Southeast Iowa Regional Hospice

“Based on hospice staff interview, hospice policy review and clinical record review, the hospice failed to ensure the provision of care in accordance with the patient’s plan of care for 1 of 4 sampled patients with hospice aide services (Patient #3). Failure to follow the patient’s Plan of Care as directed by the Interdisciplinary Group (IDG) put the patient at risk for inconsistent care that may not meet the needs of the patient. Findings include: Review of the hospice policy, titled Hospice Interdisciplinary Group, dated 09/2021, identified the IDG, in establishing the plan of care, determines the services that the individual requires for palliation and management of the patient’s symptoms. Patient #3 had a hospice admission date of 12/11/25, a death date of 12/18/25 and received hospice services while residing in a private home. Clinical record review revealed: a. Plan of Care, dated 12/11/25 to 3/10/26, included primary diagnosis of colon cancer and orders for hospice aide services two times per week starting 12/11/25. b. Hospice aide visit notes, dated 12/15/25 and 12/18/25, completed by Staff E, Hospice Aide, included documentation services were provided. c. IDG update to the plan of care, dated 12/16/25, identified no missed hospice aide visits for week of 12/11/25. During an interview on 2/18/26 at 10:05 AM, Staff F, Hospice Quality Manager, reported she had reviewed the clinical record and agreed the order was written for services to start 12/11/25, this is not the practice of the hospice. The order for hospice aide services should have started the week of 12/14/25 instead of 12/11/25. The hospice failed to provide hospice aide services the week of 12/11/25 as ordered in the plan of care or document a reason why the visits were not completed. The hospice failed to provide services as ordered in the plan of care. The above findings were reviewed with the hospice Administrator and Clinical Manager.”

“Based on hospice staff interview, hospice policy review and clinical record review, the hospice failed to ensure the Interdisciplinary Group maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care for 1 of 4 sampled patients with hospice aide services (Patient #5). Failure of the hospice interdisciplinary group (IDG) members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. Findings include: Review of the hospice policy, titled Hospice Interdisciplinary Group (IDG), dated 09/2021, identified the IDG participates in the development of the comprehensive plan of care and the plan is reviewed and revised as necessary by the IDG. The IDG, in establishing the plan of care, determines the services that the individual requires for palliation and management of the patient’s symptoms. During an interview on 2/18/26 at 8:20 AM, Staff A, Administrator, reported missed visits are verbally reported on during the IDG meetings, the missed visits are documented in the IDG summary communication note and faxed to the patient’s physician. Patient #5 had a hospice admission date of 9/30/25, a death date of 11/9/25 and received hospice services while residing in a private home. Clinical record review revealed: a. Plan of Care, dated 9/30/25 to 12/28/25, included primary diagnosis of alcoholic cirrhosis of liver with ascites (disease where long-term alcohol consumption causes liver scarring and abdominal fluid buildup) and physician orders for skilled nursing services and hospice aide services two times a week starting week of 10/5/25. b. Hospice aide visit note, dated 10/9/25, completed by Staff G, Hospice Aide, identified a missed visit. c. Paper missed visit report scanned into electronic medical record (EMR), dated Oct. 7. 2025 to Oct. 13, 2025, identified one aide visit missed, was faxed to primary physician. d. IDG update to the plan of care, dated 10/21/25, identified no missed visits. e. Hospice aide visit note, dated 10/23/25, completed by Staff G, Hospice Aide, identified a missed visit. f. Paper missed visit report scanned into EMR, dated Oct. 21, 2025 to Oct. 27, 2025, identified one aide visit missed, was faxed to primary physician. g. IDG update to the plan of care, dated 11/4/25, lacked documentation of missed visits. h. Hospice aide visit note, dated 11/6/25, completed by Staff G, Hospice Aide, identified a missed visit. i. IDG update to the plan of care, dated 11/11/25, lacked documentation of missed visits. The hospice failed to notify the IDG of the missed hospice aide visits. The above findings were reviewed with the hospice Administrator and Clinical Manager.”

“Based on clinical record review, hospice policy review and hospice staff interview, the hospice failed to ensure the Interdisciplinary Group maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care for 1 of 5 sampled patients (Patient #5). Failure of the hospice interdisciplinary group (IDG) members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care increased the risk that patients did not receive services to meet assessed needs. Findings include: Review of the hospice policy, titled Hospice Interdisciplinary Group, dated 9/2021, identified the Interdisciplinary Group (IDG) participates in the development of the comprehensive plan of care and the plan is reviewed and revised as necessary by IDG. The IDG, in establishing the plan of care, determines the services that the individual requires for palliation and management of the patients symptoms. The IDG shall be responsible for the provision and supervision of hospice care. Review of the hospice policy, titled Coordination of Services, dated 8/2024, identified the essential components of professional coordination of services include maintaining efficient communications with all care providers to ensure prompt transmission of significant information which may require immediate action or decision-making and coordinating with all involved services. Patient #5 had a hospice admission date of 6/11/24, a death date of 10/25/24, and received hospice services while residing in a private home. Clinical record review revealed the following: a. The IDG update to the Plan of Care, dated 10/8/24, included IDG direction to provide three hospice aide visits each week and one hospice volunteer visit weekly. b. Hospice aide visit note, dated 10/16/24, included documentation the visit was not made, supervisor notified. c. Communication Note, dated 10/16/24, included documentation the hospice aide visit was not made 10/16/24 but would be made up on 10/17/24. d. The week of 10/13/24 lacked documentation of a hospice volunteer visit for the week. e. The IDG update to the Plan of Care, dated 10/22/24, lacked documentation the IDG was notified of missed hospice aide visit on 10/16/24 or the missed hospice volunteer visit for the week of 10/13/24. During an interview on 12/4/24 at 9:19 AM, Clinical Manager reported she reviewed the clinical record and was unable to find documentation of a hospice aide visit for 10/17/24 or documentation the IDG had been notified of the missed hospice aide visit and no documentation of a hospice volunteer visit or a reason why the visit had not been completed. The hospice failed to provide hospice aide visits and hospice volunteer visits as ordered per the IDG updates to the Plan of Care. The he above findings were reviewed with the Administrator and Clinical Manager.”

“Based on clinical record review, staff interview, and hospice policy review, the hospice failed to ensure all documentation in the clinical record was accurate for 2 of 5 sampled patients (Patients #4 and #5). Failure to ensure all clinical record documentation was complete, accurate and included in the patient’s clinical record decreased the ability of the hospice staff to communicate and coordinate patient care effectively. Findings include: According to the hospice policy, titled Home Health Hospice Coordination of Services, dated 8/2024, the Interdisciplinary Group (IDG) is responsible for the coordination and supervision of services to the hospice patients and for the ongoing evaluation and assessment of the Hospice patients needs. According to the hospice policy, titled Hospice Interdisciplinary Group, dated 9/2021, the IDG, in establishing the plan of care, determines the services that the individual requires for palliation and management of the patients symptoms. The IDG shall be responsible for the provision and supervision of hospice care. 1.Patient #4 had a hospice admission date of 7/17/24 and received hospice services while residing in a private home. Clinical record review revealed the following: a. The IDG updates to the Plan of Care, dated 9/3/24 and 9/17/24, included orders for social work services two times a month. b. Social work routine visit note, dated 9/11/24, included documentation Social Worker visited with patient in the kitchen. c. Social work routine visit note, dated 9/25/24, included documentation a visit was made. During an interview on 12/4/24 at 9:32 AM, Administrator, reported being contacted by Staff C, RN regarding concerns Staff D, SW visits may not have been completed as documented for Patient #4. Administrator contacted patient #4 and questioned when SW had last visited in the home. Administrator ran a report identifying visit notes dated 9/11/24 and 9/25/24 were closed without patient #4’s signature. Staff D, SW, met with Administrator and Staff E, Human Resources Business Partner, Staff D, SW was given an opportunity to provide evidence to substantiate the completion of the SW visits in Patient #4 home. Staff D provided a cell phone that indicated the patient #4 phone number had been called on 9/11/24 and 9/25/24. d. Communication note, dated 10/23/24, included documentation the visit note, dated 9/11/24 had been found to be a phone call and has been corrected. e. Communication note, dated 10/23/24, included documentation the visit note, dated 9/25/24 had been found to be a phone call and has been corrected. The SW failed to accurately document visit information. 2. Patient #5 had a hospice admission date of 6/11/24, a death date of 10/25/24, and received hospice services while residing in a private home. Clinical record review revealed the following: a. Recertification Plan of Care, dated 9/9/24 to 12/7/24, included orders for SW services one time a month for one month, two times a month for one month and six as needed visits or phone calls. b. The IDG update to the Plan of Care, dated 9/24/24, included orders for SW services one time a month for 9/9/24 to 9/30/24 and six as needed visits or phone calls for 9/9/24 to 12/7/24. c. Social Work in home visit note, dated 10/1/24, included documentation the patient did not smile with the SW this visit. During an interview on 12/4/24 at 9:32 AM, Administrator, reported Patient #5 spouse kept a log of when all hospice staff visited in the home and was able to review the log to identify the last visit made by SW to the home had been near the beginning of September. When questioned if the SW had been in Patient #5’s home on 10/1/24 the spouse replied no. d. Communication note, dated 10/23/24, included documentation the visit note, dated 10/1/24 had been found to be a phone call and has been corrected. The SW failed to accurately document visit information. The above findings were reviewed with the Administrator and Clinical Manager.”

“Based on clinical record review, hospice policy, and staff interview, the hospice failed to ensure hospice nurse members of the Interdisciplinary Group (IDG) updated the comprehensive assessment with changes to the patient assessment wound assessment for 2 of 8 patients reviewed with wounds (Patients #4 and #21). The IDG failed to ensure wound treatment orders included the location of the wound for 1 of 8 patients reviewed with a wound (Patient #12). Failure of the IDG to update the comprehensive assessment placed the patient at risk for ineffective staff collaboration and communication regarding patient’s wound status and effectiveness of treatments and interventions. Findings include: According to agency policy, Wound Measuring last revised October 2023, Wound assessment is done on a weekly basis and PRN (as needed). Assessment should include peri wound integrity, amount of odor and drainage, amount of fibrin/granulation/epithelium (skin) present. Also evaluation of patient’s pain level, vital signs, dressings applied, compliance level, changes in patients medications/allergies/procedures/history, edema, and pulse assessment should all be assessed and documented on a weekly basis. According to agency policy, Hospice Interdisciplinary Team (IDT) last revised September 2021, in pertinent part, the IDT presents a total picture of the patient/family, evaluate the care given, assess changing needs and identify problems, develop plans for intervention, and provide an opportunity for all team members to discuss their needs, problems, and goals of the patient. To provide patient centered care that reflects the patients goals and strives to meet the patients physical, emotional and spiritual needs. In an interview on 4/29/24 at 4:00 PM, Staff C, Clinical Manager, reported that wound assessment is performed weekly with the first skilled nursing visit of the week. Interview on 5/7/24 at 3:00 PM, Staff B, Quality Coordinator, reported the care plan had 2 interventions related to the Patient #12s wound, 1 intervention contained the wound treatment order that did not include the location of the wound and another intervention that included the location of the wound without the treatment order. Further review of the care plan for the patients wounds revealed the patient had other wounds and Staff B reported that the only way to correlate which wound was related to the treatment order was through the start date of the interventions. In the same interview, Staff B agreed that wound assessment was needed as part of Patient #4s comprehensive recertification assessment. 1. Patient #4 had a hospice admission date of 4/20/23 and received hospice services while residing in a long term care facility. Review of the clinical record revealed the following: a. The IDG Meeting on 3/19/24 included orders for 2 skilled nursing visits per week, the first assessment of the left arm skin tear dated 3/7/24, and the first assessment of the right foot wound on 2/28/24. b. The patients skilled nursing visits on 3/25/24 and 3/28/24 did not contain assessment of the left arm skin tear. c. The recertification skilled nursing visit on 4/9/24 did not include assessment of the right foot wound. 2. Patient #21 had a hospice admission date of 2/15/24 and received hospice services while residing in a long term care facility. Review of the clinical record revealed the following: a. The POC from 2/15/24 to 5/14/24 included orders for 2 skilled visits per week and 6 PRN (as needed) visits. The POC included documentation of the patients decubitus ulcer to the right heel. b. Review of skilled nurse visit documentation from the week of 2/18/24 failed to include assessment of the right heel wound. 3. Patient #12 had a hospice admission date of 2/21/24 and received services while residing in a long term care facility. Review of the clinical record revealed the following: a. IDG Meeting documentation on 4/9/24 that included an order to perform wound care/dressing change: cleanse with dermal wound cleaner, cover with Vaseline gauze, apply Telfa pad, wrap with kerlix gauze and secure with paper tape. Perform every 3 days. Facility staff to perform on non visit days. Start date 3/29/24. The order failed to include the location of the wound. The above findings were reviewed with Staff A, Administrator , Staff B, Clinical Manager and Staff C, Quality Manager. No additional information was presented prior to the end of the survey.”

“Based on clinical record review, hospice policy review, and staff interview, the hospice failed to ensure the Interdisciplinary Group (IDG) maintained a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the plan of care (POC) for 4 of 21 patients (Patients #1, #3, #11, and #18). Failure of the hospice IDG members to maintain a system for communication and integration of patient care and services to ensure hospice staff provided care in accordance with the POC increased the risk that patients did not receive services to meet assessed needs. Findings include: 4. Patient #1 had a start of care date of 4/8/24, and initially received hospice services in the home, but was later transferred to the hospice house on 4/19/24. Clinical record revealed the following. a. The patient was seen by the Registered Nurse following the admission date of 4/8/24, consecutively on 4/9 through 4/14. The Registered Nurse documents in the clinical record the patient is receiving daily visits. No visits or reasons for missed visits are documented for 4/15 and 4/16, Then daily visits resumed from through admission to the hospice house on 4/19/24. b. The IDG (interdisciplinary group meeting) update to the POC dated 4/30/24, lacked documentation the IDG was notified of the missed Nursing visits on 4/15/24 and 4/16/24. c. During an interview with the Clinical Manager on May7th at 3:45 pm, She confirmed the Nurse was providing daily visits, but failed to obtain a physicians order and failed to notify IDG of the missed nursing visits. The hospice failed to obtain the order to increase nursing visits to daily and to provide nursing visits as ordered per the IDG updates to the POC. 3. Patient #18 had a hospice admission date of 6/27/23, a discharge date of 9/16/23, and received hospice services while residing in a nursing home. Clinical record review revealed the following: a. The IDG updates to the POC, dated 7/18/23, included IDG direction to provide one hospice aide visit each week. b. Hospice aide visit, dated 7/24/23, included documentation of a missed visit, shower had been given by facility. c. The IDG update to the POC, dated 8/1/24, lacked documentation the IDG was notified of the missed hospice aide visit on 7/24/23. The hospice failed to provide hospice aide visits as ordered per the IDG updates to the POC. According to agency policy, Home Health and Hospice Missed Visit Procedure dated 2/1/24, in pertinent part: The missed visit report will be run once a week and the missed visit forms will be filled out for each clinician. The forms will be sent to the office and given to a staff member. The staff member will collect signatures on the forms then give them to another staff member. This staff member will fax the forms to the doctors and print the proof of transmission sheet out and attach it to the missed visit form. A staff member will then scan the missed visit form as well as the fax transmission sheet into the patient’s chart with the tag “Missed Visit.” In an interview on 4/30/24 at 9:20 AM, the Quality Coordinator reported that the chaplain has not been documenting notes to include information about missed visits. The chaplain has received education about this process. 1. Patient #3 had a hospice admission date of 6/14/23 and received services while residing in a private residence. Review of the clinical record revealed: Order for chaplain to assess and evaluate the patient from 3/15/24 to 3/20/24. IDG Meeting documentation with orders for the chaplain to assess and evaluate the patient from 4/1/24 to 4/4/24. Chaplain Visit Notes dated 3/20/24 and 4/4/24 included that the visits were missed. IDG Meeting documentation failed to include the missed chaplain visits. 2. Patient #11 had a hospice admission date of 4/19/24 and received services while residing in a private residence. Review of the clinical record revealed the following: The POC dated 4/19/24 to 7/17/24 included orders for aide visits one time per week starting 4/19/24. The Visit Management list documented that an aide visit was missed on 4/19/24. The above findings were reviewed with the Administrator, Clinical Manager, and Quality Coordinator. The hospice team did not provide any further information prior to the end of the survey.”

“Based on review of written contractual agreements and hospice staff interview, the hospice failed to ensure the written agreement between the hospice and 1 of 2 sampled services under arrangement included all of the required contract components. The hospice reported a total of 17 written agreements for services under arrangement with companies and individuals at the time of the survey. Failure to include the required contract components within the contractual agreement increased the potential that hospice management and oversight failed to occur and the patient would not receive services as specified on the plan of care. Findings include: A pharmaceutical service contract, dated 10/1/07, failed to include the following contractual language: the hospice retains administrative management; the hospice retains financial management; the hospice maintains oversight of staff and services; all services are furnished in a safe, effective manner by qualified personnel; all services are authorized by the hospice; and, all services are delivered in accordance with the patient’s plan of care. On 5/7/24 at 4:05 PM, during an interview, the Administrator agreed the required components were missing. The above findings were reviewed with Staff A, Administrator , Staff B, Clinical Manager and Staff C, Quality Manager. No additional information was presented prior to the end of the survey.”

“Based on clinical record review and staff interview, the hospice failed to ensure patient clinical records included physician orders for all medications, treatments, and level of care, for 1 of 1 sampled patients at an inpatient level of care. (Patient #1) Failure to have physician orders for all medications, treatments, and level of care, created the potential for patients to receive incorrect or ineffective treatment to meet the assessed needs of the patients. Patient #1 had a start of care date of 4/8/24 and received hospice services in a private home, from 4/8/24 - 4/18/24 , then in the hospice house from 4/19/24 to current date of chart review (4/30/24). Clinical record review revealed the following: a. A physician order, dated 4/19/24, identified patient admitted to the hospice house for respite level of care. b. Physician order dated, 4/20/24 at 5:00 pm, identified instructions for insertion of a foley catheter (drains the bladder of urine). c. Physician order dated, 4/20/24 at 6:10 PM, was received to access the chest port (Intravenous site to administer medication) d. Physician order, dated 4/20/24, changed all oral medication to IV (intravenous ) medications. e Social Worker documented in the IDG (Interdisciplinary group) note, dated 4/23/24, a review of patients transition to acute care related to uncontrolled pain and anxiety. f. During an interview with Staff B, clinical manager, on 5/8/24, at 3:40 pm confirmed there was not an order for level of care change and that it was her expectation for the physician to write the order. The agency failed to ensure a physicians order was obtained for the level of care that changed from respite to acute. The above findings were reviewed with Staff A, Administrator , Staff B, Clinical Manager and Staff C, Quality Manager. No additional information was presented prior to the end of the survey.”

“Based on clinical record review, staff interview, and hospice policy review, the hospice failed to ensure all documentation was included in the clinical record for 3 of 3 sampled patients (Patient #9, #15, and #21) receiving hospice volunteer services. Failure to ensure all clinical record documentation was complete and included in the patient’s clinical record decreased the ability of the hospice staff to communicate and coordinate patient care effectively. Findings include: 2. Patient #15 had a hospice admission date of 4/1/24 and received hospice services while residing in a private residence. The Interdisciplinary Group (IDG) note, dated 4/23/24, included documentation from the Volunteer Coordinator that IDG discussed monthly volunteer visits with the patient; volunteer visits were scheduled for 4/26/24 and 5/14/24. The volunteer visit note, dated 4/26/24, was completed on paper and placed in a binder with all of the hospice patients’ volunteer notes. The hospice failed to scan and include the completed volunteer notes in the patient’s medical record upon receipt of the documents. 3. Patient #21 had a hospice admission date of 2/15/24 and received services while residing in a long term care facility. The Interdisciplinary Group (IDG) note, dated 2/20/24, included orders for weekly volunteer visits starting 2/20/24. The IDG note on 3/5/24 included documentation that the patient passed away on 2/29/24. The volunteer visit notes, dated 2/21/24 and 2/28/24, were completed on paper and uploaded into the patients electronic health record (EHR) on 3/1/24. The hospice failed to scan and include the completed volunteer notes in the patient’s medical record upon receipt of the documents. 4. Patient #3 had a hospice admission date of 6/14/23 and received services while residing in a private residence. Review of the clinical record revealed: IDG Meeting documentation dated 3/28/24 that included orders for skilled nursing visits two times per week. The skilled nurse visit for recertification of hospice services on 4/2/24 was signed on 4/8/24. 5. Patient #4 had a hospice admission date of 4/20/24 and received services while residing in a long term care facility. Review of the clinical record revealed: IDG Meeting documentation dated 4/19/24 included orders for skilled nursing visits two times per week. The skilled nurse visit for recertification of hospice services on 4/9/24 was signed on 4/13/24. 6. Patient #11 had a hospice admission date of 4/19/24 and received services while residing in private residence. Review of the clinical record revealed: IDG Meeting documentation on 4/23/24 included orders for Medical Social Worker (MSW) to visit weekly for 2 weeks that started 4/21/24. The MSW visit on 4/24/24 was signed on 4/28/24. The above findings were reviewed with Staff B, Clinical Manager and Staff C, Charge Nurse. The hospice team did not provide any further information prior to the end of the survey. On 4/30/24 at 10:30 AM, during an interview, Staff D, Volunteer Coordinator (VC), reported the volunteer care plan and notes are completed on paper and kept in one binder for all patients. Patient notes are not scanned into the medical record until a patient dies or is discharged. According to the hospice policy, titled Home Health/Hospice Completion and Retention of Patient Records, dated 7/2021, paper documents are scanned into the electronic record as they are received. 1.Patient #9 had a hospice admission date of 4/4/24 and received hospice services while residing in a hospice house. The Interdisciplinary Group (IDG) note, dated 4/23/24, included orders for volunteer services 1 time a week for 3 months with 60 visits per request needed (PRN) effective 4/16/24. The volunteer visit notes, dated 4/16/24, 4/18, 4/19, 4/22, and 4/30, were completed on paper and placed in a binder with all hospice patients’ volunteer notes. The hospice failed to scan and include the completed volunteer notes in the patient’s medical record upon receipt of the documents.”

“Based on observation and staff interview, the hospice failed to ensure staff served meals at the proper temperature in the hospice house. The hospice reported providing services to 3 patients at the hospice house at the time of the survey. Failure to ensure food is cooked to the proper temperature put the patients at risk for food borne illness. Findings include: During an interview on 4/30/24 at 8:50 AM, Staff E, Hospice Aide, identified food is reheated per the posted guidelines in the hospice house kitchen. Those guidelines identify reheated food needs to be served at 165 degrees. Observation on 4/30/24 at 8:50 AM with Staff E revealed: Staff E reheated French toast. She checked the temperature of the French toast and identified it was reheated to 130 degrees. Staff E placed the reheated French toast on a plate, covered it, and served it to the patient. Hospice staff failed to serve the reheated meal at 165 degrees; the temperature posted in the hospice house kitchen and recommended by the Food and Drug Administration. The above findings were reviewed with the Administrator. The hospice provided no further information prior to the end of the survey.”

“Based on observation and interview, the facility failed to inspect and maintain the automatic sprinkler system within the facility by assuring the sprinkler system testing is in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition, 5.3.2.1. This deficient practice could affect all smoke compartments and occupants of the facility. The facility had a capacity of 6 and a census of 4 residents at the time of the survey. Findings include: 1. Observation on 5-2-24 at approximately 11:23 a.m., revealed the Annual Sprinkler Inspection noted the dry pendants were overdue for testing/replacement and listed in the inspection as, “;critical.” At the time of survey, the dry pendants had not been tested or replaced. 2. Observation on 5-2-24 at approximately 11:24 a.m., revealed 1 of 4 sprinkler heads were dirty in the front vestibule of the building. Maintenance Staff verified these findings at the time of survey.”

“Based on record review and interview, this facility did not maintain the emergency generator by maintaining complete weekly documentation as required by National Fire Protection Association (NFPA) 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.1 or 8.3.4. The deficient practices of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator did not ensure proper operation and prompt repair affecting all occupants. This facility had a capacity of 6 and a census of 4 residents at the time of the survey. Findings include: Record review conducted on 5/02/24, at approximately 11:59 a.m., of the facilities generator paperwork revealed no weekly inspections were available. This deficient practice was confirmed by Maintenance Staff at time of inspection.”