Health inspection·July 11, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm facility had a policy in place that MDS assessments were conducted to assist in developing person-centered care plans that included direct observations and communication with residents, licensed and non-licensed direct care staff on each shift. Review of the policy revealed the facility failed to communicate to accurately complete the MDS assessments. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366015 If continuation sheet Page 2 of 11 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Mentor 8881 Schaefer St Mentor, OH 44060 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on record review, interview, and review of facility policy, the facility failed to develop and implement a plan of care for use of psychotropic medications for Resident #72. This affected one (#72) of five residents reviewed for unnecessary medications. The facility census was 84. Findings include: Review of the medical record for Resident #72 revealed and admission date of 07/10/23 with diagnoses including schizophrenia, insomnia, and anxiety. Review of the quarterly Minimum Data Set (MDS) Assessment, dated 04/18/24, revealed Resident #72 received an antipsychotic and antidepressant during the seven day lookback period. Review of the comprehensive care plan, last reviewed 04/19/24, revealed there was no care plan for use of psychotropic medications. Review of the physician's orders for July 2024 identified orders for Invega Sustenna (an antipsychotic) intramuscular prefilled syringe 156 milligrams (mg) per milliliter (ml) inject one ml intramuscularly on the first of every month (ordered 04/01/24) and Trazodone Hydrochloride (HCl) (an antidepressant) 25 mg by mouth once daily at bedtime (ordered 05/16/24). On 07/11/24 at 10:07 A.M., an interview with the Director of Nursing (DON) verified Resident #72 had physician's orders for psychotropic medications and there was no care plan in place for the use of psychotropic medications. Review of the facility policy titled Care Plans, Comprehensive Person-Centered and Advance Care Plans, not dated, indicated a comprehensive person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs would be developed and implemented for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366015 If continuation sheet Page 3 of 11 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Mentor 8881 Schaefer St Mentor, OH 44060 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 change nasal cannula oxygen tubing in a timely manner. This affected four residents (#22, #32, #64 and #69) of 18 residents identified as utilizing oxygen. The facility census was 84. Residents Affected - Some Findings include: 1. Review of Resident #32's medical record revealed an initial admission date of 04/02/24. Resident #32's significant diagnoses included chronic obstructive pulmonary disease. Review of Resident #32's admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident's cognition was intact and used oxygen continuously over the previous seven-day lookback. Review of care plan dated 04/25/24 revealed Resident #32 had an alteration in respiratory function related to chronic obstructive pulmonary disease. Interventions included to provide oxygen as ordered at three liters per minute via nasal cannula. Resident #32's physician orders included to administer oxygen at three liters per minute via nasal cannula to maintain a pulse oximeter reading of 92 percent (%). A review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) dated June of 2024 and July of 2024 revealed no documentation the nasal cannula for Resident #32 was changed. On 07/08/24 at 9:57 A.M. an observation of Resident #32 revealed the resident in bed with oxygen on via nasal cannula. There was no date on the nasal cannula to indicate when it had been changed. An interview with Resident #32 at the time of the observation revealed they were not sure the last time the nasal cannula had been changed. On 07/08/24 at 10:00 A.M. an interview with Registered Nurse (RN) #790 verified there was no date on the nasal cannula for Resident #32. 2. Review of Resident #64's medical record revealed an admission date of 05/25/23. Significant diagnoses included chronic respiratory failure. Review of Resident #64's quarterly MDS dated [DATE] revealed the resident's cognition was intact and was on continuous oxygen over the previous seven-day lookback period. Review of Resident #64's care plan dated 06/28/24 revealed Resident #64 had an alteration in respiratory function. Interventions included administer oxygen as ordered. Review of Resident #64's physician orders included to titrate oxygen as needed to maintain an oxygen level above 90% via nasal cannula. A review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) dated June of 2024 and July of 2024 revealed no documentation the nasal cannula for Resident #64 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366015 If continuation sheet Page 4 of 11 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Mentor 8881 Schaefer St Mentor, OH 44060 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 0695 changed. Level of Harm - Minimal harm or potential for actual harm On 07/08/24 at 9:48 A.M. an observation of Resident #64 revealed the resident in bed with oxygen being administered via nasal cannula. The nasal cannula was dated 05/23/24. An interview with Resident #64 at the time of the observation revealed they did not recall nasal cannula being changed. Residents Affected - Some On 07/08/24 at 9:50 A.M. an interview with RN #790 verified the date on Resident #64 nasal cannula as 05/23/24. 3. Review of Resident #69's medical record revealed an admission date of 01/24/24 with significant diagnoses included atherosclerotic heart disease. Review of Resident #69's quarterly MDS dated [DATE] revealed he resident's cognition was impaired. Review of Resident #69's care plan dated 05/31/24 revealed Resident #69 had altered respiratory function. Interventions included to administer oxygen as ordered. Review of Resident #69's physician orders included to administer oxygen at one to four liters per minute via nasal cannula as needed. A review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) dated June of 2024 and July of 2024 revealed no documentation the nasal cannula for Resident #69 was changed. On 07/08/24 at 10:17 A.M. an observation of Resident #69 revealed them sitting up in a bedside chair with oxygen being delivered via nasal cannula. There was not a date on the nasal cannula to indicate when it had been changed. Interview with State Tested Nurse Assistant #811 verified there was no date on the nasal cannula at the time of the observation. 4. Review of Resident #22's medical record revealed an admission date of 03/29/23 with significant diagnoses included chronic obstructive pulmonary disease. Review of Resident #22's quarterly MDS revealed the resident had mild cognitive impairment. Review of Resident #22's care plan dated 05/27/24 revealed Resident #22 had an alteration in respiratory function and required oxygen administration. Interventions included to administer oxygen at two liters per minute via nasal cannula. Review of Resident #22's physician orders included to administer oxygen at two liters per minute via nasal cannula to maintain an oxygen level of greater than 92%. A review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) dated June of 2024 and July of 2024 revealed no documentation the nasal cannula for Resident #22 was changed. On 07/08/24 at 10:24 A.M. an observation of Resident #22 revealed them sitting up in a wheelchair with oxygen being delivered via nasal cannula. There was not a date on the nasal cannula to indicate when it had been changed. RN #790 verified there was no date on the nasal cannula at the time of the observation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366015 If continuation sheet Page 5 of 11 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Mentor 8881 Schaefer St Mentor, OH 44060 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete On 07/10/24 at 9:47 A.M. an interview with Respiratory Therapist (RT) #840 revealed oxygen tubing and nasal cannulas are to be changed weekly. RT #840 also stated tubing is to be dated and initialed when it is changed. A review of the policy titled, Oxygen Administration revealed oxygen tubing and mask/cannula is to be changed weekly and as needed if it becomes soiled or contaminated. Event ID: Facility ID: 366015 If continuation sheet Page 6 of 11 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Mentor 8881 Schaefer St Mentor, OH 44060 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to securely administer medications according to Resident #3's needs. This affected one resident (Resident #3) of five residents reviewed for medications. The total census was 84. Findings include: Record review of Resident #3 revealed she was admitted [DATE] and had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), diabetes, visual hallucinations, major depressive disorder, and bipolar disorder. Review of Resident #3's physician orders revealed no order allowing her to keep medications at the bedside except for her nasal spray. She had an active order dated 01/27/24 for Desvenlafaxine 100 mg to be given daily in the morning for depression. She had an order for as-needed acetaminophen and for scheduled Alrex and Fluticasone doses, but no active order for Turmeric. The record review revealed no evidence of a medication self-administration assessment. Observation of Resident #3 on 07/09/24 at 8:14 A.M. revealed she was self-administering a Fluticasone inhaler when the surveyor entered the room. She had medication bottles at her bedside including one bottle of acetaminophen, one bottle of Turmeric (a dietary supplement), one bottle of Alrex (anti-allergy eye drops), and two bottles of Desvenlafaxine (an antidepressant), as well as the Fluticasone. Interview with Resident #3 on 07/09/24 at 8:41 A.M. revealed the facility often did not have her own medications in stock so she ordered her own. She also noted she self-medicated with her own Desvenlafaxine (one 25 milligram pill per day) in addition to the facility-administered dosage (one 100 milligram pill per day) to equal what she felt was the correct dose. Interview with Licensed Practical Nurse #845 on 07/09/24 at 11:57 A.M. confirmed the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366015 If continuation sheet Page 7 of 11 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Mentor 8881 Schaefer St Mentor, OH 44060 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 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5 percent (%). A total of 27 medications were observed with two errors identified for a medication error rate of 14.8 %. This affected one (Resident #3) of five residents reviewed for medication administration. The total census was 84. Residents Affected - Few Findings include: Record review of Resident #3 revealed she was admitted [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD), diabetes, visual hallucinations, major depressive disorder, and bipolar disorder. There was no order allowing her to keep medications at the bedside except for her nasal spray. The record review revealed no evidence of a medication self-administration assessment. Resident #3's physician orders dated 01/27/24 revealed orders for Desvenlafaxine 100 milligram (mg) to be given daily in the morning for depression, an order dated 01/24/24 for artificial tears to be given twice daily for dry eyes, an order dated 01/27/24 for FiberCon 625 mg two pills to be given once daily for constipation, and an order dated 01/27/24 for one inhalation of a Fluticasone inhaler to be given daily for COPD. Observation of a medication administration pass for Resident #3 by Licensed Practical Nurse (LPN) #845 on 07/09/24 at 8:14 A.M. revealed the resident was self-administering a Fluticasone inhaler upon entry into the room. The resident had multiple pill containers at the bedside including two bottles labeled Desvenlafaxine (an antidepressant). LPN #845 administered all medications scheduled for that time except artificial tears and FiberCon (a laxative), which she said could not be found. The administered medications included one 100 mg pill of Desvenlafaxine. Interview with Resident #3 at the time of the above observation revealed she frequently ordered her own medications because the facility often did not have the correct medications to give her. She also took a Desvenlafaxine 25 mg pill before the nurse gave her medications, saying she needed a 125 mg total dose of Desvenlafaxine to prevent panic attacks. Interview with LPN #845 at 9:16 A.M. on 07/09/24 confirmed the above findings. Interview with LPN #845 at 11:57 A.M. on 07/09/24 confirmed that Resident #3 had no orders to self-administer medications and that the FiberCon and artificial tears still were not found or administered. The above findings resulted in four medication errors out of 27 observed potentials for error, creating an error rate of 14.8%. Record review of the medication administration policy dated 2001 revealed medications were to be given in accordance with prescriber orders. Residents were only to self-administer medications if the attending physician and interdisciplinary care team had determined they have the capacity to do so safely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366015 If continuation sheet Page 8 of 11 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Mentor 8881 Schaefer St Mentor, OH 44060 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 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 review of facility policy, the facility failed to ensure the ice machine filter was clean and sanitary and that staff properly secured and covered their hair while working in the kitchen. This had the potential to affect all residents (except Residents #45 and #85 who were identified by the facility as having orders for nothing by mouth) who received food from the kitchen. The facility census was 84. Findings include: On 07/08/24 from 8:08 A.M. through 8:20 A.M., the initial tour of the kitchen revealed the ice machine filter was not clean and had a layer of dust. Interview at the time of observation with Dietary [NAME] #814 verified the ice machine filter was dirty and it was supposed to be cleaned monthly. On 07/10/24 at 12:26 P.M., an observation of the kitchen revealed Dietary [NAME] #815 was wearing a hairnet on top of her head with long braids hanging down her back which were not covered by the hairnet. Dietary [NAME] #815 began preparing food without securing or covering her long braids. On 07/10/24 at 1:03 P.M., an interview with Dietary Manager #812 verified Dietary [NAME] #815's braids were unsecured and uncovered. She stated that her expectation was for dietary staff to wear hairnets and keep their hair covered. Review of a facility list of resident diets revealed Resident's #45 and #85 received no food by mouth. Review of the facility policy titled Kitchen Sanitation - Cleaning Policies and Procedures, dated 2010, indicated the ice machine should be cleaned on a regular basis to maintain clean and sanitary conditions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366015 If continuation sheet Page 9 of 11 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Mentor 8881 Schaefer St Mentor, OH 44060 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of email communication between the facility and the repair company, and review of the quote for repairs, the facility failed to maintain the walk-in freezer in a proper working condition and address a malfunction of the freezer door in a timely manner. This had the potential to affect all residents (except Residents #45 and #85 who were identified by the facility as having orders for nothing by mouth) who received food from the kitchen. The facility census was 84. Residents Affected - Many Findings include: Review of the repair quote, dated 05/13/24, revealed Royal Heating and Air Conditioning Service determined the freezer door sweep needed repaired and quoted the facility $288.00 for the repair with an estimated completion date of 07/10/24 through 08/07/24. Review of an email, dated 07/01/24, sent from Royal Heating and Air Conditioning Service to the Administrator revealed the repair company needed confirmation that the repair quote had been accepted and the part needed to be ordered from the vendor. Review of a facility list of resident diets revealed Residents #45 and #85 received no food by mouth. On 07/08/24 from 8:08 A.M. through 8:20 A.M., the initial tour of the kitchen revealed the walk-in freezer had ice buildup at the top and down the side on the inside of the door, there was ice with snow-like consistency covering the floor on the right side of the freezer, ice on 12 boxes of food items on the bottom shelf along the right side of the freezer, and ice on one box of Italian ice cups on the shelf on the left side of the freezer. Interview at the time of observation with Dietary [NAME] #814 verified the ice buildup inside the walk-in freezer and stated the door did not seal properly which caused the ice buildup. Dietary [NAME] #814 said maintenance was aware of the issue and had not repaired it yet. On 07/08/24 at 8:33 A.M., an interview with Dietary Manager #812 confirmed the freezer door was not working properly and maintenance had known about the issue since at least May 2024. On 07/10/24 at 9:10 A.M., an observation of the walk-in freezer revealed there was still ice with a snow-like consistency on the floor along the right side of the freezer. Interview at the time of observation with Dietary Manager #812 verified the presence of ice buildup inside the freezer. She stated Maintenance Director #608 had cleaned up all the ice inside the freezer but more ice had accumulated. On 07/10/24 at 4:08 P.M., an interview with the Administrator verified the repair company sent her an email on 07/01/24 and she confirmed the email did not indicate the needed part had been ordered yet. The Administrator stated the facility had not yet paid for any repairs. On 07/11/24 at 8:57 A.M., an interview with the Administrator confirmed the quote for repair of the freezer was provided to the facility on [DATE]. On 07/11/24 at 9:04 A.M., an interview with Heating and Air Conditioning Service Consultant #843 confirmed the facility was provided a quote for repair of the freezer door on 05/13/24 and he stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366015 If continuation sheet Page 10 of 11 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 366015 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carecore at Mentor 8881 Schaefer St Mentor, OH 44060 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 0908 the facility did not approve the quote until 07/10/24. Level of Harm - Minimal harm or potential for actual harm On 07/11/24 at 9:15 A.M., an interview with the Administrator and Maintenance Director #608 said the freezer was maintaining an appropriate temperature. Maintenance Director #608 stated there was no need for immediate action when they got the quote for repairs. The Administrator then stated there was a delay in approving the quote because she had been out of the office for the last three weeks and it was not addressed prior to that leave because there was no immediate need for the repair. Maintenance Director #608 stated the facility was deciding between replacing the broken part of the door or replacing the whole door. The Administrator confirmed the repair quote for the freezer was not approved by the facility until 07/10/24. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366015 If continuation sheet Page 11 of 11