Care plans were not revised after significant changes for four residents. One resident with PTSD and trauma history had no documented trigger assessment or inclusion of psychiatric counseling recommendations in the care plan. Another resident had significant weight loss, but the care plan remained contradictory and no significant change assessment was found. A resident with an unwitnessed fall and head bruise had no new fall-prevention interventions added, and another resident’s care plan was not updated after a diet order changed from thickened to thin liquids.
Surveyors found that the facility did not revise a resident’s oral/dental care plan after all teeth were extracted, leaving the plan to reference natural teeth in poor repair despite the change in condition. In addition, another resident reported never being involved in a care plan meeting since admission, while the MDS coordinator stated the resident declined participation but could not provide documentation of this refusal. These issues demonstrate failures to update care plans after significant changes and to document resident choice regarding participation in care planning.
A resident’s comprehensive care plan was not updated in a timely manner after a change in mental capacity. When the surveyor reviewed the record, the plan still stated the resident had capacity to make her own medical decisions, and it was only updated after the surveyor requested it. The DON acknowledged the update was made after the request.
A resident’s care plan was not revised after a protein supplement was discontinued. The resident had significant wt. loss, average PO intake of 65%, obesity by BMI, a hx of Ozempic not currently ordered, and recent diuretic reordering with possible wt. fluctuations. The nutrition assessment noted refusal of most modular protein and recommended discontinuing it, but the care plan still listed the supplement as ordered. The DON confirmed the nutritional portion of the care plan was missed.
A resident sustained multiple lower extremity fractures after a fall, resulting in hospitalization, non-weight-bearing status, and loss of prior functional abilities such as standing, pivoting, and walking with therapy. Before the fall, the resident actively participated in out-of-room activities including Resident Council, food committee, church, and socials, but after returning from the hospital she no longer attended group activities and had only two documented 1:1 visits. Despite an MDS indicating a significant change in status and clear changes in activity participation, the activity care plan—last revised months earlier—was not updated with new interventions to address her altered condition and in-room activity needs, as confirmed by record review and staff interviews.
A resident's care plan was not revised to address a toothache that had been present for an extended period. During record review and resident interview, the issue was identified as ongoing, and the DON confirmed that it had not been included in the care plan.
A resident’s comprehensive care plan was not revised to reflect the resident’s LTC goal. Record review showed the plan still contained conflicting active entries, including one for discharge to home when abilities improved and another stating no plans for discharge due to LTC placement. The SW, Administrator, and DON acknowledged the outdated and conflicting care plan entries.
Failure to revise an activity care plan for a resident. The care plan still reflected older interventions and did not match the resident’s most current activity preference interview, which identified interests in church-related activities, country music, watching the news, and fishing. The resident’s MDS also indicated that it was not important to do things with groups of people, and the Activity Director confirmed the interventions had not been revised since the prior update.
The facility failed to update care plans for two residents. One resident’s plan did not include the one-on-one activities that were being provided and documented by the AD, and another resident’s plan still listed an old PEG tube measurement even though the current baseline length had changed to 26 cm per the physician order and the DON’s confirmation.
Care plans were not revised for two residents. One resident’s care plan still reflected antibiotic treatment for a UTI even though the one-time Fosfomycin order had been discontinued, and another resident’s advance directive care plan still listed full code despite a change to DNR. The DON confirmed both care plans were not updated to match the current orders and code status.
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.