Health inspection·December 3, 2025

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals identified with MI, DD, or ID were evaluated for services for 1 of 5 residents (Residents #48) reviewed for PASARR.The facility failed to ensure Resident #48 had a PASARR evaluation after being readmitted to the facility on [DATE] with a mental illness diagnoses of bipolar disorder. This failure could place residents who had a mental illness at risk of not receiving individualized specialized services to meet their needs.Findings included:Record review of an admission Record for Resident #48 dated 12/2/2025 indicated he was admitted to the facility on [DATE] with a readmission on [DATE] and was [AGE] years old with diagnoses of bipolar disorder (extreme mood swings), dementia, hypertension, and cerebral infarction (stroke).Record review of a Quarterly MDS Assessment for Resident #48 dated 9/23/2025 indicated he had moderate impairment in thinking with a BIMS score of 12. He had diagnoses of non-Alzheimer's dementia and psychiatric/mood disorder of bipolar disorder. Record review of a PASARR Level 1 Screening form for Resident #48 dated 2/25/2025 indicated the referring entity was from a psychiatric hospital and he had a primary diagnosis of dementia, and he also had MI.Record review of a PASARR Evaluation for Resident #48 indicated there was no evidence of an evaluation when resident readmitted to the facility on [DATE] and there was not a Form 1012 (a form that the nursing facility completes for a resident with a negative PASARR Level 1 screening for mental illness to determine if a new positive PASARR level 1 screening should be submitted) in the medical record.Record review of a care plan for Resident #48 dated 9/10/2024 indicated he had a diagnosis of mental illness, but dementia made him PASARR negative. Interventions included form 1012 completed by MD and LA to be updated as needed.During an interview on 12/3/2025 at 10:45 AM, the MDS Coordinator said she had been the MDS Coordinator for 3 years and was responsible for PASARR. She said when a resident admitted to the facility, she submitted the Level 1 Screening Form into Simple (long-term care software portal that facilitates claims data analysis, regulatory compliance, reimbursement optimization, and quality measurement) and if they had a mental illness, ID, or DD then she would alert the LA to complete a PE. She said Resident #48 was admitted back into the facility following a psychiatric hospital stay and his Level I screening was positive for dementia and MI. She said he should have had a PE completed and it was missed. She said he had a previous form 1012 that was signed in the past and dementia was primary. She said she submitted a new PASARR Level 1 screening and a new Form 1012 yesterday (12/2/2025) and it was sent to the physician to get signed. She said the Form 1012 showed if a resident had mental illness but also dementia, then dementia was the primary diagnoses. She said a new PL 1 should be completed when a resident discharged for more than 30 days from the facility or if a resident was admitted to a psychiatric facility. She said if the assessments were not done, services could be missed if they were not completed.During an interview on 12/3/2025 at 2:00 PM, the Administrator said the MDS Coordinator was responsible for PASARR. She said residents should have a level 1 screening completed prior to admission that would indicate if a resident Residents Affected - Few Page 1 of 9 676103 676103 12/03/2025 Wells Ltc Nursing & Rehabilitation 46 May Street Wells, TX 75976

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had a mental illness and the local authority would need to be contacted for an evaluation. She said if an evaluation was not completed then a resident might not get the services that they qualified for. She said she would make sure during the stand-up meetings they would discuss the status of the positive level I's. She said she expected the MDS Coordinator to contact the local authority when a resident had a positive level I for an evaluation to be conducted. Record review of a signed Form 1012 for Resident #48 dated 12/2/2025 by the physician indicated the resident had a primary diagnosis of dementia. PL1 remains negative and no new PL 1 needed to be completed.Record review of a new PL1 for Resident #48 dated 12/2/2025 indicated he had dementia as primary diagnosis. Record review of a facility policy tilted admission Criteria revised March 2019 indicated, .Our facility admits only residents whose medical and nursing care needs can be met. 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level 1 PASARR screen for all potential admissions to determine if the individual meets the criteria for a MD, ID, or Rd. b. IF the level 1 screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II screening process 676103 Page 2 of 9 676103 12/03/2025 Wells Ltc Nursing & Rehabilitation 46 May Street Wells, TX 75976

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident with a mental disorder received the appropriate treatment and services to correct the assessed problem and/or attain the highest practicable mental and psychosocial well-being, for 1 of 6 residents (Resident #39) reviewed for behavioral health services.The facility failed to document an episode of resident behaviors in the clinical record for Resident #39 on 12/1/25. The facility failed to offer a prn medication for anxiety to Resident #39 when she was exhibiting signs of anxiety on 12/1/25.These failures could place residents at risk of additional stress, feelings of hopelessness and a diminished quality of life. Findings included: Record review of a facility face sheet dated 12/3/25 for Resident #39 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Schizophrenia (a serious mental health condition that affects how individuals think, feel, and behave. It is characterized by a range of symptoms, including hallucinations, delusions, disorganized thinking, and impaired functioning), anxiety disorder (a group of mental health conditions characterized by excessive fear, worry, and anxiety that can interfere with daily activities), and schizoaffective disorder, bipolar type (a mental health condition characterized by symptoms of both schizophrenia and bipolar disorder). Record review of a quarterly MDS assessment dated [DATE] for Resident #39 indicated a BIMS score of 7, which indicated severe cognitive impairment. Resident #39 was not coded for any physical or verbal behaviors. Record review of a comprehensive care plan dated 11/26/25 for Resident #39 indicated she had the potential to demonstrate verbally, or physically abusive behaviors related to schizophrenia and had an intervention to monitor each shift and document observed behavior and attempted interventions in behavior log and also had an intervention to administer medications as ordered. Record review of a Medication Administration Record (MAR) dated 12/1/25 through 12/31/25 for Resident #39 indicated a prn (as needed) order for hydroxyzine pamoate oral capsule 50mg was not administered. Order read: .Hydroxyzine Pamoate Oral Capsule 50mg (hydroxyzine pamoate) Give 50mg by mouth every 4 hours as needed for Anxiety related to Anxiety Disorder, Unspecified, until 12/2/25 23:59. Order was dated 11/18/25. MAR was not signed off indicating medication was not given.Record review of nursing progress notes for Resident #39 indicated no progress note for Resident #39 pacing in female secured unit common area, yelling and cursing on 12/1/25 at 2:55 pm. Record review of a nursing progress note dated 12/1/25 at 6:01 pm for Resident #39 indicated she was transferred to a behavioral hospital after an escalation in behaviors. During an observation on 12/1/25 at 2:55 pm Resident #39 was observed pacing in the female secured unit common area visibly upset, yelling and cursing loudly. She stated loudly I already told you one fucking time Behavioral Support Staff observed attempting to redirect resident by talking to her calmly. Resident continued being loud. Staff took resident out to smoke at 3:00 pm, resident still appeared agitated but stopped yelling and cursing at this time.During an interview on 12/2/25 at 9:32 am Behavioral Support Staff said Resident #39 normally did not behave that way. She said she had reported resident's behaviors to the nurse. She was unsure of any interventions done by the nurse. She did not give a name of whom she had reported behaviors to.During an interview on 12/3/25 at 8:45 am LVN D said she was not working Monday (12/1/25) when Resident #39 was transferred to a behavioral hospital. She said if she had a resident that was exhibiting behaviors such as pacing, visible signs of agitation or anxiety, yelling and cursing, she would document the behaviors in a progress note or behavior note and give any prn medications that resident may have. She said Resident #39 did have an order for medication prn. During an 676103 Page 3 of 9 676103 12/03/2025 Wells Ltc Nursing & Rehabilitation 46 May Street Wells, TX 75976

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interview on 12/3/25 at 8:52 am DON said the charge nurse that had been scheduled Monday called in sick and ADON was working the female unit on Monday 12/1/25. DON said she had not been made aware of Resident #39's behaviors prior to an escalation that occurred at approximately 3:50 pm on 12/1/25 resulting in Resident #39 being transferred to a behavioral hospital.During an interview on 12/3/25 at 9:00 am ADON said she was working the day shift on the female unit on Monday 12/1/25, due to the regular nurse calling in sick. She said she was not notified of Resident #39 having any behaviors that day prior to an incident with another resident. Attempted a follow-up interview with Behavioral Support Staff on 12/3/25 at 9:09 am. Telephone call would not go through due to lack of signal. A text message was sent requesting a returned phone call, but no response was received before exiting facility.During an interview on 12/3/25 at 1:50 pm LVN B said she was working Monday 12/1/25. She said she was not working the female unit and was not notified of any resident behaviors for Resident #39.During a follow-up interview on 12/3/25 at 2:07 pm ADON said she could not remember the last time she had been on the female unit and saw Resident #39 before the escalation occurred, she said she was probably passing medications on another hall during the time Resident #39 had been exhibiting behaviors. She said if the behaviors had been reported to her, she would have documented the behaviors in a progress note and given a prn medication. She said interventions should be done appropriately to prevent an escalation of behaviors. During a follow-up interview on 12/3/25 at 2:10 pm DON said she would expect her staff to report resident's behaviors if they exhibited behaviors that were outside of their normal. She said she expected her staff to be proactive in managing resident behaviors in an effort to prevent escalation and possible altercations. She said she would be in-servicing the staff and providing education regarding behaviors, communication between staff and identifying anxiety and agitation.During an interview on 12/3/25 at 2:15 pm Administrator said she expected her staff to implement any interventions in place for resident behaviors, report resident behaviors to charge nurses, and also doctors, if needed, to obtain new interventions. She said she would be in-servicing the staff on managing resident behaviors. She said if behaviors were not managed appropriately, it could lead to altercations, and possible resident injury.Record review of a facility policy titled Resident-to-Resident Altercations dated September 2022 read: .Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff. and .Behaviors that may provoke a reaction by residents or others include: a. verbally aggressive behavior, such as screaming, cursing. 676103 Page 4 of 9 676103 12/03/2025 Wells Ltc Nursing & Rehabilitation 46 May Street Wells, TX 75976

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation in that:The facility failed to ensure the dish machine reached recommended minimal 50-100 parts-per-million, (PPM), of hypochlorite (chlorine) and water temperature of 120 degrees Fahrenheit (F) during the final rinse cycle of the facility dish machine.The facility failed to keep the freezer surfaces clean and free of ice buildup.This failure could place the residents at risk of foodborne illnesses. Findings included:During an observation and interview on 12/01/2025 at 08:45 am upon request the dish machine was checked by the Dietary manager; there was no sanitation detected on the test strips used by the Dietary Manager and the water temperature indicated 118 degrees Fahrenheit, (F) during the final rinse cycle. The Dietary Manager said they had not checked the sanitation this am before cleaning the dishes. The Dietary Manager said the test should indicate 50-100 parts per-million, (PPM), of hypochlorite (chlorine), and the water temperature should be 120 degrees Fahrenheit, (F). The Dietary Manager said she would contact the service contracted for the dish machine to service the dish machine.During an observation on 12/01/2025 at 09:05 am the freezer had one and a half inches of ice layered across the bottom of the freezer unit with food substances lying in the ice inside the freezer. The outside had dried spilled food substance that had dripped down the freezer. The Dietary Manager said she had been working in the manager's role for 6 weeks and had been the cook for the past 7 years. The Dietary Manager said she had two new employees that were still in training. She said she was responsible for ensuring all sanitation requirements are met in the kitchen. During an interview with the Administrator on 12/01/2025 at 09:10 am, the Administrator said the kitchen would serve on paper products until the sanitation level for the dish machine was resolved. The Administrator said her expectation was for the Dietary Manager to ensure that all sanitation requirements were followed including pest control. During an observation on 12/02/2025 at 10:57 am the Dish machine was tested by the Dietary Manager with a temperature of 120 degrees and sanitation of 50-100 Parts per million, meeting regulations and policy. The DM said that the contract service for the dish machine made a service call yesterday and made necessary adjustments.Record review of a facility policy titled Dishwashing Machine Use dated 2001 and revised in May 2008 read .Food Service staff are required to operate the dishwashing machine will be trained in all steps of dishwashing machine use .Record review of a facility policy titled Sanitation dated 2001 and revised in November 2022 read .The food service area is maintained in a clean and sanitary manner .1. Dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitization are.Low-Temperature Dishwasher (Chemical Sanitization):(I) Wash temperature (120 F); Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) on dish surface in final rinse; and(2) The chemical solution is maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. 676103 Page 5 of 9 676103 12/03/2025 Wells Ltc Nursing & Rehabilitation 46 May Street Wells, TX 75976

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 6 resident's personal refrigerators reviewed for food safety (Resident #42).The facility failed to ensure the refrigerator for Resident #42 did not contain expired melon, unidentified substance in white Styrofoam cup with glove over it, and open, unlabeled, undated bean dip.This failure could place residents at risk for food borne illnesses.Findings included:Record review of a facility face sheet dated 12/2/25 for Resident #42 indicated she was an [AGE] year-old female originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including asthma and dementia. Record review of a comprehensive MDS assessment dated [DATE] for Resident #42 indicated a BIMS interview should not be completed due to resident being rarely/never understood. She had severely impaired cognition. She required set-up or cleanup assistance with eating and was dependent with all other ADLs. Record review of a comprehensive care plan dated 6/22/22 for Resident #42 indicated she had a preference to keep a refrigerator in her room. She had interventions for staff to ensure all foods were dated and for staff to check refrigerator daily for spoiled or outdated foods.During an observation on 12/1/25 at 9:00 am a personal refrigerator was observed in Resident #42's room with a white Styrofoam cup in refrigerator with a glove over the top. There was no label, no date, and it appeared to have a spoon inside underneath the glove. There was also an open container of bean dip with no opened date, and an unopened container of mixed melon (watermelon, cantaloupe, and honeydew melon) with a sell by date of 10/8/25. Melon in container appeared soft and submerged in liquid.During an observation and joint interview on 12/2/25 at 9:35 am CNA E said either the CNA or housekeeping were responsible for cleaning out residents' personal refrigerators. Housekeeping supervisor was in the hallway at the time of interview and walked into Resident #42's room and was observed removing items from the refrigerator. She said if residents were to eat old food, it could make them sick. CNA E agreed that residents could get sick.During an interview on 12/2/25 at 9:43 am DON said Dietary staff were responsible for checking personal refrigerators once per day. She said if residents ate food that was expired or not good, they could get sick. During a follow-up interview on 12/3/25 at 2:10 pm DON said if residents' refrigerators were not kept cleaned out, residents could accidentally eat something they were allergic to, or they could eat old food and get sick. She said she would be conducting an in-service and training staff that dietary was to check temps of personal refrigerators daily and during temperature checks, if it needed cleaned out, they would report that to the nursing staff, and if they found a problem with the functioning of the refrigerator it would be reported to maintenance staff. During an interview on 12/3/25 at 2:15 pm Administrator said CNAs and Housekeeping would be responsible for cleaning out resident's personal refrigerators going forward. She said she would be responsible for monitoring to ensure it was being completed. She said if a resident ate spoiled food, they might get sick. Record review of a facility policy titled Foods Brought by Family/Visitors dated March 2022 read .Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date . and .The nursing staff will discard perishable foods on or before the use by date . Residents Affected - Few 676103 Page 6 of 9 676103 12/03/2025 Wells Ltc Nursing & Rehabilitation 46 May Street Wells, TX 75976

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #8) reviewed for infection control.The facility failed to ensure CNA A and the DON followed enhanced barrier precautions and wore a gown and gloves when providing direct care to Resident #8 on 12/02/2025.This failure could place residents at risk for cross contamination and infection. Findings included:Record review of Resident #8's face sheet dated 12/02/2025 revealed Resident #8 was a [AGE] year-old female that admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of chronic obstructive pulmonary disease (lung disease that affects breathing) and extended spectrum beta lactamase (ESBL) resistance (bladder infection that is difficult to treat due to medication resistance).Record review of Resident #8's nurses note dated 11/27/2025 indicated Resident #8 had colonized ESBL.Record review of Resident #8's order summary report dated 12/02/2025 did not indicate EBP for Resident #8.Record review of Resident #8's comprehensive care plan had not been completed as it was not due yet.Record review of Resident #8's admission MDS assessment dated [DATE] revealed Resident #8 had a BIMS score of 15 indicating intact cognition, required substantial assistance with toileting, and was always incontinent of bowel and bladder.During an observation on 12/01/2025 at 10:00 am there was neither an EBP sign on Resident #8's door nor PPE outside the room. After a record review Resident #8 was coded on the facility matrix to have a pressure ulcer and urinary tract infection. During an interview on 12/02/2025 at 9:11 am Resident #8 said she had some sores on her buttocks that she has had for a long time and that she has had infections in her urine on and off for a long time. She said she could not recall whether the staff wore a gown or not when they cared for her. During an observation on 12/02/2025 at 10:11 am the DON and CNA A were in Resident #8's room to complete a skin assessment and wound care to pressure ulcers on her buttocks. Resident #8 was turned on her side by CNA A while the DON assessed the resident's buttocks and provided wound care. Neither the CNA nor the DON applied PPE for EBP. During an interview on 12/02/2025 at 10:20 am CNA A said that she had been trained on EBP and residents that had open wounds and catheters should be on EBP but was not sure what types of infections and the nurses handled that. She said Resident #8 had a pressure ulcer on her buttock and should be on EBP and was not sure why she did not have a sign on her door and PPE outside of her room. She said the nurses put out the signs and PPE for them to know who needed EBP. She said by not following EBP germs could spread. During an interview on 12/02/2025 at 10:22 am the DON said that Resident #8 was admitted to the facility with pressure ulcers, but the wound did not require a dressing. She said Resident #8 also had colonized ESBL and should be on EBP for that reason. She said when EBP was needed there should be an order, care plan and a sign on the door notifying staff of the need to wear a gown and gloves with care. She said she was responsible for the infection control program and by not following EBP infections could spread. During an interview on 12/03/2025 at 10:13 AM LVN B said she cared for Resident #8 and had spoken to the urologist about her ESBL and that her urinary infection was colonized with ESBL and Resident #8 did not need contact isolation. She said she thought she was already on EBP for her wound but realized she was not and there was never an order put in to monitor EBP use. She said by not following the EBP guidelines infections could spread. During an interview on 12/03/2025 at 12:04 PM the Administrator said the DON was responsible for the infection control program, but all nurses should initiate EBP for any of the required reasons when admitted or when an issue was newly identified. She said the DON was responsible for making sure the EBP Residents Affected - Few 676103 Page 7 of 9 676103 12/03/2025 Wells Ltc Nursing & Rehabilitation 46 May Street Wells, TX 75976

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few process was followed by placing signs on the door, PPE outside the room and ensuring the staff were following EBP. She said if EBP was not followed cross contamination could happen and expected the infection control program was followed in its entirety to prevent infections from spreading. Record review of a facility policy titled Enhanced Barrier Precautions dated August 2022 indicated, .Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. 2.EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). 3.Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:a.dressing;b.bathing/showering;c.transferring;d.providing hygiene;e.changing linens;f.changing briefs or assisting with toileting;g.device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); andh.wound care (any skin opening requiring a dressing).4.EBPs are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with the following:a.Pan-resistant organisms; b.Carbapenemase-producing carbapenem-resistant Enterobacterales;c.Carbapenemase-producing carbapenem-resistant Pseudomonas spp;d. Carbapenemase-producing carbapenem-resistant Acinetobacter baumannii; e.Candida auris;f.Methicillin-resistant Staphylococcus aureus (MRSA); g.ESBL-producing Enterobacterales;h.Vancomycin-resistant Enterococci (VRE);I. Multidrug-resistant Pseudomonas aeruginosa; and j.Drug-resistant Streptococcus pneumonia.10.Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPB required.11.PPE is available outside of the resident rooms 676103 Page 8 of 9 676103 12/03/2025 Wells Ltc Nursing & Rehabilitation 46 May Street Wells, TX 75976

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for one of one facility reviewed for pest control.The facility failed to ensure an effective pest control program was in place to keep roaches, rats and flies out of the kitchen and the remainder of the facility.This failure could place residents at risk of exposure to ineffective pest control at the facility and food borne illnesses. Findings included:During an observation in the kitchen on 12/01/2025 at 08:55 am a live roach was crawling on the door of the white freezer. The dry storage area had large rodent droppings below the bottom shelf on the floor. The area of droppings was a 6-inch circle of droppings and wet rodent urine. The DM said she would have the area cleaned and that the large rodent droppings were a sanitation issue.During an observation and interview on 12/01/2025 at 09:05 the kitchen freezer had a one and a half inch of ice layer across the bottom of the freezer unit with 3 dead flies lying in the ice inside the large three compartment freezer. Flies were observed flying in the food preparation area. The Dietary Manager said all residents consumed meals prepared in the facility kitchen. She said she had been working in the manager's role for 6 weeks and had been the cook for the past 7 years. She said she was responsible for ensuring all sanitation requirements were met in the kitchen. The Dietary Manager said she reported pest concerns to maintenance and the Administrator. Record review of pest control logs on 12/03/25 revealed that pest control was last at the facility on 10/27/2025 for monthly service with additional treatments when requested by the facility. Invoices revealed the kitchen was treated for flies, roaches and rodents and in other areas of the facility also. Requested invoice for November 2025 and no invoice was provided.During an interview with the Administrator on 12/01/2025 at 09:10 am, the Administrator said her expectation was for the Dietary Manager to ensure that all sanitation requirements were followed including pest control. She said pests and rodents in the kitchen were a sanitation problem.During a phone interview on 12/02/2025 at 2:30 pm the contract pest control consultant said he comes monthly with the last visit in November. He said he checks rodent traps and rebaits them. He said he treats the facility for large flies and roaches. He said he had been contacted 12/01/2025 to return to the facility for additional treatment after this surveyor had found pests and evidence of rodents in the kitchen. He stated that with all the structural issues, baseboards, and food debris, this issue has persisted. He stated that he had been treating this building for 7-8 years and this problem had been the same for the entire 7-8 years. During an interview on 12/03/2025 at 8:30 am the Maintenance Director said that he treats the kitchen when he is made aware that insects are visible. He said the last treatment by himself was on 11/20/2025 with a canned spray for roaches. He said he was not aware there were large rodents in the Kitchen.Record review on 12/03/2025 of policy titled Pest Control dated May 2008 stated .this facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . Residents Affected - Some 676103 Page 9 of 9