Based on interview and record review, conducted during a site visit on

05/22/24, it was confirmed the facility failed to implement a service plan that

reflects the resident's needs for 1 of 2 sampled residents (#1). Findings

include, but are not limited to:

During an interview on 05/22/24, Staff 1 (ED) indicated s/he was aware the

behavioral service plan wanted the staff to check on Resident 1 every two

hours. Staff 1 indicated the facility does not always check on Resident 1 every

two hours due to increasing his/her behaviors.

Witness 1 indicated in the complaint on 12/07/23, the facility was not

complying with Resident 1's behavioral service plan. Staff 1 indicated to

Witness 1 the facility does not need to be checking on Resident 1 every two

hours and that s/he needed to be in a behavioral/special needs facility.

A review of Resident 1's behavioral service plan dated 09/05/23, indicated

staff are expected to "check in" on resident 1 at least every two hours to

ensure needs are met to prevent behaviors.

A review of Resident 1's quarterly evaluation dated 02/28/24 and service plan

dated 02/20/24 had not indicated staff were to check on Resident 1 every two

hours.

It was confirmed the facility failed to implement a service plan that reflects the

resident's needs.

On 05/22/24, the findings were reviewed with and acknowledged by Staff 1.

Verbal plan of correction: The facility will change Resident 1's service plan to

match his/her behavioral service plan.