F0656

D

Failure to Develop Person-Centered Care Plan for Resident With Hoarding Behaviors

Philadelphia, Pennsylvania Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the development of a person-centered care plan for a resident with documented hoarding behaviors. The resident, admitted in 2021, had physician orders in March 2026 reflecting diagnoses including seizures, anxiety, COPD, and multiple sclerosis. During an observation of the resident’s shared room, the resident was seen lying in bed surrounded by an abundance of personal items. These items, which included stuffed animals, papers, and pocketbooks, were piled on top of both her own and her roommate’s drawers, on the floor around her bed area, on the heating unit, bedside table, chair, and bedside dresser. The piles were so compacted that items in between could not be identified without lifting the piles. The resident stated that her room was “junky” and attributed this to having had items go missing since she had been at the facility.

The DON acknowledged during interview that the resident had hoarding behaviors and that the condition of the room, which the resident shared with another female resident, was as described. Review of the resident’s current person-centered care plan showed that hoarding was identified as a behavior problem, with a goal that there be no evidence of hoarding behavior by the next care plan review date. However, the care plan did not include any specific interventions or measurable actions to address the hoarding behavior or to support the resident in managing her belongings. No strategies such as behavioral health treatment, assistance with storage, help prioritizing or sorting items, or involvement of family or friends were documented, resulting in a failure to develop and implement a complete, person-centered care plan to meet the resident’s identified needs.