Jan 23 2026 | F684 – Quality of Care – The Basics

For those of you that may have missed the recent WHCA Top 10 citations for 2025, the number one federal citation in our state is F684-Quality of Care.

The Centers for Medicare & Medicaid Services (CMS) requires nursing homes to ensure that every resident receive the care and services they need to reach and maintain their highest practicable physical, mental, and psychosocial well-being. This is not new wording and has been a core of the nursing home requirements even before the Requirements of Participation (ROP) revisions in the last 10 years. In simple terms, nursing homes must do everything reasonably possible to help residents function and feel as well as they can, based on each resident’s health conditions and the normal aging and disease processes.

Quality of care applies to all treatments and services provided in a nursing facility. CMS clearly states that care cannot be one-size-fits-all. Instead, it must be based on a comprehensive and individualized assessment of each resident. This assessment looks at medical conditions, physical abilities, mental health, emotional well-being, and social needs. The information gathered by the facility is then used to create a person-centered care plan that reflects the residents’ preferences, goals, and choices. Knowing the residents’ choices and beliefs regarding their health care, treatment and services is key to demonstrating the facility’s actions and interventions taken towards each resident reaching their highest practicable level. For example, people have a right to make decisions that we may not make or that may not be in what is believed to be their best interest. However, with the knowledge of risks and benefits associated with these decisions, it is vitally important that the facility document the resident’s choices to demonstrate the “why” a resident’s status is what it is.

F684 also states that residents must receive care that follows professional standards of practice, meaning care is delivered according to accepted medical and nursing guidelines. Staff are expected to provide care competently, safely, and consistently. While each credentialed staff and professional has a personal responsibility for the care they provide, the facility is also responsible for the care, services and treatment provided in their certified and/or licensed setting.

The intent of F684 is to ensure that facilities identify problems early and provide needed care and services in a way that is centered on the residents. This includes meeting physical needs like pain control and mobility, mental needs such as cognition and mood, and psychosocial needs like emotional support, dignity, and meaningful relationships.

F684 also recognizes the importance of hospice and palliative care. Staff need to recognize the differences and similarities between the two. Hospice care provides comprehensive services for terminally ill residents, focusing on comfort and support for both the residents and their family. Palliative care can be provided at any stage of illness and focuses on improving quality of life by preventing and relieving suffering. Both types of care address physical symptoms as well as emotional, social, and spiritual needs.

Surveyors reviewing F684 do not only look for physical harm when determining facility failed practice or failure to meet the requirements under F684. They also evaluate residents for psychosocial distress, such as signs of fear, sadness, isolation, or loss of dignity. These outcomes are considered when determining the seriousness of a deficiency.

If a resident declines or does not improve, surveyors must decide whether the decline was avoidable or unavoidable. This is where facility documentation is critical. A decline is considered unavoidable only if the facility:

• Completed an accurate and thorough assessment.
• Developed and consistently implemented a person-centered care plan.
• Monitored the resident’s response to care.
• Updated the care plan as needed.

If any of these steps were missing, and harm occurred, the decline is considered avoidable, and the facility may be cited under F684.

Overall, F684 ensures nursing homes remain focused on individualized, respectful, and high-quality care that supports each resident’s overall well-being. If you have questions, please contact WHCA’s Elena Madrid.