Inspection·April 17, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review and review of local health department documentation the facility failed to ensure the kitchen was maintained in a safe and sanitary manner. This had the potential to affect all residents residing at the facility. The facility census was 27. Findings include: Observation on 04/17/25 at 7:58 A.M. of the kitchen revealed an uncovered trash can placed to the right side of the steel clean utensil cart. Food was observed splattered along the side of the cart. Food debris was noted encircling the clean utensil holders. A two layered steel cart was noted to have three open soda cans, with food debris and an uncovered plastic container of butter. A hooded sweatshirt was observed wadded up in the corner of the bottom shelf. The food service prep area had a pan of scrambled eggs and a second pan with bacon and seven over easy eggs. Food particles were observed on the steel cart where the clean plates were held encircling the clean plates. This was verified with [NAME] #25 at the time of the observation. Further observation of the kitchen on 04/17/25 at 8:07 A.M. revealed the following: a. The two-compartment sink had an approximate eight inch by 12 inch area coated with a cream colored powder b. Wired storage shelves had clean pans stored upside down on grease caked wire shelves. c. Food debris caked onto the glass plate of the microwave, with food splattered on all sides inside the microwave, including the inside of the door. d. The mixer on the microwave stand had dried food on both inside and on the outside of the bowl, as well as the mixing tool. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 366234 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 366234 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/17/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Colonial Nursing Center of Rockford 201 Buckeye Street Rockford, OH 45882 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)