F656 — Develop and Implement Comprehensive Care Plan
Failure to develop and implement an individualized, person-centered comprehensive care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs.
Reg cite · 42 CFR 483.21(b)(1)(2)
188 surveys in corpus
36 states
What surveyors look for
- Initial care plan within 48 hours of admission, full IDT care plan within 7 days after MDS completion
- Interventions are specific, measurable, time-bound, and individualized — not generic 'monitor and report'
- Resident/family participation documented (signature, video, attestation)
- Care plan revised after every significant change, every quarterly review, after falls/wounds/behavior events
Common gotchas
- Care plans copy-pasted from previous resident or template language
- Falls intervention listed as 'fall mat' but no fall mat present in room
- Goals like 'will not fall' instead of measurable goals like 'will use call light prior to ambulation in 80% of opportunities'
- Care plan not updated after wound progressed from Stage 2 to Stage 3
Real survey examples
From CMS-published 2567s in our corpus. Resident identifiers redacted.
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews, Resident Identifier (RI) #103's medical record review, and a facility policy titled Care Plan,
Comprehensive, the facility failed to ensure Employee Identifier (EI) #7 Certified Nursing Assistant (CNA),
followed RI #103's care plan intervention to have two persons assistance for transfer…
-Develop/Implement Comprehensive Care Plan. The immediate jeopardy began on [date] and
continued until [date], when the facility implemented corrective actions to correct the identified
deficient practice and prevent recurrence; thus, immediate jeopardy past noncompliance was cited. Total
census 50.
Findings Include:
A facility policy titled, Care Plan, Comprehensive, implemented 09/2016 and last reviewed/revised 01/2023
documented:
Purpose: . The facility develops a comprehensive plan of care for each resident . to meet a resident's
medical, nursing, and mental/psychosocial needs that are ide…
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
Policy: .3 . f. Resident specific interventions that reflect the resident's needs and preferences .
RI #103 was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's Disease and
Macular Degeneration.
RI #103's annual Minimal Data Set (MDS), with an Assessment Reference Date of [date] assessed RI
#103 as a two person assist with transfers.
RI #103's care plan for being at high risk for falls related to impaired balance and total dependence on two
staff and mechanical lift for transf…
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
make sure she/he was in the sling properly and it was a safe transfer. EI #7 further said, RI #103 sustained
a laceration and was told he/she may have a C2 fracture. EI #7 said the care plan was to be followed to
avoid situations such as falling and having an injury, such as the case with RI #103. EI #7 confirmed this fall
could have been avoided if two people assisted with the lift.
On [date] at 12:30 PM, an interview was conducted with EI #8, Registered Nurse (RN). EI #8 reported
she went to RI #103's ro…
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Few
This deficient practice was cited as a result of the investigation of complaint/report number AL00042944.
*********************************************************
The facility took immediate action to correct the noncompliance by:
1. Reported the incident to Alabama Department of Public Health (ADPH) [date] and conducted an
investigation.
2. Completed in-service with staff on following care guides with transfer using the mechanical lift.
Completed [date].
3. The Care Plan Coordinator and designee reviewed…
Accepted POC examples
Real accepted-POC examples for this F-tag are not yet in the open corpus. The POC drafter above generates a structurally correct draft from CMS S&C Letter 13-21's four-question schema — edit it to fit your facility's specifics before submission.
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