Staff failed to develop a comprehensive, person-centered care plan for a resident who was cognitively intact and had diagnoses including anxiety, cardiac arrhythmia, vitamin deficiency, and pain. The only documented care plan focus was smoking, noting that the resident could smoke unsupervised and should avoid injury from unsafe smoking practices, with no care plan entries for ADLs, behaviors, or medical diagnoses. The administrator and MDS Coordinator acknowledged that the care plan should have been more complete and reported that the MDS nurse had been pulled to work as an RN on the floor, contributing to delays and backlogs in care plan development.
Failure to include blood thinner interventions in care plans: Two residents had orders for anticoagulants, but their care plans did not address the medications or include resident-specific, person-centered interventions. One resident had CKD, ecchymoses, cerebrovascular disease, TIA history, and prior cerebral infarction and was receiving apixaban for AFib; the other had COPD and paroxysmal AFib and was receiving rivaroxaban. The ADON, Administrator, and DON stated that residents on blood thinners should be addressed in the care plan with specific interventions.
The facility failed to include specific goals and interventions in the care plans for two residents. One resident with dementia, bipolar disorder, MDD, asthma, and a history of self-harm/suicide attempts had no care plan details for those conditions, and staff interviewed were unaware of the resident’s history or interventions. Another resident with obstructive sleep apnea had no care plan address for CPAP use at bedtime.
The facility failed to develop comprehensive person-centered care plans for two residents. One resident’s care plan did not include the resident’s goal to return to the community, despite being cognitively intact and stating that goal during interview. Another resident’s care plan did not address DNR/code status, even though the face sheet and physician orders reflected DNR and the DON stated care plans should address code status.
A resident with severe cognitive impairment, diabetes, atrial fibrillation, reduced mobility, and a history of falls had an incomplete care plan. The plan addressed oxygen use but did not include insulin monitoring, anticoagulant monitoring for Eliquis, high fall-risk interventions, or toileting needs, even though the resident was always incontinent and required extensive assistance with ADLs.
The facility did not ensure care plans were updated and individualized to reflect residents' current needs, including documentation of falls, transfer status, and the use of side rails. For example, a resident who fell and fractured a hip did not have this event or related interventions documented in the care plan, and two residents using side rails did not have this reflected in their care plans, despite physician orders and staff observations.
A resident with a colostomy, open abdominal wound, and need for ADL assistance did not have a comprehensive care plan addressing these needs. Staff confirmed that care plan meetings had stopped, and only fall risk was documented in the care plan, leaving critical care interventions unaddressed.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
A resident with Huntington's disease, traumatic subdural hemorrhage, and anxiety did not have a comprehensive, person-centered care plan addressing the specific symptoms and care needs related to Huntington's disease. Staff were not adequately informed about the disease, leading to fear, miscommunication, and misunderstanding of the resident's behaviors. Family and staff interviews confirmed that the lack of a disease-specific care plan resulted in inadequate and inappropriate care approaches.
Staff failed to complete a comprehensive care plan for a resident with multiple complex diagnoses after admission, and did not update another resident's care plan to address repeated behavioral incidents and a subsequent move to a locked unit. Interviews with the SSD, MDS Coordinator, Administrator, and DON confirmed that care plans were not completed or updated as required by facility policy.
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 June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account