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F0657
E

Failure to Review and Revise Care Plans for Two Residents

York, Pennsylvania Survey Completed on 09-11-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to review and revise care plans for two residents as required by policy and regulation. For one resident with diagnoses including congestive heart failure and gastroesophageal reflux disease, the care plan included an intervention to encourage discussion about an ostomy, despite the resident never having had an ostomy or being at risk for one. This intervention was entered erroneously and was not removed or corrected in a timely manner. For another resident with diagnoses of type 2 diabetes mellitus, cerebrovascular accident, and localized edema, the care plan continued to list interventions related to insulin administration and anticoagulant therapy (Plavix), even though both medications had been discontinued. The care plan was not updated to reflect the discontinuation of these medications, resulting in outdated and inaccurate care planning for the resident.

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