Every nursing home administrator knows the feeling: the survey team leaves on a Thursday, and by Monday morning there's a stack of deficiencies sitting on your desk that needs a plan of correction by next week. No extensions. No partial credit. CMS will accept your plan or they will send it back — and "send it back" is not a situation you want to be in.
A plan of correction isn't an apology letter. It isn't a promise to "do better." It's a formal regulatory document with five required elements — one for each cited F-Tag. For context on which deficiency areas generate the most citations nationally, see our guide to the top CMS survey deficiencies in skilled nursing facilities. specific language CMS expects to see, and zero tolerance for vague commitments. This guide breaks down what that looks like in practice with real nursing home plan of correction examples — covering three of the most commonly cited F-tags.
What CMS Expects in Every Plan of Correction
Before we get to the examples, let's establish the baseline. Every plan of correction for a nursing home must address five elements for each deficiency cited. These aren't suggestions — CMS will reject any PoC that's missing one.
- How the corrective action will be accomplished — What you actually did or are doing to fix the problem for the specific resident(s) affected.
- How the facility will identify other residents with the same potential to be affected — Your facility-wide audit process.
- What measures or systemic changes will be put in place — The policy, procedure, or practice change you're implementing so it doesn't happen again.
- How the facility will monitor performance — Your ongoing Quality Assurance process (who reviews what, how often, until when).
- The date by which the deficiency will be corrected — A specific calendar date, never "ongoing" or "as soon as possible."
The most common reason PoCs get rejected? Facilities write them like apology emails instead of regulatory documents. Let's look at what each element looks like when done right — and when done wrong.
Don't Write Your PoC from Scratch
FacilityKit's Plan of Correction Templates ($69) cover 9 of the most-cited F-tags — complete with corrective action language, audit frameworks, responsible parties, monitoring schedules, and completion timelines. Fill in your specifics and submit with confidence.
F-880 is one of the most cited tags in nursing homes — and one of the most commonly botched in PoC responses. Surveyors cite it for everything from hand hygiene gaps to improper PPE use to isolation protocol failures. The default incorrect response? Something vague about "re-educating staff."
❌ What Gets Rejected
"Staff will be re-educated on infection control protocols. The Director of Nursing will ensure all staff are trained on proper hand hygiene and PPE use. Education will be completed as soon as possible."
"On [DATE], Resident #1 was assessed by the DON and ADON. Isolation precautions were immediately reinforced per facility policy. The unit charge nurse audited all 14 residents on [UNIT] for active isolation orders and PPE compliance on [DATE]."
✅ Complete F-880 PoC Example Structure
- State what was done for the cited resident on the date of discovery (assessment, care plan update, isolation order, family notification if applicable)
- Use specific dates, not ranges
- DON/ADON audited all residents on [UNITS] for active isolation orders and documented PPE compliance on [DATE]
- Revised Infection Control Policy #XX to include [specific change, e.g., "double verification step for droplet precaution initiation"] effective [DATE]
- Staff education: all nursing staff on [UNITS] completed competency on PPE donning/doffing on [DATE], documented in training log #XX
- IPCO/DON will conduct weekly PPE compliance audits (10 direct observations per unit) for 12 weeks beginning [DATE], reviewed at monthly QAPI committee
- Results reported to QAPI until two consecutive quarters show 100% compliance
CMS wants a single date of correction — the date by which all five elements will be completed, not just the education. Pick the date when your monitoring plan is fully in place. Then honor it.
F-689 fall citations are painful because the surveyor already knows exactly what happened to which resident. Your PoC needs to address that specific incident, then demonstrate you've looked at everyone else who could have the same problem — without making it sound like you waited for the citation to care about falls.
❌ What Gets Rejected
"The facility will review its fall prevention program and ensure all at-risk residents have appropriate interventions in place. Staff will be educated on fall prevention best practices. The Administrator and DON will monitor compliance."
"On [DATE], Resident #1's care plan was updated to include a bed and door alarm, non-slip footwear requirement, and 2-hourly toileting schedule. The DON completed a post-fall root cause analysis on [DATE], identifying [specific gap]."
✅ Complete F-689 PoC Example Structure
- Post-fall assessment completed by RN on [DATE]
- Care plan updated to add/modify specific fall prevention interventions on [DATE]
- Environmental hazards in resident's room addressed on [DATE] (e.g., bed height lowered, personal items repositioned)
- Physician notified on [DATE]; new orders obtained if applicable
- DON/unit charge nurses audited all [#] residents with a fall risk score of [threshold] or above on [DATE], reviewing care plan interventions for completeness and current implementation status
- Revised Fall Prevention Protocol to require documented care plan review within 24 hours of any fall event, effective [DATE]
- All nursing staff on affected unit completed fall prevention competency training on [DATE]
- DON will conduct weekly fall prevention care plan audits (minimum 5 high-risk residents per unit) for 12 weeks beginning [DATE]
- Post-fall root cause analysis will be completed within 24 hours of any fall event and reviewed at monthly QAPI committee
- Fall data will be tracked on the QAPI dashboard and reviewed quarterly for trend analysis
One more thing: F-689 citations often stem from documentation failures as much as care failures. If the surveyor couldn't find evidence that a fall risk assessment was done or that interventions were in the care plan — that's your root cause to address directly.
F-600 citations are the most serious on this list. CMS treats abuse and neglect deficiencies with significantly less patience for vague language. Your PoC needs to demonstrate immediate action was taken and that your systems — not just your staff — have been strengthened. Any whiff of minimization will get you a rejection and a closer look.
❌ What Gets Rejected
"Staff have been counseled regarding appropriate resident interactions. The facility will continue to monitor for abuse and neglect and will take appropriate action if future incidents occur."
"On [DATE], the involved staff member was immediately removed from resident care pending investigation per policy. The Social Worker assessed Resident #1 for psychological distress on [DATE] and documented findings. Mandatory abuse reporting to the State Agency and Adult Protective Services was completed on [DATE]."
✅ Complete F-600 PoC Example Structure
- Staff member removed from resident care on [DATE] pending investigation
- Social Worker / Resident Care Coordinator assessed resident on [DATE]; care plan updated to reflect resident's current status and preferences
- Mandatory abuse reports filed with [State Agency] and [APS] on [DATE]
- Family/responsible party notified on [DATE] per facility policy
- DON/Social Worker conducted resident interviews with [#] of residents on [DATE] to identify any additional concerns; documented in grievance log
- Reviewed personnel files of all CNAs/nurses on cited unit for prior abuse/neglect history on [DATE]
- Revised Abuse Prevention Policy to require supervisory observation of staff new to the unit for first 30 days, effective [DATE]
- All nursing staff completed abuse prevention and mandatory reporting training on [DATE]; competency documentation filed in HR records
- Administrator and DON will review all grievances, incident reports, and abuse allegations weekly for a minimum of 6 months beginning [DATE]
- Random supervisory observations of resident-care interactions conducted 2x per week per unit for 12 weeks beginning [DATE]; documented on observation log
- Abuse and neglect data reviewed at monthly QAPI committee with trending analysis for 4 consecutive quarters
The 4 Mistakes That Get Plans of Correction Rejected
After walking through these examples, the patterns become clear. CMS rejections almost always trace back to one of four problems.
1. Treating "education" as the entire plan
Education is Element 3 — one piece of a five-part response. When "we re-educated staff" is the entire corrective action, it signals to CMS that you don't understand the root cause. Education is a supplement to systemic change, not a substitute for it. If your root cause was a policy gap, the fix is the policy. If it was a supervision gap, the fix is a supervision system. Then you educate staff on the change.
2. Using dates like "ongoing" or "as needed"
CMS requires a specific date of correction. "Ongoing" monitoring is fine in your monitoring plan after a specific implementation date — but the correction date itself must be a calendar date. Pick one. Make it realistic. Then meet it.
3. Auditing only the cited unit or cited residents
Element 2 asks you to identify all residents with the potential to be affected. That's a facility-wide question. If your fall prevention PoC only audits the unit where the citation occurred, CMS will reasonably ask: what about the other three wings? Your audit scope should be defensible — and documented.
4. Writing the PoC to prove you were right, not to show you're fixing it
This is the hardest one. After a survey, it's natural to want to explain context, demonstrate that staff were following policy, or point out that this was an isolated incident. Resist every instinct to do this in your PoC. CMS is not looking for your defense. They're looking for your corrective action. Write toward the future, not the past.
What to Do Before You Write Another Word
Before you sit down to draft, do three things. First, read the full citation language carefully — not your recollection of what the surveyor said, but the actual 2567 language. The PoC must respond to what was written, not what was implied.
Second, identify your root cause before you identify your corrective action. If you don't know why it happened, your corrective action will be generic — and CMS will see right through it. A root cause analysis doesn't have to be formal for lower-level deficiencies, but it does need to be honest.
Third, collect your dates. A PoC with placeholder dates ("DATE TBD") will be returned. Know when each action was completed or will be completed before you submit. If you're submitting before some actions are done, use future dates that you can actually meet.
If your facility was cited for any of the F-tags covered here — or any of the other six in our PoC Templates collection — you don't need to start from a blank page. Each template in our $69 bundle comes pre-structured with the language framework for all five required elements, responsible party assignments, audit checklists, and monitoring plan schedules. You fill in your specifics; the structure is already there.