Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A resident admitted after hip replacement surgery, cognitively intact and continent of bladder, had a baseline care plan indicating stand-and-pivot transfers. Shortly after admission, the resident reported that a CNA, unable to locate a bedpan and concerned about pain with transfers, suggested the resident could void in an incontinent brief if unable to wait, which upset the resident. Review of the baseline and comprehensive care plans showed they were not revised to include person-centered, comprehensive interventions following this incident. Staff interviews revealed that CNAs depend on care plans for transfer and toileting instructions, that care plans are expected to be available at admission, and that bedpans are typically stored in a main supply closet, while the DON acknowledged that no immediate care plan interventions were added after the event.
Care Plan Not Updated for Current Needs: A resident with diabetes, amputations, contractures, pain, and urinary retention had a care plan that still listed opioids, hand splints, foot care, and urinal assistance even though opioids had been stopped, hand splints were refused, and a Foley catheter was in place. The MDS showed the Foley catheter, but the care plan was not revised to reflect the resident’s current status.
Care plans were not accurately reviewed and revised for multiple residents. A resident with dementia had outdated fall interventions listed, did not have current wheelchair safety measures reflected, and had fall care plans that were not updated after falls. Another resident had abuse-related safety interventions in place, but they were not added to the care plan, and his fall care plan was also not revised after a fall. A third resident’s care plan omitted an order for Prevalon boots at all times and listed ambulation assistance even though therapy and the DON stated he did not ambulate.
Care Plan and Kardex Not Updated for Diet Change: A resident with vascular dementia, severe cognitive impairment, and Hospice services had a diet change to pureed foods with thin liquids, plus an order allowing regular texture comfort foods only with supervision. The care plan and Kardex were not revised to reflect the updated diet or the supervision instruction, and staff confirmed the records remained inaccurate.
A resident admitted with confusion, a history of falls, and moderately impaired cognition was care planned as a fall risk with limited initial interventions, but the care plan was not updated after multiple subsequent falls, including one with major injury. Although new fall interventions (such as a "Call for Help" sign and changes in mobility equipment placement) were documented in other records and observed in the room, they were not incorporated into the formal care plan. Staff described different fall interventions based on report and observation rather than a unified, updated care plan, and the DON confirmed that nursing staff had not revised the care plan to include the post-fall interventions.
The facility failed to keep care plans current for two residents. One resident’s plan still directed bilateral hand splints even though staff had switched to washcloths because the splints caused redness, and surveyors observed the resident without the ordered hand splints in place. Another resident’s plan still included Norovirus outbreak precautions after the outbreak had ended and still listed fluoxetine-related interventions even though the antidepressant had been discontinued. The DON, ADON, and other staff stated care plan changes should be updated when resident needs change.
A resident with Alzheimer’s disease, prior stroke, dysphagia, and aphasia had a care plan for a torticollis orthosis to be worn during meals, but staff observed the cushion was often not in place. The resident said it hurt and did not like it, and CNA, RN, OT, and PT interviews confirmed inconsistent use and discomfort. The care plan did not reflect the resident’s resistance, discomfort, or alternatives for neck alignment, and documentation of use was incomplete.
A resident with multiple chronic conditions had a PHQ-9 increase from minimal depression to moderate depression, along with documented statements about feeling depressed and thoughts of suicide. Although staff noted mood concerns, offered talk therapy, and briefly monitored behaviors, the care plan and treatment record did not reflect the resident’s changed mental status or include interventions for monitoring suicidal thoughts. During survey interviews, the resident reported contemplating suicide and a plan to obtain narcotics, while the DON stated the issue had been handled as a one-time situational event.
A resident with dementia, severe cognitive impairment, and an activated POA experienced a physical and verbal altercation with another resident and later displayed repeated physical aggression toward staff, including inappropriate grabbing. Despite these documented behaviors and a facility policy requiring care plan review and revision upon status change, the resident’s care plan initially lacked any mention of aggression or sexually inappropriate behavior. When surveyors reviewed the record, the electronic care plan history showed that aggression-related problems and interventions were only added later, while paper copies inaccurately reflected earlier creation dates, demonstrating that the care plan was not updated in a timely or accurate manner after the incidents.
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.
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.