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F0744
E

Failure to Update Care Plans and Implement Interventions for Dementia-Related Behaviors

Gibson City, Illinois Survey Completed on 12-23-2025

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 appropriate interventions to address dementia-related behaviors for multiple residents diagnosed with dementia or Alzheimer's disease. Specifically, there were documented incidents where one resident with a history of mood swings and aggression physically struck other residents in the dining room. These altercations were witnessed by staff and involved the resident hitting another on the arm and slapping another on the face. Despite these incidents, the resident's care plan was not updated with new interventions, and there was no documentation of evaluation by psychiatric services following the altercations. Additionally, staff interviews and record reviews revealed that seating arrangements intended to prevent further altercations were not consistently followed, and some staff were unaware of the required seating changes. The care plan for the aggressive resident included general interventions, such as monitoring whereabouts and reporting behaviors, but lacked updates or new strategies after the incidents. Staff also expressed uncertainty about what new interventions, if any, had been implemented following the altercations, indicating a lack of communication and follow-through on care planning for residents exhibiting dementia-related behaviors.

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