Health inspection·October 25, 2024

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to maintain a medication error rate below five percent (5%). During the medication pass on 10/22/24, four medication errors were observed out of thirty-three opportunities for two out of four residents, resulting in an error rate of 12.12%. This failure had the potential to result in harm in the health and safety of residents. Residents Affected - Some Findings: 1. According to the facility policy, Medication Administration - Eye Drops, Section 7.11, dated 05/2016, to ensure safe and accurate administration of eye drops according to facility, staff should begin by washing their hands thoroughly and putting on gloves, reducing the risk of contamination and protecting patient safety. Using a gloved finger, gently pull down the patient's lower eyelid to create a small pouch, an area ideal for placing the medication with minimal risk of spills or eye irritation. Instruct the patient to look upward, exposing the eye pouch and facilitating precise administration of the drops. Position the eye drop bottle close to the eye, being careful not to touch it, and administer the prescribed number of drops into the pouch. After applying the drops, gently press on the inner canthus-the corner of the eye near the nose-for about a minute to prevent drainage into the nasal passage and allow the medication to be absorbed more effectively in the eye. These steps, as outlined in the policy, support accurate and safe delivery of eye medication. By adhering to this facility policy, healthcare providers can administer ophthalmic solutions accurately and safely while minimizing the risk of adverse events or complications. During an observation on 10/22/24 at 9:20 AM, S08 administered one drop of medication in both eyes of Resident A01R; however, she did not wear gloves during the process, raising concerns about proper infection control practices. Additionally, resident did not have their head positioned correctly, as they fully extended their neck to look directly upward rather than tipping their head back slightly as recommended. During the administration,S08 did not gently pull down each lower eyelid to form a pouch, which is necessary for accurate placement, nor did she instruct the resident to look upward while steadying her other hand on the resident's forehead for control. Furthermore, she failed to hold the inner canthus after administering the drops, which is crucial for preventing drainage into the nasal passage. Instead, she held the vial high above the eyes and placed one drop in each eye without making contact with eye area or forming a pouch, which could impact the effectiveness and safety of the medication delivery. During an interview conducted on 10/23/24 at 11:45 AM, S08 acknowledged that during the administration of eye drops to Resident A01R , she did not wear gloves while administering one drop in each eye. She further indicated that she was unaware of the necessity for gloves when not directly touching the patient. S08's statement corroborates this deviation from recommended practices for maintaining sterility during eye drop administration, emphasizing the need for proper techniques to ensure the safe and effective delivery of ophthalmic solutions. Additionally, S08 did not hold the inner canthus after administering the drops, a crucial step for preventing drainage and maximizing absorption. 2. A review on 10/22/24 of the manufacturer insert for Victoza indicates that, when administering the subcutaneous injection, the needle should be held in place for a minimum of six seconds post-injection to ensure complete delivery of the medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 2 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 10/22/24 at 09:15 AM a routine audit of medication administration, it was identified that Victoza SQ was not administered according to the recommended technique. Specifically, the administering nurse failed to hold the needle in place within the subcutaneous tissue for a minimum of six seconds post-injection, potentially impacting medication absorption and efficacy. After inserting the needle, S08 removed the needle immediately, without holding it in place for the recommended minimum of six seconds while injecting the medication. During an interview conducted on 10/23/24 at 11:45 AM, S08 acknowledged and confirmed they were not aware of the administration guidelines of a six-second hold. The nurse acknowledged they had not followed this aspect of the protocol when administering Victoza and had not received recent training specific to Victoza administration. 3. A review on 10/22/24 of the manufacturer insert for Advair indicated to properly administer the Advair inhaler, it is essential to follow the manufacturer's instructions. Begin by shaking the inhaler vigorously for five seconds to ensure that the medication is well-mixed. Hold the inhaler with the mouthpiece facing downwards, and exhale deeply through the mouth to empty the lungs as much as possible. While inhaling deeply, press the top of the canister all the way down to release the medication. After inhaling, hold your breath for up to 10 seconds, or as long as comfortably possible, allowing the medication to settle in your lungs. Once you have held your breath, resume normal breathing to restore regular respiratory function. After delivery, it is advised to rinse and swish with water then spit out. By carefully following these steps, you can ensure that the medication is administered effectively and reaches the lungs, providing the intended therapeutic effect. During an observation on 10/22/24 @0920 AM, the resident B02R's self-administration of Advair was observed and noted to have several deviations from the recommended technique. Firstly, the LVN3 failed to repeat the correct usage instructions to the resident prior to self-administration, which may have contributed to confusion. Secondly, B02R did not exhale before inhaling the medication and did not hold their breath for the 5-10 second recommended duration, both of which are essential steps to ensure proper absorption of the medication. Lastly, after inhalation, the resident experienced a coughing episode during rinsing and subsequently swallowed the water instead of swishing and spitting, as advised, which increases the risk of oral candidiasis. These observations highlight the importance of thorough instruction and adherence to proper inhalation techniques to maximize the effectiveness of the medication and minimize potential complications. During an interview on 10/22/24 @0940 AM, with LVN3, who was responsible for the resident's medication administration, the staff member stated, I assumed the resident already knew the steps, so I don't go over them each time. LVN3 did not instruct the resident prior to administering the Advair and acknowledged that resident B02R did not follow the manufacturer's instructions for proper administration. This lack of guidance and adherence to the recommended technique may have contributed to the observed deviations in the administration process. 4. A review of the manufacturer's insert for Lovenox, the recommended technique for subcutaneous injection of Lovenox involves maintaining a pinch on the injection site throughout the duration of the injection. This helps to ensure that the medication is delivered into the subcutaneous tissue, rather than into the muscle or other surrounding tissues, which can affect the drug's absorption and effectiveness. During an observation on 10/22/24 @ 0852AM for medication administration review, it was observed that a licensed staff member S08 preparing and administering Lovenox (enoxaparin) to Resident A01R (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 3 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some using an incorrect injection technique. Specifically, the staff member S08 did not maintain a pinch on the injection site throughout the injection, contrary to manufacturer recommendations for proper subcutaneous delivery and absorption of the medication. During an observation on 10/22/24 @ 0910AM during a direct observation of medication administration, the staff member initially pinched the injection site but released the pinch immediately after needle insertion, holding only for a few seconds. The manufacturer's instructions specify that the pinched site should remain held for the entire duration of the injection to ensure subcutaneous placement and minimize risk of tissue damage. During an interview conducted on 10/23/24 at 11:45 AM, LVN1 acknowledged regarding the importance of proper technique. The staff member stated, I wasn't aware that I needed to hold the pinch throughout the entire injection. I thought it was just for inserting the needle. During an interview conducted on 10/23/24 at 1:45 PM, the Director of Nursing (DON) acknowledged and confirmed that all staff are expected to follow manufacturer instructions for Lovenox administration and agrees this includes holding the pinch until the injection is complete. The DON was also unaware of this technique & noted that regular training on injection techniques is provided but acknowledged that recent sessions did not emphasize this specific instruction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 4 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews, and record reviews, it was determined that two separate vials of incorrectly labeled eye drop medications lacked proper labels for prescription medications for a resident. This is an issue because the absence of labels can lead to confusion in medication administration, increasing the risk of administering the wrong medication or dosage, which could adversely affect the resident's health and safety. Findings: A review of the facility's Section 7.1 Medication Administration Policy indicates that the facility had protocols in place for all medications to have proper labeling and organization. On 10/22/24 at 09:55 AM the inspection of the medication storage revealed two vials of prescription eye drop medications stored together, neither of which had a prescription label. Consequently, it was unclear to which resident the medications were prescribed. In an interview conducted on 10/22/24 at 12:05 PM, the licensed staff member stated, Those meds should have both the name of the resident and the date they were opened. When questioned about the mislabeled vials, the nurse acknowledged the oversight and mentioned, The staff member who handled these meds did not check to label them properly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 5 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to ensure the Certified Dietary Manager (CDM), the position responsible for supervision of daily food service operations, was fully qualified when the facility did not have a full-time kitchen manager. This failure had the potential for inadequate supervision of the dietary department for 73 out of 75 residents who received food from the kitchen. Findings: During a concurrent observation and interview on 10/21/24 at 9:33 a.m., with [NAME] 1 in the kitchen, the facility's kitchen manager was not seen. [NAME] 1 stated, Right now, we don't have a kitchen manager, when asked to bring in the facility's kitchen manager at this time. [NAME] 1 stated, Two days a week, somebody is coming to help . He is coming Tuesdays and Thursdays when asked about their kitchen manager. During an interview on 10/21/24 at 11:26 a.m., with Director of Nursing (DON), DON stated, Not today, when asked if the facility had the kitchen manager that day. DON sated, the kitchen manager comes twice a week, on Tuesdays and Thursdays. During an interview on 10/21/24 at 11:40 a.m., with Administrator (ADM), ADM stated, the previous kitchen manager resigned about a month ago and they are in the process of hiring a new kitchen manager. During an interview on 10/22/24 at 1:10 p.m., with Registered Dietitian (RD) 1 who oversees the kitchen, RD 1 stated, he works part-time as a contractor and comes twice a week, on Tuesdays and Thursdays usually, but sometimes Tuesdays, Thursdays, and Saturdays. RD 1 stated, he began working at the facility in mid-September 2024 after the previous kitchen manager resigned. During an interview on 10/22/24 at 1:21 p.m., with ADM, ADM stated, they are hiring a new kitchen manger, but that person will not be available in October, so will start on 11/6/24. During an interview on 10/22/24 at 1:40 p.m., with RD 2, RD 2 stated, she works part-time as a contractor and comes twice a week, usually Mondays and Wednesdays. RD 2 stated, Check the significant weight changes, check new admit and re-admit . pressure injury review . check tube feeding . check dialysis resident . when asked about her role. RD 2 stated, she focuses on the clinical part, not the kitchen. RD 2 stated, RD 1 supervises the kitchen. Review of the facility's Operational Organizational Chart undated indicated, the dietary manager was under the facility administrator. Review of the facility's job description titled, DIETARY MANAGER (Kitchen Manager) dated November 2010 indicated, . The purpose of the Dietary Manager is to ensure that residents receive healthful, attractive meals and snacks on a timely basis . REPORTS TO: Administrator . DUTIES AND RESPONSIBILITIES . 3. Selects, evaluates, recognizes and disciplines Dietary staff . 4. Coordinates dietary services with Nursing and Activities Director . 5. Checks trays for accuracy before they are delivered. 6. Checks diet orders against physician orders monthly . 8. Inspects storage areas and dietary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 6 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many department regularly for proper temperatures and cleanliness. 9. Plans, presents and participates in inservice educational programs for the Dietary department . 12. Partners with Dietary consultants and Nursing to achieve quality food service . Review of the facility's consultant dietitian's job description titled, ORIENTATION, INSERVICE, & PERSONNEL MANAGEMENT undated indicated, . The Consultant Dietitian is a Registered Dietitian . The Registered Dietitian provides consultation to the facility for the purpose of providing nutrition care and oversight of the operations of the Department of Food and Nutrition Services, which will result in optimal health of the resident/patient . RESPONSIBILITIES: Evaluates the nutritional needs of residents/patients and documents in the nutritional record . Coordinates, implements, and evaluates the facility menus for nutritional adequacy . Reviews and assists the Director of Food and Nutrition Services in interdisciplinary care planning and Department of Food and Nutrition Services care plans . Reports to the Administrator and Director of Food and Nutrition Services, or designee, monthly or as needed regarding findings and concerns regarding the Department of Food and Nutrition Services and the nutritional care of residents/patients . Review of State of California Health and Safety Code 1265.4 (a) indicated, . A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 7 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm 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 safe and sanitary conditions were met for food storage in the kitchen when: Residents Affected - Some 1. There were 4 rotten tomatoes with the delivery date of 10/9/24 in the walk-in refrigerator. 2. There were 4 apple pies on a tray with no label/expiration dates, covered with one aluminum tray with black colored old grime in the refrigerator #2. 3. There was a bag of chicken wings with no label/expiration date in the freezer #2. These failures had the potential to put residents at risk for foodborne illnesses. Findings: 1. During a concurrent observation and interview on 10/21/24 at 9:57 a.m., with [NAME] 1 in the kitchen, there were 4 rotten tomatoes with the date of 10/9/24 in the walk-in refrigerator. [NAME] 1 stated, It's not good. We have to throw it away when asked if the 4 rotten tomatoes looked ok. [NAME] 1 stated, 10/9/24 was the delivery date and the tomatoes were good for 7 days from the delivery date when asked. [NAME] 1 acknowledged, the 4 rotten tomatoes were over 7 days, so they were expired already, then she threw the items away. During a concurrent interview and record review on 10/22/24 at 10:11 a.m., with Registered Dietitian (RD) 1, the facility's policy and procedure (P&P), titled, SUGGESTED REFRIGERATED STORAGE GUIDELINES, dated 2023 was reviewed. The P&P indicated, fruit such as avocado, bananas, grapes, and plums were recommended to store for 3-7 days in the refrigerator, based on quality, but tomatoes were not on the list. RD 1 stated, they consider tomatoes as fruit, and tomatoes are good for 7 days from the delivery date when asked. 2. During a concurrent observation and interview on 10/21/24 at 10:16 a.m., with [NAME] 1 in the kitchen, there were 4 apple pies on a tray with no label/expiration dates, covered with one aluminum tray with black colored old grime in the refrigerator #2. [NAME] 1 acknowledged, there were no label/expiration dates on top of the 4 apple pies on the tray. [NAME] 1 stated, grime when asked what was the black colored one on the tray. 3. During a concurrent observation and interview on 10/21/24 at 10:46 a.m., with [NAME] 1 in the kitchen, there was a bag of chicken wings with no label/expiration date in the freezer #2. [NAME] 1 acknowledged, there was no label/expiration date on the bag of chicken wings. During an interview on 10/24/24 at 9:41 a.m., with Administrator (ADM), ADM stated, they should label and put the expiration dates on the food items to track the food safety, so they can prevent foodborne illness such as salmonella. Review of the facility's P&P, titled, SANITATION AND INFECTION CONTROL, dated 2023 indicated, . All the perishable food items purchased by the department of food and dining services will be stored properly. Perishable food will be kept refrigerated or frozen except during necessary periods of preparation and service. All open food Items will have an open date and use-by-date . 9. All refrigerated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 8 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 foods will be covered properly. All cooked food must be labeled and dated . 11. Labeled with pull by date and used by date all frozen uncooked meat, poultry . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 9 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0911 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident rooms accommodated no more than four residents in each room when room [ROOM NUMBER] had six residents in the room. This failure had the potential to negatively impact the safety and well-being of residents. Findings: During an observation on 10/21/24 at 9:32 AM, in room [ROOM NUMBER], the room was divided into two sections. The right section had two beds and the left section had four beds. room [ROOM NUMBER] had a common entrance door and a shared bathroom. During an observation on 10/21/24 at 2:21 PM, no residents occupied the room. room [ROOM NUMBER] was used as a Physical Therapy (PT) Room. During an interview on 10/24/24 at 1:29 PM, the Administrator stated, she had written a letter to the Centers for Medicare & Medicaid Services (CMS) requesting a waiver for rooms [ROOM NUMBERS]. For now, room [ROOM NUMBER] was used as PT Room. During a review of the room waiver form completed by the Administrator, the waiver indicated, the following floor measurements: room [ROOM NUMBER] had 581 total square feet, and room [ROOM NUMBER] had 581 total square feet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 10 of 10