F699 Citations: What Surveyors Are Really Looking For

If you've received an F699 citation — or you're trying to prevent one — there's something important to understand right away. Surveyors citing F699 aren't primarily looking for missing paperwork. They're looking for evidence that a person was harmed, or placed at risk of harm, because your facility failed to see them literally and figuratively.

F699 is grounded in §483.25(m) of the State Operations Manual (SOM), which requires that residents who are trauma survivors receive culturally competent, trauma-informed care — care that actively works to eliminate or reduce triggers that could cause re-traumatization. The tag exists not to create a new compliance box, but to make visible the impact of something that was already happening in long term care settings: residents were, and still are, being retraumatized by routine care.

What the Surveyor Is Actually Measuring

The key elements of noncompliance under F699 fall into three areas. First, did the facility identify the resident's cultural preferences? Second, did the facility identify the resident's trauma history and recognize specific actions that re-traumatize? This is not about specific events a history can expose, it’s about how their impact shows up. Third, did staff consistently use trauma informed approaches in actual care delivery — not just in the care plan?

Notice what's in the center of all three questions: consistency, relationship, and outcomes. A care plan that documents trauma isn’t met with different behavior from staff members as they assist a resident to the bathroom — or how a night shift aide responds to a resident who wakes up screaming — is not trauma informed care. It is trauma informed documentation. Those are not the same thing.

In reality, all LTC residents have histories of trauma, just like staff: everyone has been overwhelmed by something so powerful they think they might die, be badly injured or lose their mind. Perhaps only 20% will need mental or behavioral health treatment for their past experiences. The rest, or really all of us, need interactions that are sensitive to the impact of these events in our lives.

The chronic “uneasiness” from which we all seek escape in these relationships? That feeling that we all want to avoid, staff, residents and family alike? That feeling matters.

The Psychosocial Culture Behind the Citation

At The Trauma Informed Academy, we see F699 citations most often as symptoms of something deeper than a documentation gap. They are evidence of a facility culture that hasn't yet integrated trauma awareness into its relational practices — how staff relate to staff and with residents moment to moment, shift to shift.

The guidance is explicit: the transition to a long-term care setting itself is traumatic and may be profoundly re-traumatizing. Loss of independence, loss of privacy, exposure to strangers performing intimate care, power differentials that reduce resident openness— these are not clinical edge cases. They are the daily reality of nursing home life. Facilities need to account for this in their culture, training, relationships and their universal care plans. Otherwise, retraumatization becomes routine. The gaps this causes is what surveyors are trained to find.

What This Means for Your Team

An F699 citation is a signal that the distance between what your organization says it values and what residents actually experience has become wide enough to cause harm. Closing that gap isn't a compliance project. It's a workforce development and culture project — and it starts with building your team's Trauma-Responsive Emotional Intelligence (TR-EQ).

TR-EQ is the capacity to recognize trauma responses — in residents, in colleagues, and in yourself — and to respond in ways that reduce harm rather than compound it. It's the foundation of what surveyors are looking for, even when they don't use that language, looking for what is evident as well as what is missing.

Somehow, it means being willing to “lean in” to the discomfort instead of trying to avoid it--something that is necessary to resolve it with the highest level of integrity for staff and residents.

Ready to help your team close the gap between policy and practice?

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