Leadership Strategy Is the Difference Between Accident Prevention and F689 Citations
Insights from Colleen Toebe, MSN, CWCN, RAC-MTA, RAC-MT, DNS MT – Vice President of Clinical Services
As I work with nursing home leaders across the country, one thing is clear: accident prevention is no longer just a clinical priority. It is a leadership, quality, risk management, and survey readiness priority.
For Nursing Home Administrators and Directors of Nursing, the challenge is not simply recognizing that falls, medication errors, elopement risks, injuries of unknown origin, delays in treatment, and other high-risk events exist. The real challenge is ensuring the systems designed to prevent harm are working consistently at the bedside—every day and on every shift.
F689, Free of Accident Hazards/Supervision/Devices, is currently the #2 citation in the nation, with 3,321 citations so far in FY 2026 and 19.5% of SNF providers cited. CMS Appendix PP reminds facilities that the resident environment must remain as free of accident hazards as possible and that each resident must receive adequate supervision and assistive devices to prevent accidents.
When I review this data, I do not just see citation numbers. I see an opportunity for leaders to pause and ask deeper questions:
• Do we truly understand where our accident risks exist?
• Are interventions individualized and consistently implemented?
• Are we learning from incidents—or simply documenting them?
The Office of Inspector General (OIG) has also identified significant concerns related to the underreporting of falls with major injury in nursing homes, resulting in inaccurate federal quality data. According to the OIG analysis, 43% of serious falls requiring hospitalization were not reported on federally mandated Minimum Data Set (MDS) assessments, despite reporting being a regulatory requirement. Inaccurate reporting ultimately impacts the quality data families rely upon when evaluating nursing homes.
Accident prevention cannot rest solely on policies, annual education, or completed incident reports. It requires visible leadership, interdisciplinary ownership, real-time follow-through, and honest root cause analysis. The most effective organizations are those where leaders stay close to the work, ask the right questions, and foster a culture where teams feel accountable for prevention—not just response.
Source: CMS State Operations Manual, Appendix PP – Guidance to Surveyors for Long Term Care Facilities; U.S. Department of Health and Human Services Office of Inspector General (OIG), “Hospitalizations of Nursing Home Residents for Serious Injuries From Falls Were Frequently Not Identified and Reported as Required,” OEI-06-11-00370.
Leadership strategies for operational implementation:
- Hardwire risk identification into daily operations. Use daily clinical meetings, stand-up, QAPI, and change-of-condition reviews to identify residents with evolving fall, medication, behavioral, environmental, or supervision risks.
- Strengthen root cause analysis beyond the incident report. Ask whether the care plan, supervision approach, environment, assistive devices, staffing patterns, communication, and follow-up interventions matched the resident’s actual risk.
- Audit high-risk systems before surveyors do. Focus audits on falls, elopement, medication-related incidents, injuries of unknown origin, delayed treatment, bed rail use, abuse and neglect concerns, and advance directive-related risk decisions.
- Build accountability from bedside to boardroom. Accident prevention must be owned by nursing, therapy, environmental services, pharmacy, medical providers, leadership, and QAPI—not delegated to one department after an event occurs.
How Pathway Health Can Assist Leaders
At Pathway Health, we understand the pressure nursing home leaders are under. You are balancing resident safety, staffing challenges, regulatory expectations, family concerns, clinical complexity, and operational demands—all while trying to keep your teams focused and proactive. Our role is to come alongside leaders with practical, focused support that helps identify risk, strengthen systems, and improve readiness.
Pathway Health can support nursing home leaders with a focused view of accident prevention, incident management, fall prevention, and organizational risk management processes. Support options include:
Mock Survey Support
A focused review to help leaders evaluate accident prevention practices, survey readiness, documentation, follow-up, and operational implementation. Contact us for special pricing.
Targeted Mock Survey: Accident and Fall Prevention Programs
A targeted review of the organization’s accident and fall prevention programs, risk management processes, and root cause analysis reviews to identify system gaps and opportunities for improvement. Contact us for special pricing.
Customized Education and Training
Tailored education for nursing home leadership and interdisciplinary teams focused on accident prevention, fall prevention, post-fall response, incident investigation, risk identification, documentation, and sustainable operational implementation.
Practical Tools Available through the Pathway Health Store
Leaders can order resources designed to support implementation, audit readiness, and staff education, including:
Fall Prevention and Post-Fall Response Workflow
Chart Audit Tools, including: Elopement; Falls; Delay in Treatment; Injury of Unknown Origin; Abuse and Neglect; Advance Directive; Bed Rail Use
Complimentary Leadership Resource: Download the complimentary Post-Fall System Review Tool for Leaders to help evaluate post-fall response, root cause analysis, care plan revision, and follow-through on risk reduction strategies.
