
        • Routine maintenance should be performed according to the manufacturer’s recommendations.
        • Ensure that staff are properly trained on the proper use of these devices.

Devices include: Mobility Devices (walkers, wheelchairs, motorized scooters), Transfer Devices (mechanical lift/sit-to-stand lift and gait belts. Note: ensure any slings/belts use with lifts are in good condition), and Devices Associated with Entrapment Risks (physical restraints, bed rails, specialty air-filled mattresses)

      • Resident-to-Resident Altercations – The facility should take reasonable precautions and provide adequate supervision, when the risk of resident-to-resident altercation is identified, or should have been identified. Staff should be educated in identifying risks factors for altercations:
        • Resident with history of aggressive behaviors with other residents
        • Resident with behaviors that may disrupt or annoy other residents, which could precipitate a negative response from others.
      • Vulnerability – The facility has a responsibility to respect resident’s rights and at the same time, protect them from harm. This should be done through education of the resident/family and working with them to find the safest options for each individual.
        • Regulatory guidance states – Verbal consent or signed consent/waiver forms do not eliminate a facility’s responsibility to protect a resident from an avoidable accident, nor does it relieve the provider of its responsibility to assure the health, safety, and welfare of its residents.
      • Environmental Hazards – Supervision and/or containment of hazards are needed to protect residents from harm caused by environmental hazards. Examples of hazards might include fire doors that have been propped open, disabled locks or latches, nonfunctioning alarms, buckled or badly torn carpets, cords on floors, irregular walking surfaces, improper storage and access to toxic chemicals, exposure to unsafe heating unit surfaces, and unsafe water temperatures.
        • Staff should be educated on identifying and properly reporting environmental hazards.
        • Preventive maintenance and QA should include some type of routine monitoring to minimize or prevent these hazards.
      • Electrical Safety – Any electrical device, whether or not it needs to be plugged into an electric outlet, can become hazardous to the residents through improper use or improper maintenance. Examples: Halogen lamps or heat lamps, extension cords, power strips, electric blankets/heating pads.
        • Facility policy(s) should address any electrical items that are not allowed to be brought in to the facility and/or any electrical items that need to be inspected by maintenance before use.
        • Staff, residents and families should be educated on these policies.
      • Falls – Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., when a resident pushes another resident). Regulatory guidelines list the following as proper actions to take following a fall:
        • Assess for injury and provide treatment as necessary
        • Determine what may have caused or contributed to the fall – what was the resident trying to do before the fall
        • Address risk factors for the fall
        • Revise the plan of care and/or facility practices, as needed, to reduce the likelihood of another fall.
      • Elopement/Wandering – Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so.
        • Facilities should have policies in place for assessing/identifying residents at risk for elopement, and how to manage/monitor those at risk.
        • If alarm systems are used, then routine maintenance and testing should be done according to manufacturer’s recommendations.
        • Education should be provided to staff for proper steps to be taken when responding to a door alarm or the event of a potential elopement, in accordance with facility policy.


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:

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

Surveyors utilize the CMS 20127 – Accidents Critical Element Pathway form when they are reviewing a resident who requires supervision and/or assistive devices to prevent accidents and to ensure the environment is free from accident hazards as is possible. This pathway provides a step-by-step checklist that incorporates the Guidance Overview, Risks and Environmental Hazards, and Key Elements of Noncompliance. Facilities can utilize this Pathway tool as part of their Quality Assurance process to achieve and maintain compliance with F689.

Preventing Accident Hazards

  1. Assess for risks – resident specific and environmental risks
  2. Develop individualized resident care plans based on their comprehensive assessment
  3. Ensure consistent care plan implementation
  4. Educate staff and monitor their compliance with safety and accident prevention policies and procedures
  5. All staff should be responsible for maintaining a safe environment and should be trained on potential risks and preventative measures.
  6. Confirm that policies are followed when an accident/incident occurs


Contact Proactive for a review of policies and programs related to accident prevention, or for care plan reviews and intervention guidance. Make plans to join us for the upcoming Fundamentals of Defense webinars October 5, 6 (Part 1) and November 2-3 (Part 2). Access the on-demand Standards of Care: Fall Prevention & Management webinar.


Angie Hamer, RN, RAC-CT, Proactive Medical Review

Learn more about the rest of the Proactive team.