The facility failed to develop and implement updated care plan interventions for two residents. One resident with severe cognitive impairment, transfer dependence, and a history of fracture had three unwitnessed falls, but the care plan was not updated with new fall interventions. Another resident with moderately impaired cognition and ADL deficits had only limited bathing and dressing assistance in the care plan, despite family reporting the resident was left unattended and unclothed with water spilled on the floor and concerns that more ADL support was needed.
A resident with MS, muscle wasting and atrophy, and acute and chronic respiratory failure with hypoxia had a care plan requiring two staff for bed mobility, based on MDS findings of bilateral UE/LE impairment and dependence for rolling and hygiene. A CNA provided linen care alone despite the two-person assist requirement, and the resident rolled off the bed, sustaining a forehead laceration, right ankle sprain, and abdominal wall contusion; the CNA said she was unaware of the requirement, and the LPN and DON confirmed the care plan was not followed.
Incomplete Care Plans for Residents with Foley Catheters: The facility failed to include Foley catheter care in the comprehensive care plans for two residents. One resident had diagnoses including HTN, DM, Alzheimer's disease, and BPH, with an MDS showing an indwelling catheter and MD orders for catheter site assessment and catheter care every shift, but no catheter plan was in the care plan. Another resident's MDS triggered urinary incontinence and indwelling catheter, and MD orders included Foley catheter care, but the care plan still did not address the Foley. The MDS Coordinator said the comprehensive care plan had not yet been updated, and the DON, IP, and Administrator confirmed the care plan was incomplete.
A resident with atrial fibrillation was ordered Eliquis and the MDS showed anticoagulant use, but the care plan did not address anticoagulant therapy. Staff interviews confirmed the plan should have included monitoring and care guidance related to bleeding risk, bruising, and related interventions.
A resident admitted with PTSD and depression had a psychiatrist order for Mirtazapine and a BIMS score showing intact cognition, but the care plan did not include PTSD-related goals or interventions. The resident confirmed the PTSD diagnosis, an LPN/unit manager said the diagnosis was included in the original order, and the SSD stated she was not aware of the diagnosis despite reviewing the psychiatrist’s notes.
The facility failed to develop comprehensive care plans for two residents. One resident was receiving continuous oxygen and nebulizer treatments for respiratory failure, but oxygen therapy was not addressed on the care plan and staff confirmed there was no oxygen order in place. Another resident had severe cognitive impairment and spoke Vietnamese, but the care plan did not identify communication needs despite staff noting language and communication concerns.
Failure to develop comprehensive care plans for oxygen therapy and wounds. Two residents with physician orders for O2 therapy had no care plan focus areas for oxygen use, and a resident with multiple pressure ulcers had no wound care plan. The DON confirmed the missing care plans, and the RN MDS Coordinator acknowledged the wound care plan for the resident was not developed.
Surveyors found that the facility failed to develop and implement complete, person-centered care plans for two residents. One resident was receiving an antipsychotic (Haloperidol) for schizophrenia with associated behavior and side-effect monitoring orders, but there was no corresponding care plan addressing antipsychotic use or its indication. Another resident had an indwelling Foley catheter for neurogenic bladder related to prostate cancer, with goals to prevent catheter-related trauma; however, the care plan omitted key interventions such as balloon volume parameters and use of a leg strap or securement device, despite physician orders requiring a leg strap and observations showing the catheter positioned under the leg without securement. An MDS coordinator and the administrator acknowledged that required interventions and standard catheter care components were missing from the care plans.
Incomplete Oxygen Therapy Care Plan: A resident with asthma had a physician order for oxygen at 2 LPM via NC, but the comprehensive care plan did not include individualized interventions tied to the prescribed flow rate. The MDS Coordinator confirmed the plan lacked specific oxygen-related guidance for staff, including following the ordered rate.
Care plan not updated for a resident with dementia and severe cognitive impairment who was identified as wandering and exit-seeking. Staff observed the resident wandering the halls, touching the med cart, and entering other residents’ rooms, while interviews confirmed this happened often. The care plan addressed location checks but did not include interventions for entering other residents’ rooms.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.