F689: free of accident hazards, supervision and devices
Short answer
F689 is the CMS nursing home tag for accidents. The facility must keep the resident environment as free of accident hazards as possible and give each resident enough supervision and assistive devices. CMS cites falls, elopement, burns and unsafe equipment. A fall alone is not a deficiency; an avoidable one is.
- Tag title
- Free of Accident Hazards/Supervision/Devices
- Regulation
- 42 CFR 483.25(d)(1) and (d)(2)
- Guidance relied on
- Appendix PP Rev. 232 (issued 07-23-25, in use since 04-28-25); F689 section Rev. 225 (08-08-24)
- Severity note
- Level 1 does not apply. Immediate jeopardy examples: chemical access, unsupervised overdose
- Reporting clock
- None of its own. F580 notice and abuse clocks can apply
- How often cited
- 3,393 citations nationally in the first half of 2026, second only to F880 (Wisconsin DHS summary)
- Often cited with
- F580, F600, F604, F656, F700, F867
Applies to: Medicare-certified skilled nursing facilities · Medicaid-certified nursing facilities
What F689 covers
F689 enforces 42 CFR 483.25(d). CMS cites falls, elopement, scalds, unsafe smoking, chemical access, transfer and lift injuries, and hazardous equipment here.
The test is whether the accident was avoidable. It was avoidable if the facility missed one of four steps. The steps: identify the hazard or the resident's risk, evaluate and reduce it, put interventions in place, and monitor whether they worked.
Bed rails go to F700 and physical restraints to F604. F689 covers other hazardous devices, such as defective, misused, removed or poorly fitted ones. Resident-to-resident altercations (fights between residents) go to F600 first; F689 applies if the act was not deliberate.
What surveyors check and ask for
Surveyors use the Accidents Critical Element Pathway. They walk the building for hazards and review the assessment, care plan and orders for residents with a concern. For anyone in the building under 14 days, they also review the baseline care plan (due within 48 hours).
| Surveyors ask for | Have ready |
|---|---|
| Incident or accident report | Date, time, place, what the resident was doing, injuries, who was told, response |
| Fall risk assessment and the care plan in force that day | Risk factors, interventions, owners |
| Proof the plan changed after the event | Care plan revision dated after the event, with the reason |
| Supervision and staffing on that shift | Assignment sheets, supervision plan, call light and alarm response |
| Environment and equipment checks | Rounds logs, device inspections, hot water temperature logs, repair orders |
| QAA committee review of accidents | Trends by location, shift and time, and the action plans |
Incident and accident reports are open to surveyors; see F865. CMS also tracks falls with major injury as a quality measure (MDS item J1900C).
What makes an F689 deficiency more severe
Severity rises with harm, and scope rises with the number of residents and staff involved. Level 4 is immediate jeopardy: noncompliance that has caused or is likely to cause serious injury, harm, impairment or death.
| Level | Example from CMS guidance |
|---|---|
| 4: immediate jeopardy | Corrosive cleaner within reach of residents with dementia; one drank drain opener. A resident with known substance use disorder was away about five hours, unassessed for hours after return, then found unresponsive from an overdose. |
| 3: actual harm | The care plan's two-person transfer was not used; the resident fell and needed sutures. The care plan's smoking apron was not applied; the resident had a second-degree burn. |
| 2: potential for more than minimal harm | Clutter and building materials beside a walkway residents use. No consistent process to know when a resident with substance use disorder leaves. |
Once immediate jeopardy is removed, surveyors lower what remains at that tag to level 2, or to harm if other residents were also harmed. Section 483.25 findings can count as substandard quality of care, a CMS category for serious findings. This happens at immediate jeopardy, pattern or widespread harm, or widespread potential for more than minimal harm.
Reporting clocks that apply after a fall
F689 has no reporting clock of its own. Three others apply.
- Notify now. After an accident that causes injury and may need a physician, the facility must act immediately. It must inform the resident, consult the physician and notify the representative (42 CFR 483.10(g)(14), F580).
- Unexplained injury. If nobody saw the cause, the resident cannot explain it and it looks suspicious, it is an injury of unknown source. The F609 clocks run: 2 hours if abuse is alleged or serious bodily injury results, otherwise 24 hours.
- State rules. Some states require every fall to be reported to the state agency; check yours.
Documentation gaps that lead to citations
- The report says what happened, not what the resident was doing.
- The same intervention (non-skid socks, call light in reach) follows every fall.
- A position-change alarm is the only intervention; CMS says alarms should not be the primary or sole one.
- The care plan calls for a two-person assist, but no record shows it happened.
- Hazards staff notice are not logged, so nobody owns the fix.
- Nobody checks whether the new intervention worked.
Show a good investigation and corrective action
After a fall, CMS lists these steps: treat any injury, find the cause, address risk factors, and revise the care plan or practice. Record each step with a time and an owner.
- Examine and treatAssess, treat, and notify the physician and representative. Record the times.
- Retrace the eventWhere, when, what the resident was doing, footwear, equipment, staff on the unit.
- Name contributing factorsCheck CMS's list: environment, medications, acute change, continence, cognition, pain.
- Change the planGive the change an owner and start date. Set an interim measure if it cannot start today.
- Check that it workedSet a review date. Check falls and near misses for that resident, place and shift. Close only with evidence.
How IncidentKit supports F689
IncidentKit runs alongside your EHR and does not replace clinical assessment. Staff report by text, QR quick report, email or web form (voice reporting is rolling out). Lauren asks follow-up questions and drafts the investigation. A person always reviews, edits and signs; drafted fields read "Lauren · draft" until approved.
Investigations record contributing factors and disposition. Corrective actions carry an owner, due date, evidence and an effectiveness check. Analytics show clusters for the QAA committee.
How IncidentKit supports this requirement
| What the rule asks for | Where it lives in IncidentKit |
|---|---|
| Identify hazards and each resident's accident risk | QR quick report, text, email and web form capture hazards and near misses. |
| Evaluate and analyze hazards and risks | Investigations record contributing factors and five whys. Analytics show clusters by location, shift and cause. |
| Implement interventions with adequate supervision and devices | Corrective actions carry an owner, due date and evidence. |
| Monitor effectiveness and modify the plan | Each corrective action has an effectiveness check. Nothing closes until verified. |
| Notify the physician and representative after an injury (F580) | Routing and escalation alerts the roles you set, such as the DON. The audit trail logs each notification. |
| Show the QAA committee accident trends (F867) | Compliance packets include a QAPI summary built from incident and corrective action data. |
Product parts involved: Incident reporting, QR and quick report, Lauren, the AI assistant, Investigations and RCA, Corrective actions (CAPA), Analytics, Routing and escalation, Audit trail. Capabilities marked “rolling out” are being released in stages; see the changelog.
Frequently asked questions
Is every resident fall an F689 deficiency?
No. CMS says a fall does not necessarily mean deficient practice (failing the rule), because not every fall can be avoided. An avoidable fall, where the facility missed a step, is what gets cited.
Do bed or chair alarms satisfy F689?
No. CMS says alarms should not be the primary or sole intervention and do not replace supervision. If you use them, document why and check that they work.
Which records do surveyors usually ask for after a fall?
The incident report, fall risk assessment, care plan before and after the event, physician orders, shift staffing and QAA reviews of accident trends. Incident reports are not shielded from surveyors.
When is a resident injury an abuse or neglect issue instead of F689?
When the act was deliberate. A deliberate resident-to-resident altercation is reviewed as potential abuse at F600, even when a resident has dementia. A non-deliberate act stays at F689. Neglect at F600 needs evidence the facility knew or should have known and did not act.
Sources
- eCFR, 42 CFR 483.25 (quality of care, including (d) accidents), current through 2026-10-01
- CMS State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities (Rev. 232, issued 07-23-25; revised guidance used on surveys since 04-28-25): F689 section (Rev. 225, issued 08-08-24, implementation 08-08-24)
- eCFR, 42 CFR 483.10 ((g)(14) notification of changes), current through 2026-10-01
- CMS State Operations Manual, Chapter 7, Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities (Rev. 244, issued 06-26-26): scope and severity matrix, immediate jeopardy, substandard quality of care
- CMS memo QSO-25-14-NH (revised 2025-03-10): Revised Long-Term Care Surveyor Guidance, effective April 28, 2025
- Wisconsin Department of Health Services, Top Ten Federal Health Citations, First Half 2026 (national, state and CMS Region 5 citation counts)
- CMS, MDS 3.0 Quality Measures User's Manual v16.0 (effective October 1, 2023): falls with major injury, item J1900C
Reviewed against the sources above on Oct 5, 2026. Rules change: confirm current requirements with the issuing body or your counsel before relying on any summary.
Map this requirement to your records.
IncidentKit connects each rule to the incident, investigation and corrective action that satisfy it.