F684: quality of care
Short answer
F684 is the nursing home quality of care tag. It covers care that no other section 483.25 tag covers. Care must meet professional standards, the person-centered care plan and the resident's choices. Surveyors use it for non-pressure wounds, end-of-life and hospice care, and a missed change in condition.
- Tag title
- Quality of Care
- Regulation
- 42 CFR 483.25 (opening paragraph); used when no other 483.25 tag fits
- Guidance relied on
- Appendix PP Rev. 232 (issued 07-23-25, in use since 04-28-25); F684 section Rev. 229 (04-25-25, implementation 04-28-25)
- Core test
- Avoidable or unavoidable decline
- Reporting clock
- None of its own. Immediate physician and representative notice of significant change (F580); immediate hospice contact
- Severity note
- CMS says level 1 does not apply
- How often cited
- 2,660 citations nationally in the first half of 2026, fourth most cited (Wisconsin DHS summary)
Applies to: Medicare-certified skilled nursing facilities · Medicaid-certified nursing facilities
What F684 covers
42 CFR 483.25 says quality of care applies to all treatment and care. Residents must get care based on the comprehensive assessment. It must meet professional standards of practice, the comprehensive person-centered care plan and their choices. F684 covers concerns no other tag fits.
Most care topics have their own tag. Vision and hearing are F685, pressure ulcers F686, accidents F689, continence F690 and enteral feeding F693. IV fluids are F694, respiratory care F695, pain F697 and bed rails F700. CMS says to use F684 only when no other rule covers the problem, such as assessment, care planning or physician supervision.
Examples in the guidance: non-pressure skin ulcers and wounds (arterial, diabetic neuropathic and venous), and end-of-life and hospice care.
How surveyors judge avoidable decline
When a resident declines or fails to improve, surveyors ask if it was avoidable. It is unavoidable only if the home did all four of these:
- Did an accurate, comprehensive assessment of condition and risks.
- Built a person-centered care plan with the resident or representative, with interventions that fit needs, goals and standards.
- Carried out the plan and watched the response.
- Reviewed and revised the plan as needed.
If one is missing and the resident declined, CMS treats the decline as avoidable. A resident who refuses care must be told the risks and benefits, offered alternatives and helped to limit decline.
What surveyors investigate and ask for
Surveyors use the General Critical Element Pathway. If it applies, they use the Hospice and End of Life Care and Services pathway. For a resident in the building under 14 days, they review the baseline care plan, due within 48 hours.
| Surveyors ask for | Have ready |
|---|---|
| Recent comprehensive assessment, care plan and orders | Proof the need was seen and the order matched the care plan |
| Proof orders were followed | Monitoring at the ordered frequency, such as daily weights or wound measurements |
| Change in condition | When it was noticed, who assessed it, and physician and representative notice (F580) |
| Care plan revision | A dated revision after the resident's response to interventions |
| Resident refusal of care | Risk and benefit talk, alternatives offered, steps to limit decline |
| Hospice residents | The written agreement, coordinated care plan and a log of communication with the hospice |
What makes an F684 deficiency more severe
F684 sits in section 483.25, which counts toward substandard quality of care, CMS's label for serious findings. It applies at immediate jeopardy (serious harm happened or is likely). It also applies at pattern or widespread actual harm, or widespread potential for more than minimal harm. Surveyors also look for signs of psychosocial distress.
| Level | Example from CMS guidance |
|---|---|
| 4: immediate jeopardy | No prompt action on an acute change in a resident's heart failure. The family called 911 and the resident was admitted with respiratory distress and pulmonary edema. Repeated failure to carry out care-planned comfort measures led to uncontrolled vomiting and nausea |
| 3: actual harm | A stasis ulcer care plan was not followed and the wound grew. A coordinated plan said no hospital transfer, but the resident was sent without contacting hospice. A symptom plan was not followed and the resident was too drowsy to talk with family |
| 2: potential for more than minimal harm | No daily weights on three consecutive weekends for a resident with heart failure. A bowel plan in the coordinated care plan was not consistently carried out |
CMS says level 1 does not apply to F684.
Notification clocks
F684 has no reporting clock of its own. Under 42 CFR 483.10(g)(14) (F580), the home must immediately inform the resident, consult the physician and notify the representative. It must do so after an accident with injury, a significant change in condition, or a transfer or discharge decision. It must also do so when treatment needs to change significantly. For a hospice resident, also tell the hospice immediately about significant changes. Examples are sudden decline or a fall with a suspected fracture.
Documentation gaps that lead to citations
- An aide notices a change, but it never reaches a nurse or physician.
- Physician and representative notice is not time-stamped.
- An order, such as daily weights, was missed until the resident worsened.
- The care plan is unchanged after the resident worsened.
- A resident declined care with no record of risks or alternatives discussed.
- Hospice communication is verbal and undocumented.
- Unexpected hospital transfers are never reviewed, so patterns stay hidden.
How to show a good investigation and fix
When a resident worsens or goes to the hospital unexpectedly, test the case against the four steps above. The record should show when the change was noticed, who was told and when, and whether the care plan was followed. Fix the process, not just one chart: aide reporting, handoffs, order tracking or monitoring. Then check the fix held. Take the pattern to the QAA committee.
How IncidentKit supports F684
IncidentKit runs alongside your EHR and does not hold the clinical record. It records events behind F684 citations: an unexpected transfer, a missed order, a change in condition not escalated. Lauren drafts the incident for a person to review and sign. Investigations and corrective actions track the fix to a verified close, and analytics show clusters by location, shift and cause.
How IncidentKit supports this requirement
| What the rule asks for | Where it lives in IncidentKit |
|---|---|
| Recognize and act on a change in condition | Staff report by text, QR quick report, email or web form. Routing and escalation alerts the roles you set. |
| Show when staff noticed, assessed and notified | The incident record and audit trail log who recorded what and when. Your EHR keeps the clinical record. |
| Find why a plan was not followed | Investigations record contributing factors and five whys. Human-authored RCA templates are rolling out. |
| Revise the plan and monitor the response | Corrective actions carry an owner, due date, evidence and an effectiveness check. Nothing closes until verified. |
| See patterns the committee should act on | Analytics show clusters by location, shift, equipment and cause. |
Product parts involved: Incident reporting, Lauren, the AI assistant, Routing and escalation, Investigations and RCA, Corrective actions (CAPA), Analytics, Audit trail. Capabilities marked “rolling out” are being released in stages; see the changelog.
Frequently asked questions
When does CMS use F684 instead of a specific tag?
Only when no other section 483.25 tag fits a concern that could cause a negative outcome. Topics with their own tag, such as pressure ulcers, falls, pain and catheters, are cited there.
What is an avoidable decline?
A decline is avoidable when the home missed one or more of four steps. The steps are assessment, care plan, carrying it out and review. It is unavoidable only when all four were in place.
Does F684 apply to residents on hospice?
Yes. The home must keep a coordinated plan with the hospice, immediately communicate significant changes in condition, and keep the written agreement. Surveyors may ask for the agreement and communication records. Hospice failures go to the state agency that oversees hospices.
Which clinical records do surveyors look at first?
The latest comprehensive assessments, comprehensive care plan and orders, to see if the home recognized the need. For a resident in the building fewer than 14 days, they review the baseline care plan, due within 48 hours.
Is there a reporting deadline attached to F684?
Not of its own. The related duty is immediate notice, not a set number of hours. The home must inform the resident, consult the physician and notify the representative. This applies after a significant change in condition, an accident with injury, a treatment change or a transfer decision.
Sources
- eCFR, 42 CFR 483.25 (quality of care), current through 2026-10-01
- CMS State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities (Rev. 232, issued 07-23-25; revised guidance used on surveys since 04-28-25): F684 section (Rev. 229, issued 04-25-25, effective 04-25-25, implementation 04-28-25)
- eCFR, 42 CFR 483.10 ((g)(14) notification of changes), current through 2026-10-01
- CMS State Operations Manual, Chapter 7, Survey and Enforcement Process for Skilled Nursing Facilities and Nursing Facilities (Rev. 244, issued 06-26-26): scope and severity matrix, immediate jeopardy, substandard quality of care
- eCFR, 42 CFR 488.301 (definitions: immediate jeopardy, substandard quality of care), current through 2026-10-01
- CMS memo QSO-25-14-NH (revised 2025-03-10): Revised Long-Term Care Surveyor Guidance, effective April 28, 2025
- Wisconsin Department of Health Services, Top Ten Federal Health Citations, First Half 2026 (national, state and CMS Region 5 citation counts)
Reviewed against the sources above on Oct 5, 2026. Rules change: confirm current requirements with the issuing body or your counsel before relying on any summary.
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