Free of Accident Hazards, Supervision & Assistance Devices
Cited for F689? Here's what surveyors were looking for, how serious it tends to be, and how to structure a Plan of Correction that holds up.
Citation figures from the CMS Provider Data Catalog. Rank reflects the most recent CASPER data.
What the regulation says
What F689 actually means
F689 is one of the most-cited tags in the country, currently #4 nationally, because it covers the single most common source of resident harm: accidents. The regulation, 42 CFR §483.25(d), has two parts. First, the resident environment has to stay as free of accident hazards as possible. Second, each resident has to receive the supervision and assistance devices they need to prevent accidents.
In plain terms: if your facility identified that a resident was at risk, for falls, for wandering, for burns, for anything, surveyors expect to see that you put a plan in place, actually carried it out, and adjusted it when things changed. Most F689 citations aren't about a freak accident. They're about a gap between what the facility knew about a resident's risk and what it actually did about it.
What surveyors check
Surveyors work backward from an incident or an identified risk. They'll pull the resident's fall-risk assessment, elopement assessment, or other risk screens and ask: did the care plan reflect that risk? Were the interventions specific and actually in place? Is there evidence staff followed them?
When a resident's status changed, a new medication, a decline, a prior fall, did the facility reassess and update the plan? They also look at the environment itself: unsecured hazards, water temperatures, wheelchair and bed-rail safety, secured units for residents who wander. The recurring theme they're testing is whether your systems connect risk identification to action, and whether that action was monitored over time rather than just documented once.
What most often triggers it
- Falls, especially repeat falls where the care plan wasn't updated after the first one
- Elopement or wandering by a resident with known exit-seeking behavior
- Burns from hot liquids, food, or unregulated water temperature
- Unsafe use of bed rails, wheelchairs, or mechanical lifts, including transfer injuries
- Accessible hazardous chemicals or medications
- Resident-to-resident altercations that result in injury
- Smoking-related incidents where supervision requirements weren't followed
How serious is it? Scope & severity
F689 spans nearly the full scope-and-severity grid, which is part of why it's cited so often. At the lower end (D–E), it's an isolated or pattern deficiency with no actual harm, a missing intervention caught before anything happened. In the middle (G), a resident was actually harmed; a fall with a fracture is the classic example. At the top (J, K, L), it becomes Immediate Jeopardy, an elopement that led to serious injury or death, or a pattern of accidents reflecting a systemic breakdown.
The same tag can be a minor finding or the most serious citation a facility receives, so the scope/severity level assigned drives how urgent and how far-reaching your Plan of Correction needs to be.
The CMS scope & severity grid runs from an isolated no-harm gap (A) up through widespread Immediate Jeopardy (L). The level a surveyor assigns drives how urgent and far-reaching your Plan of Correction must be.
Example citation
How to write the Plan of Correction
A defensible F689 Plan of Correction works through four standard elements:
1. Corrective action for the resident(s) named. Address the specific resident cited, reassess their risk, put the missing interventions in place, and document current status.
2. Identification of others at risk. State how you'll find other residents with the same risk (for example, audit all fall-risk or elopement assessments) and correct any gaps found.
3. Systemic change. Describe what changed so it doesn't recur, staff education on linking assessments to care-plan interventions, revised protocols, environmental rounds.
4. Monitoring. Define who audits what, how often, for how long, and how results report up through QA/QAPI.
The most common reason an F689 POC gets rejected: a vague monitoring plan, or corrective action that fixes the one resident without addressing the system that let it happen.
Cited for F689? Draft your Plan of Correction now.
Upload your Form 2567 and EasyPOC generates a tailored, CMS-aligned Plan of Correction in minutes.
Upload your citation →Need the policy behind it? Quality of Care policies & procedures →Common questions
What is F689?+−
F689 is the CMS F-tag for accidents, under 42 CFR §483.25(d). It requires that the resident environment stay as free of accident hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents.
What most commonly triggers an F689 citation?+−
Falls are the most common trigger, particularly repeat falls where the care plan wasn't updated. Elopement, burns, unsafe device use, and accessible hazards are also frequent.
How serious is an F689 citation?+−
It varies widely. F689 is cited anywhere from a no-harm "D" up to Immediate Jeopardy (J/K/L) when an accident causes serious harm or death. The scope/severity level determines how urgent your response must be.
How do you write a Plan of Correction for F689?+−
Address the cited resident, identify others at the same risk, make a systemic change (usually staff education plus protocol revision), and put a specific monitoring plan in place that reports through QA. Vague monitoring is the most common rejection reason.
Related tags
This page is a compliance reference and does not constitute legal or clinical advice.