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F0656
D

Failure to Timely Develop Person-Centered Behavior Care Plan

Chicago, Illinois Survey Completed on 08-25-2025

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 develop and implement a person-centered behavior care plan to address a resident's mental and psychosocial needs, specifically for a resident with schizoaffective disorder, depression, and mild intellectual disabilities. The resident exhibited a history of dysfunctional behavior, including anger, agitated depression, and restless or agitated actions such as rocking, picking, and banging. Despite these behaviors and a specific incident where the resident kicked a door after becoming upset, the facility did not initiate a behavior care plan until prompted by a surveyor. The care plan addressing inappropriate and maladaptive behaviors was only created on the day it was requested by the surveyor, rather than at the time the behaviors were first observed. Staff interviews confirmed that the resident was known to become angry quickly and had demonstrated both verbally and physically abusive behaviors, such as raising his voice, using profanity, and making demeaning statements. The psychiatric rehabilitation services coordinator acknowledged that the resident's quickness to anger and other behavioral issues were not care planned as required. Facility policy states that any observed behavior should be care planned immediately to ensure appropriate interventions can be implemented, but this was not followed in the resident's case.

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