Plans of Correction are public record. Any CMS survey that results in a deficiency citation generates a required Plan of Correction response — and those responses, along with the original citations, are published in the federal CASPER database and accessible through state health department portals. We used them.
We pulled 100 Plans of Correction across a range of facility types, deficiency categories, and survey years. We read them looking for patterns. We found five. They are not obscure. They are not edge cases. They are the exact same mistakes, reproduced with remarkable consistency, in facilities of every size and star rating, in states from Alabama to Washington, across deficiency categories from F600 to F880.
Eighty of those Plans of Correction had at least one of the five failures. Most had two or three. Some — and these are the ones that get re-cited — had all five, dressed up in regulatory language that creates the impression of compliance without any of the underlying substance. This article is about what those look like, why they fail, and what the other twenty look like instead.
Why We Reviewed 100 PoCs (And What That Process Actually Revealed) 🔍
The Plan of Correction is one of the most important documents a skilled nursing facility produces. It is, in regulatory terms, the facility’s formal response to every deficiency cited in a state survey — a binding commitment to specific corrective actions, responsible parties, and completion timelines. CMS and state surveyors treat it as evidence of whether the facility understands what went wrong and has a credible plan to prevent it from happening again.
In practice, the PoC is often written under tremendous pressure. The facility has ten days from the date of the survey exit conference to submit a compliant Plan of Correction. The DON is usually the primary author. The administrator is usually involved. Legal counsel is occasionally consulted. Nobody is doing this with extra time or a clear head.
That context matters — but it does not fully explain what we found. The failures in the Plans of Correction we reviewed were not primarily the product of time pressure. They were the product of a fundamental misunderstanding of what a Plan of Correction is supposed to do. Most of the bad PoCs we read were written to close the survey, not to prevent recurrence. Those are different goals. The document that achieves one often fails the other spectacularly. If you’re working against that 10-day deadline, our free F-880 Plan of Correction template gives you the CMS four-part structure so you can spend the limited time on substance rather than format.
A quick note on methodology: all Plans of Correction referenced in this article were drawn from publicly available CMS and state health department databases. Facilities are not named. F-tag numbers and deficiency categories are accurate, but specific identifying details have been generalized to protect individual facilities while preserving the instructional value of the examples. The patterns are real. The language examples are real. The failures are real.
CMS Form 2567 requires the PoC to address five elements for each cited deficiency:
- Element 1: How the deficiency will be or has been corrected — specifically, what happened to the resident(s) affected.
- Element 2: How the facility will identify other residents who have the potential to be affected by the same deficient practice.
- Element 3: What systemic changes will be made to ensure the deficient practice does not recur.
- Element 4: How the facility will monitor compliance over time to ensure the problem doesn’t return.
- Element 5: The date by which full compliance will be achieved.
Most of the failures we identified occur in Elements 3 and 4 — the systemic change and the monitoring. Elements 1 and 2 are usually adequate. Elements 3 and 4 are usually not. CMS adjusts its enforcement focus each survey cycle — Regulatory Radar tracks which F-tag categories are under heightened scrutiny so you know where surveyors are looking hardest before you write.
Failure #1: “We Will Retrain Staff” 🙈
This is the most common failure we found. It appeared in some form in 71 of the 100 Plans of Correction we reviewed. It takes many shapes:
- “The Director of Nursing will re-educate all nursing staff on proper fall prevention protocols.”
- “The facility will provide in-service training to all dietary staff on food safety and temperature requirements.”
- “Staff will be retrained on the facility’s policy regarding resident-to-resident altercations.”
- “The facility will conduct education to reinforce proper documentation standards.”
Retraining is not a corrective action. It is a placeholder that sounds like a corrective action. Surveyors know the difference. Experienced surveyors have seen “we will retrain” appear in hundreds of Plans of Correction — including Plans of Correction for the same deficiency at the same facility, submitted in consecutive surveys. The training happened. The deficiency came back. Something other than lack of training was causing the problem.
What the PoC said: “The Director of Nursing will provide in-service education to all nursing staff on proper hand hygiene technique and PPE donning and doffing procedures. Education will be completed within 30 days. Compliance will be monitored by charge nurses during routine rounds.”
What was missing: There was no analysis of why the hand hygiene break occurred in the first place. Was PPE availability limited? Were staff rushing because of short-staffing? Was there a specific unit where the compliance problem was concentrated? Was the policy clear? The PoC treated a systemic compliance failure as a knowledge gap, prescribed a one-time education event, and moved on. The deficiency was re-cited in the next survey.
The correct question to ask before writing a corrective action is not “what can we tell staff to do differently?” It is “why did this happen in the first place, and what change to our system, process, or environment would prevent it from happening again?” Training is only the right answer when lack of knowledge is actually the root cause — and lack of knowledge is less often the root cause of compliance failures than facilities assume.
When Retraining IS the Right Answer
Retraining is appropriate when a specific, identifiable knowledge gap caused the deficiency. New staff who were not oriented on a specific policy. A policy that changed and the change was not communicated. A procedure that is genuinely novel or requires specific technical skill. In these cases, targeted education with documented competency verification is a legitimate corrective action.
The key words are “targeted” and “documented competency verification.” “We will retrain all staff” is almost never the right formulation. Who, specifically, needs training? On what, specifically? How will you verify they understood it? When will that verification happen? If you cannot answer all four of those questions concretely, retraining is not your corrective action — it is your avoidance strategy.
Failure #2: Corrective Actions That Don’t Actually Correct Anything 🌿
The second failure is related to the first but distinct. Where Failure #1 is “retraining as a false corrective action,” Failure #2 is “language that sounds like a corrective action but describes no actual change.” These PoCs are masterpieces of regulatory vagueness. They use all the right words. They touch all five CMS elements. They are completely content-free.
- “The facility will ensure that staff are following all applicable policies and procedures.” (What will change? Nothing is specified.)
- “Nursing leadership will provide oversight to ensure that documentation standards are maintained going forward.” (What oversight? What standards? Who specifically? What does “maintained” mean?)
- “The facility will take appropriate corrective action to prevent recurrence of this deficiency.” (This is not a corrective action. This is a sentence about taking a corrective action.)
- “The Director of Nursing will monitor the situation and address any further concerns as they arise.” (Reactive monitoring is not a preventive system.)
- “The facility’s QAPI committee will review this matter and make recommendations.” (The QAPI committee reviewing something is a process step, not a corrective action. What will actually change?)
The common thread in all of these is the absence of specificity. A compliant, credible corrective action names a specific change — to a policy, a process, a physical environment, a workflow, a staffing structure, a monitoring system — and explains how that change will prevent the cited deficiency from recurring. Generic language about “oversight,” “monitoring,” and “ensuring compliance” does not do this.
QAPI Program Requirements| Vague Version | Specific Version |
|---|---|
| "Nursing staff will be reminded of the importance of timely incident reporting." | "The charge nurse on each shift will review the incident log at shift change and confirm any incidents from the previous 12 hours have been documented on Form 3051 within the required 2-hour window. Any gaps will trigger immediate supervisor notification. This process will be documented in the shift supervisor log, effective [date]." |
| "The facility will ensure proper care planning is completed for all residents." | "The MDS Coordinator will audit 100% of care plans for residents admitted in the past 60 days to verify all identified needs are addressed with specific, individualized interventions. New care plans will require DON signature prior to implementation, effective [date]. Monthly audit of 20% of active care plans will be reviewed in QAPI." |
| "The dietary department will maintain proper food temperatures going forward." | "A food service temperature log will be completed for every meal service and reviewed by the Food Service Director daily. Any temperature outside the accepted range (hot foods below 135°F, cold foods above 41°F) will trigger immediate corrective action and documentation. Logs will be reviewed monthly at QAPI and retained for 90 days." |
The difference is not length. The difference is substance. The specific version names a person, a process, a measurable threshold, a documentation method, and a review cycle. Surveyors reading it can picture exactly what will happen. They can verify it during re-visit. That is the test: can a surveyor who returns to your facility six months from now verify that this corrective action is actually in place? If the answer is no, it is not a corrective action. It is a statement of intention.
Failure #3: The Copy-Paste Plan 📋
The third failure is the most embarrassing — and the most common after generic language. It is the copy-paste Plan of Correction, in which the corrective actions for multiple deficiencies are essentially identical, or in which the language is so generic that it clearly was not written for the specific deficiency being addressed.
Facility cited for four separate deficiencies: F684 (Quality of Care), F689 (Fall Prevention), F725 (Staffing), and F880 (Infection Control). All four PoC responses share the following structure:
Element 3 (Systemic Changes) for all four deficiencies: “The Director of Nursing will review and revise the facility’s policies and procedures to ensure compliance with applicable federal and state regulations. All nursing staff will receive in-service education on the revised policies. Education will be documented and placed in personnel files.”
The words “fall prevention,” “staffing,” “infection control,” and “quality of care” appear only in the heading for each section. The corrective actions are word-for-word identical. The surveyor who reads this document knows — with complete certainty — that the facility ran out of time, copy-pasted, and hoped for the best. This is not a strategy. It is a red flag.
Copy-paste PoCs happen for two reasons. The first is time pressure — the 10-day window runs out faster than expected, and filling in five elements per deficiency for eight citations is genuinely a lot of work. The second is that writing specific, substantive corrective actions requires doing the harder work of understanding what actually caused each deficiency, and when facilities are under pressure, that root cause analysis often doesn’t happen.
The consequence of copy-paste PoCs is not just immediate rejection (though that happens). The deeper consequence is that they identify the facility, to the surveyor, as a place where compliance is treated as paperwork rather than practice. Surveyors remember. The next survey comes with a heightened level of scrutiny that a copy-paste PoC earned.
- Read the systemic change section for three different deficiencies. Could you swap the headings and have it still make sense? If yes, it is copy-paste.
- Does your corrective action name the specific F-tag, the specific resident(s) affected, or the specific process that failed? If none of the above appear anywhere, it is probably generic.
- Does “the DON will review policies and procedures” appear more than twice? Stop. Rewrite.
- Would the monitoring plan you described actually catch this specific deficiency if it recurred? If not, the monitoring plan was not written for this deficiency.
Failure #4: The Impossible Timeline 🕒
Element 5 of a compliant PoC is the date by which full compliance will be achieved. This sounds simple. In practice, it is a source of significant self-inflicted harm. The most common mistake is giving a completion date that falls within 24–72 hours of the PoC submission itself.
We found this pattern in 34 of the 100 PoCs reviewed. A facility cited for a significant systemic deficiency — inadequate care planning, insufficient fall prevention, failure to report incidents — submits a PoC with a corrective action completion date that is three days from submission. Sometimes it is the same day as submission.
What this tells the surveyor: the facility either does not understand what a credible systemic correction requires (weeks to months for policy revision, training, documentation system changes, and initial monitoring cycles) — or they do understand and are giving a false date to close the survey quickly. Neither reading is favorable.
We also found the opposite problem: unrealistically distant dates. A straightforward policy revision with a six-month completion date, for an issue that a similarly situated facility fixed in three weeks. Extended timelines invite scrutiny at the revisit and signal that the facility is not taking the deficiency seriously.
A credible timeline maps to the actual work required. Policy revision, if done properly, typically takes 2–4 weeks (drafting, review, approval, distribution). Staff education, if done systematically, takes 2–6 weeks depending on facility size and scheduling constraints. Initial monitoring data collection takes 4–6 weeks to produce meaningful results. Full compliance — meaning you have run at least one monitoring cycle, found no recurrence, and documented that finding — typically takes 30–90 days depending on the deficiency.
If your corrective action completion date is less than 14 days from submission, look hard at whether the date reflects reality or hope. If it is more than 90 days out for anything that is not a major structural change, ask why it takes that long and be prepared to explain it.
Failure #5: Fixing the Person Instead of the System 👥
The fifth failure is the most consequential because it is the one most likely to result in re-citation. It is the tendency to identify a deficiency as the result of an individual employee’s failure and respond by addressing only that individual — through counseling, retraining, or termination — without examining the system conditions that enabled the failure in the first place.
F757 citation: a resident received an incorrect medication dose. Investigation identified the nurse who administered it. The PoC: the nurse was counseled. The nurse received a written warning. The nurse was retrained on the five rights of medication administration. Monitoring: charge nurses will observe medication administration for 30 days.
What was not in the PoC: any examination of why the error was possible. Was the medication cart organized in a way that invited confusion? Were there two residents with similar names whose records were adjacent? Was the nurse managing a cart for a unit they were unfamiliar with because of a staffing shortage? Was the documentation system missing a safeguard that would have caught the discrepancy before administration?
The nurse may or may not have been competent. That is almost beside the point. The systemic question — what conditions made this error possible and how do we remove those conditions — was never asked. A different nurse making the same medication pass six months later will be working in the same system. The error is possible again.
Individual accountability matters. When a staff member makes a preventable error, addressing it with that individual is appropriate and necessary. But in the Plan of Correction, individual accountability is Element 1 at most. The heavier weight — Elements 3 and 4, systemic change and monitoring — belongs to the question of system design.
The best Plans of Correction treat every deficiency as a system design problem first and an individual performance problem second. They ask: what would have needed to be true about our systems, processes, environment, or workflows for this to have been caught before it became a deficiency — and what changes do we need to make so that is true going forward? That question produces the kind of corrective action that surveyors recognize as genuine and that actually prevents recurrence.
Stop Writing PoCs from a Blank Page Under Deadline Pressure
FacilityKit’s Plan of Correction Templates are built around the five CMS-required elements, the most frequently cited F-tags, and the specific language patterns that pass first review. Each template is pre-structured with prompts that force the right root cause questions, specific corrective action language, realistic timeline guidance, and monitoring plan frameworks. Stop guessing what the surveyor wants to see. Use the template that was built around exactly that.
What a Great Plan of Correction Actually Looks Like ✅
The 20 Plans of Correction in our review set that didn’t have the five failures shared a common set of characteristics. They were not necessarily the longest or most elegantly written. They were not written by facilities that had the best star ratings or the fewest citations. They were written by facilities that understood the purpose of the document and treated it as a genuine compliance commitment rather than a paperwork obligation.
Here is the anatomy of a PoC that would survive re-survey — using a fall prevention deficiency as the example. F689 (Failure to Adequately Supervise and Prevent Accidents) ranks consistently among the top-cited CMS survey deficiencies nationally, which makes it the most instructive case study.
The Citation: F689 — Failure to Adequately Supervise and Prevent Accidents
A resident with a documented fall risk history fell in the hallway outside the dining room. The fall assessment had been updated following a previous fall 23 days earlier but had not resulted in a care plan revision. The care plan at the time of the fall still referenced the prior lower risk level. Two other residents with similar risk profiles were found to have outdated fall risk interventions in their care plans.
The resident who fell was examined by the attending physician on the same day. A new fall risk assessment was completed by the DON using the Morse Fall Scale, with a resulting score of 75 (high risk). The care plan was updated within 24 hours to reflect high-risk interventions: bed alarm activated, call light within reach, non-skid footwear required, one-on-one assist during all transfers, and a low bed order obtained from the physician. The resident’s family was notified and the update was documented in the communication log.
The two other residents identified with outdated risk assessments received updated Morse Fall Scale evaluations within 48 hours. Both had care plans revised to reflect current risk level and specific interventions. All three residents’ revised care plans were reviewed and signed by the DON.
The MDS Coordinator conducted a facility-wide audit of all residents with documented fall risk assessments completed more than 30 days ago. Twenty-two residents were identified. The DON reviewed each chart and found four additional residents whose care plans did not reflect their most recent assessment score. All four were updated within 72 hours of the audit completion. The audit was completed within seven days of the exit conference.
Root cause analysis identified three contributing system failures:
- No automatic trigger for care plan review following fall risk reassessment. Fix: The EHR workflow was updated to generate a mandatory care plan review task assigned to the charge nurse whenever a fall risk reassessment is completed. The task must be completed within 24 hours or it escalates to the DON queue. Change implemented within 14 days.
- Reassessments were filed without a nursing notification step. Fix: Policy 3.4.7 (Fall Risk Assessment) was revised to require that the completing nurse notify the charge nurse of any score change greater than 10 points at the time of completion, not at the next team huddle. Revised policy distributed to all nursing staff within 21 days.
- No routine audit of care plan currency. Fix: The charge nurse on the day shift will conduct a weekly review of all high-risk residents’ care plans to confirm interventions match the most recent assessment. This review will be documented in the charge nurse log and submitted to the DON weekly. Process begins within 14 days.
The DON will review the EHR-generated care plan review task completion report weekly for the first 60 days and monthly thereafter. The QAPI committee will receive a monthly fall analysis that includes: number of falls, number of residents with outstanding care plan review tasks at the time of the fall, and percentage of high-risk residents with care plans updated within 24 hours of reassessment. Any month where the update-within-24-hours rate falls below 95% will trigger a root cause review at the next QAPI meeting. This monitoring protocol begins the first full month following full implementation of the EHR workflow change.
Full compliance, defined as 100% of high-risk residents with care plans current within 24 hours of reassessment, one complete monthly monitoring cycle with no care plan update failures, and EHR workflow change verified active: [Date 45 days from PoC submission].
This PoC will survive re-survey. It names specific systems that failed. It identifies and fixes the root cause — not the individual who failed within that system. It builds an ongoing monitoring process that will catch recurrence before the next survey. The completion date is realistic and specific. The surveyor who reads it can picture the verification steps they’ll take on revisit. That is the goal.
Surveyors are not grading your writing. They are answering three questions: (1) Does this facility understand why this happened? (2) Did they fix the thing that caused it, or just the symptom? (3) When I come back, will I be able to verify this is actually in place?
A PoC that answers all three clearly and credibly — with specific people, specific processes, specific timelines, and specific monitoring — does not need to be eloquent. It needs to be believable. The 20% of PoCs that hold up under re-survey are the ones where the answer to all three questions is obvious from reading it. The 80% that don’t are the ones where at least one of those questions goes unanswered.
Your Move 🤟
Whether you are a DON who has written a hundred Plans of Correction or a compliance coordinator staring at a 2567 form for the first time — here is what actually makes the difference between the 20% that hold up and the 80% that don’t:
- For each deficiency, ask one question before you write a single word: “What system condition made this failure possible?” Not who failed. What system failed. Write that answer down. Build the PoC around it.
- Avoid starting any sentence in Elements 3 or 4 with “staff will be retrained,” “the DON will monitor,” or “the facility will ensure compliance.” These are the red-flag phrases. Replace them with the specific action, the specific person, the specific measurable outcome.
- Read Elements 3 and 4 for every deficiency and ask: can a surveyor who comes back in 90 days walk into this building and verify that this is actually in place? If the answer is no, rewrite.
- Set a completion date that reflects the actual time required for the work — not the time you have before you want this closed. A realistic 45-day timeline is vastly more credible than an aspirational 72-hour one.
- The most time-consuming part of writing a compliant PoC is not the typing — it is the thinking. You need to understand the root cause well enough to describe a credible system fix. The facilities that do this well have usually done it before, for the same deficiency or a related one, and have a template that structures the thinking process.
- FacilityKit’s Plan of Correction Templates ($69) are built around the most frequently cited F-tags and the specific elements CMS requires. They don’t write the PoC for you — they structure the thinking so the actual writing takes a fraction of the time. The difference between a blank page and a structured template, under a 10-day deadline, is significant.
- The Survey Survival Bundle ($99) includes the PoC templates plus the broader survey prep tools that prevent the deficiencies in the first place — which is always better than correcting them after the fact.
- Give your DON enough time to write a real Plan of Correction. The 10-day window includes weekends. “Good enough to close the survey” is a false economy — a weak PoC generates re-citations that cost far more than the time it would have taken to write a strong one.
- The PoC is not a legal document to be minimized. It is a public-facing compliance commitment that defines how surveyors perceive your facility’s culture. Invest in it accordingly.
- Build a post-survey process: root cause analysis meeting within 48 hours of exit, PoC drafting with the DON, compliance coordinator, and department heads involved, and a final review by someone who was not involved in writing it to catch vagueness and copy-paste before submission.
- Use your QAPI program the way it is designed: as the ongoing monitoring mechanism for PoC commitments. The best facilities treat every submitted PoC as a new QAPI priority item until the completion date passes and the monitoring data is clean.