Print Inspection: GH28

Based on interview and record review, conducted during a site visit on 12/03/24, the facility's failure to ensure the service plan must reflect the resident's needs as identified in the evaluation was substantiated for 1 of 1 resident (#2). Findings include, but are not limited to:

A review of Resident 2's behavioral support plan (BSS), dated 04/16/24, indicated the following:

* Resident 2 had a history of declining meals;

* Resident 2 had a history of declining meals, then later alleging s/he was never offered food;

* Staff were to have Resident 2 sign the days s/he declined meals; and

* Staff were to record when Resident 2 accepted meals.

In separate interviews, Staff 4 (MT) and Staff 5 (CG) stated they had no knowledge of the facility having documentation of Resident 2's signature on days s/he declined meals.

A review of Resident 2's progress notes, dated 11/04/24 to 11/29/24, showed the following:

* Staff documented when Resident 2 refused meals;

* Staff did not document all instances when Resident 2 accepted meals; and

* There was no indication Resident 2 was signing documentation of his/her meal refusals.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Health Services Director), and Staff 3 (Resident Care Coordinator).

The facility's failure to ensure the service plan must reflect the resident's needs as identified in the evaluation was substantiated.

Verbal Plan of Correction: The facility will implement the resident's BSS recommended documentation for resident's refusal of meals.