Last time, we talked about why “we have a care plan” isn’t the same as “we’re compliant.” This week, we’re looking at what that gap actually looks like when it lands in a SOD. In Part 2, we’ll walk through the patterns we see again and again in F656 citations, and we’ll let the surveyors’ own words do much of the talking.
A quick reminder of what we’re measuring against: Appendix PP of the State Operations Manual (SOM) requires a comprehensive, person-centered care plan that’s built from the resident’s assessment, includes measurable objectives and timeframes, and is actually carried out. Surveyors at the Centers for Medicare & Medicaid Services (CMS) and state agencies look at both halves – was it developed and was it implemented.
Pattern 1: A known need that never made it into the plan
This is the most straightforward development problem. The assessment, the physician’s orders or the nursing notes show a need, and the care plan is silent. Surveyors will often work backward from a resident outcome (a fall, a pressure injury, a significant weight change) and ask a simple question: where in the care plan is this addressed?
Here’s how this shows up in 2026 survey citations:
- Missing hospice care plans
- No care plan for anticoagulant use
- Care plans not found for asthma or nebulizer use
- A care plan for antibiotic use initiated “the day after the surveyor brought the missing care plan to the DON’s attention”
These commonly missing care plans are even more frustrating to see as trends because these are the care plans related to issues that will show up in your Matrix. You’re handing these right to a surveyor – and potentially indicating that the surveyor should dig deeper, because if you can’t even initiate a care plan, what else is not being done?
Pattern 2: Generic, copied-forward interventions
This is the cookie-cutter plan we mentioned in Part 1. The interventions would fit almost any resident in the building, which usually means they weren’t chosen for this resident. Look for the same wording across unrelated residents, or interventions that no longer match the resident’s condition.
This is what it looks like on 2026 surveys:
- Review of one resident’s CCP found a care plan for an infection with no indication of the type of infection, a dietary care plan which didn’t specify diet type, texture or fluid consistency and a toileting care plan which didn’t indicate the number of staff needed to provide assistance.
- Care plans intentionally written to use “may” verbiage to “reflect the resident’s right to refuse” observed used in care plans for totally dependent residents. “May reposition q 2 hours and as needed” doesn’t ensure this happens. For some residents, “optional” language may work in the care plan, but not across the board.
- Care plan interventions were not person-centered because the care plan did not indicate “what the structured activities consisted of” and the other interventions in the care plan were not included on the Kardex.
- Care plan for a cognitively impaired resident was not found to be specific to her individualized activity care needs or interventions/ tasks for staff to implement to meet the resident’s psychosocial and clinical care needs.
We’ll say it again in case you missed it at the start of this section. You may have a care plan library with templates, but they can’t possibly address the unique needs of the residents in your building. It’s not a good look when every care plan looks the same for every resident with that issue. Problems, goals and interventions should be resident-specific.
Pattern 3: Goals that can’t be measured
“Resident will be comfortable.” “Resident will remain safe.” Nice sentiments, but how would anyone know if they’d been met? Appendix PP expects objectives that are measurable and have timeframes. If a reviewer can’t tell whether the resident got there, the objective isn’t doing its job.
Here’s what surveyors are finding:
- “a safe environment maintained” – with staff acknowledging on interview that the goal was “probably general” and not person-centered
- A resident with significant weight loss without documentation in the plan of care acknowledging the resident’s significant weight loss or interventions or measurable goals to address the weight loss.
Reviews to determine if care plan goals are measurable are always a good step to take. Staff are notorious for rushing through this part and not individualizing goals, so get ahead of it before a surveyor looks.
Pattern 4: Preferences and refusals that were documented but not planned for
The note says the resident declines showers, refuses repositioning or prefers to stay up late. The care plan doesn’t mention it. A refusal is information, not a reason to stop planning. The plan should show what staff will offer, how, and what alternatives were discussed with the resident.
Do we need to provide examples for this one? Resident refusals are common in nursing homes – but documented evidence of these refusals doesn’t always make its way to the care plan. The opposite also holds true. A resident who refused one shower in 2023 still has a “behavior” care plan indicating refusals that staff don’t evaluate and keep changing the goal dates on. We encounter this a lot more than you’d think when we’re doing record reviews during a mock survey or other client project. Another area that’s often missed is when we question staff about a resident’s “preference” to be in a hospital gown well into the day. Preferences such as these should be documented – otherwise we may assume a worse case.
Pattern 5: The plan says one thing, the bedside says another
This is the implementation failure. The surveyor observes care, reads the plan, and the two don’t match. The intervention may be missing (a device that isn’t in place, repositioning that isn’t happening) or staff may simply not know the plan exists. Interviews with the aides providing care are often what tip the scale.
Here’s some common survey citations from this year which you may very well find in your own facility:
- A resident assessed to have fragile skin and required the use of Geri sleeves per the CCP. During multiple observations, the resident was observed without them in place. The CNA Accountability Record did not indicate Geri sleeves as an intervention. The care planned intervention wasn’t carried over for staff to implement the appropriate interventions according to the resident’s plan of care.
- Staff tell the surveyor that they have never assisted the resident with hearing aids and didn’t even know the resident had hearing aids. That conversation happened after an intervention was added to the plan of care to ensure staff checked the placement and functioning of the resident’s hearing aids daily.
Your plan can say anything you want – but you need to ensure staff know what they’re responsible for.
What the excerpts tell us
Read enough of these and a theme emerges: few citations are about a facility that had no care plan at all. They’re about plans that didn’t keep up with the resident, or care that didn’t keep up with the plan.
One exception worth noting was F656 cited at a widespread scope/severity (F) when surveyors identified that bathing, dressing, bed mobility and eating were not addressed on any resident’s plan of care. Only transfers were care planned in the whole facility.
Which of these five patterns could a surveyor find in your building today? In Part 3, we’ll get practical, with ways to catch and correct them first.
