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F0744
D

Failure to Provide Person-Centered Dementia Care and Activities

Three Rivers, Michigan Survey Completed on 10-30-2025

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 person-centered dementia care interventions for a resident diagnosed with vascular dementia and severe cognitive impairment. The resident exhibited behaviors such as wandering, disorientation, emotional frustration, and stress, but the care plan did not accurately reflect the resident's needs or preferences. The care plan included an incorrect nickname, omitted specific non-pharmacological interventions suggested by the resident's DPOA, and did not address known triggers or effective calming techniques such as gentle handling of the resident's hands or back rubs. Additionally, the care plan did not document the resident's preference for napping after breakfast, which was known to reduce agitation. Observations revealed that the resident spent extended periods in bed with no access to preferred items such as a radio, books, or magazines, and the call light was out of reach. The activity attendance log showed minimal participation in sensory stimulation activities, and interviews with staff indicated a lack of knowledge about the resident's preferences and effective interventions. Staff members, including LPNs and activity assistants, reported not receiving dementia care training and expressed difficulty in managing the resident's behaviors. The resident's DPOA and guardian reported that their input regarding triggers and calming strategies was not incorporated into the care plan or daily care practices. The facility's dementia care policy required individualized, person-centered care and staff training, but these standards were not met. There were no planned activities for men or for residents on the locked dementia unit after certain hours, and staffing levels were insufficient to provide appropriate care and activities, especially in the evenings. Staff interviews confirmed that residents with dementia were not receiving adequate attention, activities, or individualized interventions, contributing to ongoing behavioral issues and emotional distress for the resident.

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