Kim, who presented the manor report, told the board that five surveyors (four state, one federal) completed an inspection and that the preliminary findings included three complaint reviews of which two were substantiated. One substantiation stemmed from a resident‑to‑resident physical altercation and another related to an accessible call light found on the floor, which surveyors considered a safety risk.

Kim outlined additional citations related to documentation: missing written transfer/discharge notices, incomplete resident assessments (one case where a new diagnosis should have triggered a higher-level reassessment), incomplete wound‑measurement documentation and medication‑documentation gaps related to targeted symptoms. Kim said the survey results were preliminary; the facility expected a written report from the state within 10 business days and then would submit a plan of correction within 10 working days.

Operational context: Kim reported the manor census at 53 residents (91% occupancy) with a payer mix that is predominantly Medicaid. She said the facility is relying on agency CNAs (10 CNAs reported on shift and 1 RN) and that Medicaid pending approvals currently take about six months, adding financial and administrative strain. The board discussed recruitment and retention strategies, including CNA training through EWC and internal "farm team" clinical partnerships to hire and retain CNAs rather than relying on higher‑cost travelers.

Ending: The board asked staff to finalize the state report, prepare the plan of correction within the regulatory timeline and accelerate recruitment and retention efforts to reduce reliance on agency staffing.