F689 addresses accident hazards, adequate supervision and assistance devices under 42 CFR 483.25(d). A citation depends on the facility’s deficient practice and the facts, not merely on an accident occurring. We outline the records and operational questions to review after a finding without prescribing a single clinical intervention for every situation.
Start with the cited practice
The requirement concerns keeping the environment as free of accident hazards as possible and providing adequate supervision and assistance devices. Appendix PP explains how surveyors consider identified risks, assessment, interventions, monitoring and changes when an intervention is ineffective.
Read the narrative to determine whether the finding concerns an environmental hazard, an assessment gap, missing supervision, equipment or another failure. Do not treat F689 as a catch-all for every adverse event or infer scope and severity solely from the injury.
Review the evidence and current exposure
- Check the assessments and individualized care instructions that applied when the event occurred.
- Compare those instructions with assignments, handoffs, observations and staff accounts of what actually happened.
- Identify others exposed to the same hazard or process gap and arrange the appropriate assessment and protective action.
- Review equipment condition, maintenance records and environmental controls relevant to the finding.
- Check whether earlier incidents or monitoring findings called for a change that was never carried out.
Specific tools, observation intervals and device choices require individualized assessment. CMS does not prescribe the Morse Fall Scale for every nursing home, a universal 15-minute supervision interval or a standard 30-to-45-day correction allowance. State rules and the clinical circumstances may impose additional requirements.
Connect the PoC to actual work
For a deficiency requiring a PoC, address the affected people, others potentially affected, systemic changes, monitoring and completion dates. We recommend making each promised change traceable to an owner and supporting record. If a handoff failed, explain how the handoff will change and how you will check it in use.
Training or a new form alone does not establish that the underlying problem is corrected. Monitoring should test the practice, record findings and trigger action when the change fails. Choose the frequency and scope for the identified risk rather than copying a sample audit schedule.
Avoid substituting devices for assessment
Alarms, supervision arrangements and assistance devices need an individualized review. Restraints are subject to separate restrictions and cannot be used for discipline or convenience. A device label or consent form does not resolve those requirements. Clinical staff should determine the appropriate care response and document the reasoning.
If the facts support current IJ, use the immediate removal process without waiting for a routine PoC. Otherwise, follow the agency’s correction instructions and retain the evidence needed to verify implementation. No template guarantees acceptance or prevents another citation.
Sources and applicability
We checked these sources on . This guide covers federal requirements for Medicare- and Medicaid-certified nursing homes. State licensing and assisted living requirements need a separate check. Use the current agency notice for your facility and involve the appropriate clinical or legal adviser for decisions.
- CMS State Operations Manual, Appendix PP (opens in a new tab)
Tag-specific federal nursing home requirements and survey guidance. Read later amendments alongside this manual.
- CMS survey and enforcement guidance — effective March 30, 2026 (opens in a new tab)
Chapter 7: PoCs (§7317), scope and severity (§7400), IDR/IIDR (§§7212–7213), IJ (§7308) and remedies (§7500 onward).