F684 — Quality of Care
Catch-all citation for failure to provide care and services consistent with the resident's comprehensive assessment and care plan to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Frequently cited for missed treatments, medication errors, and clinical decline.
Reg cite · 42 CFR 483.25
257 surveys in corpus
34 states
What surveyors look for
- Treatments documented as completed on the TAR/MAR, with no extended gaps in administration
- Resident outcomes (weight, ROM, skin integrity, behavior) trending in line with care plan goals or with documented justification when not
- Hand-off communication ensures continuity across shifts, especially weekends
- Use of evidence-based practice standards (AHRQ, Braden, MNA, fall risk tools)
Common gotchas
- Order written but not transcribed onto the active TAR within 24 hours
- Treatment 'held' multiple times without physician notification
- Decline in ADL function not investigated for reversible cause
- Vital signs documented within normal range but the resident is clinically distressed
Real survey examples
From CMS-published 2567s in our corpus. Resident identifiers redacted.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
.
Based on record review, observation, and interview, the facility failed to ensure 1 resident (#40), out of 14
sampled residents received quality care. Specifically,1) a Certified Nurse Aide (CNA #2) failed to follow 2
person assist during a transfer and toileting as specified in the comprehensive care plan; 2) CNA #2 did not
safely handle the resident during transfer; and 3) the internal doorway to Resident's room was…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
trained on transferring residents and lift devices during orientation. She further stated Resident was a
2-person assist, and staff should never pull on residents while assisting them. In addition, resident
doorways should remain clear because resident safety was a priority.
During an interview on [date] at 10:25 AM, CNA #4 stated when a Hoyer lift was needed inside of a
resident's room, he/she would park it by the end of the resident's bed or in the bathroom, but never in front
of the door where it could block …
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
.Based on record review, interview and observation, the facility failed to ensure care and services were
provided in accordance with professional standards of practice and the comprehensive person-centered
care plans for 3 residents (#12, #18, and #68) out of 43 residents (total census). Specifically, the facility
failed to follow standards, care plan interventions, and physician's order directing staff not to obtain b…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
readings obtained in the right arm on [date], [date], [date] (3:37 AM), [date] (8:50 AM) and
[date].During interview on [date] at 8:50 AM, when asked how blood pressure readings should be
assessed on Resident, Licensed Nurse (LN) #2 stated: Place the cuff on his/her arm and take the BP.
you can use either arm, he/she doesn't have any restrictions.Review of the facility-provided standard used
in resident care Lippincott Nursing Procedures Ninth Edition book, dated 2023, revealed: .Don't measure
blood pressure in…
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
.Based on record review, observation, and interview, the facility failed to ensure 1 resident (#29), out of 18
sampled residents, received treatment and care, in accordance with the professional standards of practice
based on manufacture's recommendations. Specifically, the facility failed to use an appropriately sized lift
sling while using a mechanical lift (a device designed to assist in the safe lifting and transfer…
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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