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F0691
E

Failure to Provide and Document Colostomy Care for Two Residents

Latrobe, Pennsylvania Survey Completed on 12-10-2025

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 provide proper colostomy care for two residents as required. For one resident with paraplegia and a colostomy, the care plan specified that staff were to change the colostomy appliance as necessary. However, a review of the clinical records, physician's orders, and treatment administration records revealed no documented evidence that colostomy care was being provided. This was confirmed by the Nursing Home Administrator during an interview. For another resident with a colostomy, physician's orders indicated that ostomy care was to be provided every shift. Observations confirmed the presence of a colostomy bag, and the resident reported that staff usually emptied the bag at least once per shift, but sometimes only after prompting. There were no physician's orders for changing or emptying the colostomy appliance, and no care plan was in place for the resident's colostomy. The DON confirmed the absence of both physician's orders and a care plan for colostomy care.

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