A resident with a foley catheter, scrotal abscess, active wound infection, and surgical wound care needs did not have a comprehensive care plan completed within the required timeframe after the MDS assessment. The MDS documented moderate cognitive impairment, an indwelling catheter, and wound care requirements, but the care plan was not completed until 24 days later. The ADON stated the care plan was not completed timely and should have been person-centered, accurate, and implemented within 7 days of the MDS.
Incomplete Comprehensive Care Plans: Multiple residents had care plans that did not reflect documented needs and treatments. Records showed omissions involving high-risk meds such as anticoagulants, opioids, insulin, wound care for pressure ulcers, EBP, discharge planning, activity preferences, weekly weights, edema with refusal to elevate legs, oxygen use, and dialysis details. The DON confirmed several of these omissions.
Incomplete Care Plans for Diabetes, Anticoagulant Use, and Edema: The facility failed to develop care plans for a resident with DM2 and for another resident with DM2, long-term anticoagulant use, and edema. Records showed insulin orders for the first resident and furosemide for the second, while observation found visible lower-leg redness and swelling in the second resident. The DON confirmed the missing care plan elements.
Failure to develop a care plan for a resident's behavioral health needs and SI. A resident with dementia, cognitive impairment, and moderate depression made a statement about hurting herself, later denied active SI, and had ongoing anxiety, insomnia, and increased behavior symptoms. Although an IDT review included an ASAP psych service order, the care plan did not address the resident's dementia-related behaviors or psychiatric service needs, and the DON confirmed the omission.
A resident with identified fall risk had a care plan intervention to use a fall mat, but the mat was observed stored under the bed while the resident was lying in bed. An RN confirmed the mat should have been placed on the floor next to the bed, and the DON acknowledged that the recommended use was floor placement when the resident was in bed and that the care plan was not person-centered or specific about this recommendation.
Surveyors found that two residents with documented unstageable pressure ulcers and identified needs for pressure ulcer care on their admission MDS and Care Area Assessments did not have corresponding pressure ulcer or wound care interventions included in their comprehensive care plans. One resident’s care plan lacked any pressure ulcer component despite multiple unstageable and deep tissue injuries noted on admission, and another resident’s care plan omitted pressure ulcer care until it was added at a later date. The DON acknowledged that the comprehensive care plans for these residents did not address their pressure ulcers or wound care needs, contrary to facility expectations.
Surveyors found that care plans for two residents were not updated to reflect current medical needs. One resident with COPD and other chronic conditions had a physician order for PRN oxygen at 2 L/min via nasal cannula, but this oxygen use was not included in the care plan, as confirmed by the DON. Another resident with multiple neurologic and urologic diagnoses, as well as wasting disease and sarcopenia, was observed with red, swollen ankles and legs; a physician note documented ankle edema, yet the care plan did not address this condition, which the DON acknowledged was missing.
Surveyors found that the facility failed to maintain comprehensive, person-centered care plans for two residents. One resident, at risk for PUs and later found to have a sacral wound with physician-ordered treatment, did not have wound care interventions added to the care plan for approximately two months after the wound was identified. Another resident with documented respiratory failure and pulmonary edema had a care plan that omitted O2 use as an intervention and lacked any problem, goal, or interventions related to hearing limitations or hearing aids. The DON confirmed these omissions and stated that hearing difficulties and O2 use should have been included in the residents’ care plans.
A resident was admitted with multiple diagnoses, including osteoporosis, epileptic spasms, GERD, hemiplegia/hemiparesis after cerebral infarction, insomnia, recurrent major depressive disorder, dementia, and a need for ADL assistance. Review of the care plan showed it only addressed elopement risk, dementia-related nutritional risk, and behavior changes after stroke, while omitting other significant conditions such as epileptic spasms, GERD, insomnia, depression, and ADL needs. During interview, the DON confirmed these omissions and acknowledged that the care plan was not person-centered and did not reflect the resident’s overall condition.
A resident was receiving supplemental O2 via nasal cannula and had a floor mat placed beside the bed, but the facility failed to develop and implement a comprehensive care plan addressing these interventions. Record review showed an active O2 order without corresponding care plan interventions, and there was no order for the floor mat. Observations confirmed the resident’s use of O2 and the floor mat, and both the ADON and DON acknowledged that these should have been included in the care plan but were not.
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 July 29, 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.