F0656

E

Failure to Maintain Comprehensive, Current Care Plans for Two Residents

Canonsburg, Pennsylvania Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The facility failed to develop and update comprehensive, person-centered care plans to reflect the current clinical status and needs of two residents. For one resident with diagnoses including diabetes, obstructive sleep apnea, and renal insufficiency, the clinical record and current physician orders showed multiple active conditions and medications, such as glargine insulin and Jardiance for diabetes, Eliquis as an anticoagulant, Bumex for fluid management, Flomax and finasteride for BPH, Lyrica for neuropathy, oxycodone for pain, and metoprolol for hypertension. However, the resident’s care plan did not include goals or interventions for management and monitoring of diabetes, anticoagulant therapy, fluid status, BPH, neuropathy, pain, hypertension, or potential constipation related to oxycodone use. The MDS also did not indicate CPAP use in Section O0110 G3. The DON confirmed that the care plan was lacking the required medications and disease processes.

For another resident with documented traumatic brain dysfunction, anxiety, depression, and PTSD, the MDS, facility diagnosis list, and multiple psychiatry notes described a history of severe trauma, a traumatic brain injury, a long hospital stay, and ongoing symptoms including mood swings, depression, hypervigilance, increased anxiety, and feeling nervous around other people. Despite this documented PTSD diagnosis and related symptoms, the resident’s current care plan did not include goals or interventions that accounted for the resident’s past experiences and preferences to eliminate or mitigate triggers that could cause re-traumatization. The DON confirmed that the facility failed to update this resident’s care plan to accurately reflect the resident’s current status.