Based on interview and record review, conducted during a site visit on 07/09/25, the facility's failure to complete quarterly service plans was substantiated for 1 of 1 sampled resident (# 5). Findings include, but are not limited to:

A review of service plans for Resident 5 indicated there was a service plan completed on 10/02/23 and the next service plan available was dated 07/10/24.

In an interview on 07/09/25, Staff 1 (Executive Director) stated s/he was unable to locate the service plans with signature pages or any indication that there were service planning teams present. S/He also confirmed there were no service plans completed between 10/02/23 and 07/10/24.

The facility failed to complete quarterly service plans.

The findings were reviewed and acknowledged by Staff 1.