F689 — Free from Accident Hazards / Supervision
Most-cited F-tag nationally. Failure to ensure the resident environment is as free of accident hazards as is possible, and that each resident receives adequate supervision and assistance devices to prevent accidents — falls, elopement, choking, burns, scalds, entrapment, abrasions.
Reg cite · 42 CFR 483.25(d)
295 surveys in corpus
37 states
What surveyors look for
- Fall risk assessment within 24 hours of admission; reassessment quarterly and after every fall
- Individualized interventions (not generic 'fall risk' care plan): bed alarms, low beds, fall mats, hourly rounding, supervised toileting
- Post-fall huddles within 24 hours, with root cause analysis and care plan revision
- Elopement risk assessment with WanderGuard, door alarms tested and working
- Equipment in good repair (no broken bedrails, broken commode chairs)
Common gotchas
- Bed alarm ordered but not in use during survey observation
- Multiple falls without escalating interventions — same care plan after fall #1 and fall #4
- Hourly rounding documented as 'completed' for periods staff weren't on the unit
- Elopement risk resident with door code posted visibly in the unit
- Falls in toileting incidents repeatedly involving the same staff or same shift
Real survey examples
From CMS-published 2567s in our corpus. Resident identifiers redacted.
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficient
practice was cited as a result of the investigation of complaint/report number AL00042944.
*********************************************************
The facility took immediate action to correct the noncompliance by:
1. Reported the incident to Alabama Department of Public Health (ADPH) [date] and conduct…
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
appropriate size sling to according to the RI #103's weight during transfer using the mechanical lift. EI #7
stated she observed RI #103 slipping from the mechanical lift sling, resulting in RI #103 falling from the lift
and hitting his/her head on the floor. RI #103 sustained a laceration to the scalp, with a hematoma (blood
collected or pooled under the skin). RI #103 was transported to the local hospital for evaluation. While at the
hospital, RI #103 was found to have a laceration to the scalp that requ…
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
resident, and as I started to move (him/her) (he/she) started sliding out of the sling and then went
backwards and hit (his/her) [NAME] (head). The nurse on the hall immediately came to address the
situation .
A handwritten statement dated [date], signed by EI #8 RN documented: I was coming around the
corner at nurses desk, when I heard a staff yelling, we need a nurse. resident . was laying on the floor,
(his/her) left leg still in the sling. With CNA next to (his/her) and another staff member. As I got t…
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
On [date] at 12:30 PM, an interview was conducted with EI #8 RN. EI #8 said, she heard someone
say they needed a nurse. EI #8 stated, when she got on the hall, she observed RI #103 on the floor and RI
#7 was by RI #103's side. EI #8 stated, she observed blood on the floor. When asked how RI #103 came to
be on the floor, EI #8 said, she assumed RI #103 fell from the lift. EI #8 stated that RI #103 required a
mechanical lift for transfers and the facility's policy was to use a two person assist with a mechan…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, interviews, and facility policy review, facility failed to conduct a thorough falls root cause
analysis for two of eight residents (Residents(R) 137 and R3) reviewed for falls of 38 sample residents. This
failure could result in the facility's inability to discover the reason behind the resident's fall…
Accepted POC examples
Real accepted-POC examples for this F-tag are not yet in the open corpus. The POC drafter above generates a structurally correct draft from CMS S&C Letter 13-21's four-question schema — edit it to fit your facility's specifics before submission.
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