Based on interview and record review, conducted during a site visit on 01/22/25, the facility's failure to complete quarterly service plans was substantiated for 2 of 2 sampled residents (#s 2 and 3). Findings include, but are not limited to:

Department records indicated the facility had a change of ownership on 02/01/24.

Resident 2 and Resident 3's 2023 Service plans were requested on 01/22/25.

In an email on 01/24/25 Staff 1 (Administrator) explained  she was not able to locate any service plans from 2023 for Resident 2 and Resident 3.

The facility failed to complete quarterly service plans.

The findings were reviewed with and acknowledged by Staff 1 on 01/24/25.

Verbal plan of correction: All service plans were to be audited for last day of completion within 30 days. Service plans to be updated quarterly or with any change of condition and overseen by administrator.