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F0657
D

Failure to Develop Behavior Care Plan for Resident with Behavioral Symptoms

Warroad, Minnesota Survey Completed on 12-04-2025

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 care planned interventions for a resident who exhibited behavioral symptoms, including physical and verbal behaviors toward other residents. The resident, who had diagnoses of adjustment disorder, delusional disorders, and dementia, was noted in progress notes to wander into other residents' rooms, collect items, and have altercations, including slapping another resident during supper. Despite these documented behaviors and the use of psychotropic medications for behavioral symptoms, the resident's care plan did not include a specific behavior care plan addressing these issues. Observations and interviews confirmed ongoing behavioral concerns, such as the resident entering other residents' rooms and displaying agitation. Staff interviews indicated awareness of the resident's behavioral interactions with others, including incidents of swearing and physical altercations. Facility policy requires the development of a comprehensive, person-centered care plan with measurable objectives and interventions based on assessment findings, but this was not completed for the resident in question.

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