Health inspection·November 10, 2022

F 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete She said a 1012 form (a form that eliminates the need for a PASRR Level II Screening (PE) due to the resident having a primary DX of Dementia or Alzheimer's) had also not been completed either. In an interview, on 11/10/22 at 9:04 AM, the DON said it was the responsibly of the MDS Coordinator to review the diagnosis of a resident when admitted to the facility and complete/update a PASSAR Level I or II if warranted. The DON said a resident might not receive PASARR services if they are eligible if this is not done. There was no facility policy regarding PASARR. Event ID: Facility ID: 676212 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 676212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE College Park Rehabilitation and Care Center 1715 Martin Dr Weatherford, TX 76086 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a care plan was developed within seven days after completion of the comprehensive MDS assessment, for three residents of six residents (Residents #1, #48 and #79) reviewed for comprehensive care plans. 1) The facility failed to develop a comprehensive care plan for Resident #1 after completion of the comprehensive MDS assessment. 2) The facility failed to develop a comprehensive care plan for Resident #48 within seven days after completion of the comprehensive MDS assessment. 3) The facility failed to develop a comprehensive care plan for Resident #79 after completion of the comprehensive MDS assessment. These failures could place residents at risk for not receiving the required care. The findings were: 1) Record review of Resident #1's admission Record, dated 11/10/2022, revealed Resident #1 was an [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #1's had diagnoses which included Acute Respiratory Failure (fluid builds up in the sacs in your lungs), Congestive Heart Failure (heart does not pump blood as well as it should), Chronic Obstructive Pulmonary Disease (a group of lung diseases that blocks air flow and make it difficult to breathe), and Major Depressive Disorder (clinical depression that last more than 2 weeks). Record review of Resident #1's Significant Change MDS Assessment (MDS), dated [DATE], revealed Resident #1 was initiated due to a recent hospital stay resulting which resulted in IV medications in and out of the hospital. Section V (CAAS ) Care Assessment Summary showed completion on 09/16/2022. Section Z, Assessment Administration showed completion on 09/16/2022. Record review of Resident #1's care plan conference sign in sheet showed a care plan meeting was conducted on 09/15/2022 before the completion of the Significant Change MDS. There was not a RN in attendance for this care plan meeting. 2) Record review of Resident #48's admission Record revealed Resident #48 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #48 had diagnoses which included, Chronic Obstructive Pulmonary Disease (a group of lung diseases that blocks air flow and make it difficult to breathe), Gastrointestinal Hemorrhage (blood in your digestive tract), and Major Depressive Disorder (clinical depression that last more than 2 weeks). Record review of Resident #48's Annual MDS Assessment (MDS) revealed it was done on 07/08/2022 . Record review of Resident #48's care plan conference sign in sheet showed a care plan meeting was conducted on 06/09/2022 and 09/29/2022. There was not a comprehensive care plan meeting completed for the comprehensive Annual assessment on 07/08/2022 .There was a care plan in the resident's file. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676212 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 676212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE College Park Rehabilitation and Care Center 1715 Martin Dr Weatherford, TX 76086 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 0657 Level of Harm - Minimal harm or potential for actual harm 3) Record review of Resident #79's admission Record, dated 11/10/2022, revealed Resident #79 was an [AGE] year-old female who was initially admitted to the facility on [DATE]. Resident #79's had diagnoses which included Mild Intellectual Disabilities (deficits in intellectual functions), Schizoaffective Disorder (mental disorder characterized by marked schizophrenia symptoms and behaviors), and hypertension (high blood pressure). Residents Affected - Some Record review of Resident #79's Annual (MDS) assessment, dated 07/20/2022, revealed Resident #79 was recently admitted to the facility on [DATE]. Section V (CAAS) Care Assessment Summary showed completion on 07/27/2022. Section Z, Assessment Administration showed completion on 07/27/2022. Record review of Resident #79's care plan conference sign in sheet showed a care plan meeting was conducted on 07/20/2022 before the completion of the Annual MDS . There was a care plan in the resident's file that was completed after the MDS assessment was completed. In an interview on 11/09/2022 at 2:48 a.m., MDS Coordinator 1 and MDS Coordinator 2 both said they did not schedule the care plan meetings and the care plan meetings should be conducted after the MDS was completed and signed. They were unsure why they were done before the MDS was signed. They were also unsure why they were not completed after every assessment within 7 days after the completion of the MDS. They both said it was the LBSW responsibility to conduct the care plan meetings . The MDS coordinators were not asked to do the scheduling for care plans. In an interview on 11/10/2022 at 9:27 a.m., LBSW said she was the one responsible for the care plan meetings and the care plan schedule. She said she was given the MDS list by dates and they were done every 90 days. She did not realize they were supposed to be completed after the MDS assessment was done, which reflected the care areas that were triggered in section V. She said that she realized it was important to complete the care plan meeting after the MDS assessment was complete so that the care plan would show an accurate picture of what was going on with the resident. She also did not realize there was a difference between a comprehensive care plan meeting and quarterly care plan meetings. Record review of the facilities Comprehensive Care plans policy, titled Care Plans, Comprehensive Person-Centered, dated December 2016, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676212 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 676212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE College Park Rehabilitation and Care Center 1715 Martin Dr Weatherford, TX 76086 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 6 residents (Resident #246) reviewed for activities of daily living. Residents Affected - Some The facility failed to shave and assist Resident #246 with personal care. This failure could place residents at risk for loss of dignity, risk for infections, skin breakdown, and a decreased quality of life. Findings include: Record review of Resident #246's face sheet, dated 11/10/22, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: urinary tract infection, low potassium level, muscle weakness, major depressive disorder recurrent. Record review of the admission Minimum Data Set (MDS) for Resident #246, dated 11/3/22, reflected a BIMS score of 15, which indicated the resident was cognitively intact. Resident #246 was assessed to require extensive assistance of two with transfers, limited assistance of one with personal hygiene and bathing. In an observation and interview on 11/08/22 at 10:30 AM Resident #244 stated he needed a shave. His face had a growth of beard approximately ¼ in in length and his hair was not combed. He was in a hospital gown. He stated he asked the aide yesterday for a shave when he was bathed, but they did not shave him. In an observation and interview on 11/9/22 9:00 AM, Resident #246 stated he should get a bath today and the aide was supposed to shave men on their bath days. Resident #246 stated he had a bath on Tuesday, Thursday, and Saturday. He stated he would like a shave today. Resident #246's hair was not combed and his face was not shaved. In an observation and interview on 11/10/22 at 09:41 AM revealed Resident #246 had not been shaved. He stated he asked for a shave yesterday and the aide said he would do it later; but he never came back. Resident #246 was wearing sweats that he had on during an observation on 11/9/22. Hospitality Aide B was the aide on his hall and the aide he asked to shave him. Resident #246's hair was not combed. Resident #246 stated he did not like going without his face shaved and he was not accustomed to wearing a beard. He stated he didn't feel clean when he did not shave. In an interview on 11/10/22 at 10:00 AM, the ADON said it was her expectation for resident's to be shaved daily if they wished to do so. She stated it was the responsibility of the aides to shave the residents when needed. She stated she would see that Resident #246 was shaved today. She stated the resident was not shaved because the aide failed to properly carry out his job duties. She stated another factor was the resident had transferred to another hallway and the resident was not on the bath schedule for that hall. She stated Hospitality Aide B was assigned to the resident's hall yesterday, and this aide was no longer employed by the facility. She stated he should have informed the charge nurse of the duties he had not completed before leaving the facility, but he did not. She stated it was the nurses responsibility to monitor the residents to ensure the aides performed their job (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676212 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 676212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE College Park Rehabilitation and Care Center 1715 Martin Dr Weatherford, TX 76086 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 0677 duties . Level of Harm - Minimal harm or potential for actual harm Record Review of the facility policy Activities of Daily Living (ADLs), Supporting, revised March 2018, revealed the following in part: Residents Affected - Some .Policy Statement Residents will provide with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676212 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 676212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE College Park Rehabilitation and Care Center 1715 Martin Dr Weatherford, TX 76086 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that 2 of 2 resident's (ID #'s 244 and 84 ) of reviewed for indwelling catheters received the appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. The facility failed to ensure that the indwelling catheter remained secure for resident #84 to reduce friction and movement at the insertion site. The facility failed to ensure that the indwelling catheter of resident # 244 remained secure and was positioned properly off the floor. These failures placed residents with indwelling catheters at risk for injury, suffering pain, and/or infection. The findings included: Resident #84 Record review of the admission Record for resident #84 dated 11/8/22, documented he was an [AGE] year-old male with an initial admission date of 10/20/22. The following diagnoses were documented: acute kidney failure, hypertension, retention of urine, sepsis, acute pyelonephritis (infection in the kidney) Review of Resident #84's admission MDS (Minimum Data Set) dated 10/26/22 revealed the resident had a BIMS of 13 which indicated mild cognitive impairment and he required extensive assistance of two people with bed mobility and transfers, dressing, and personal hygiene; total assistance of two persons with transfers; total assistance of two people with toileting and bathing, the resident had an Indwelling catheter, and was occasionally incontinent of bowel. Review of Resident #84's Care Plan, which was last revised on 10/21/22 documented in part: Resident has a urinary catheter and is at risk for urinary tract infections and injury. Approaches: Position catheter bag and tubing below the level of the bladder. Review of the admission Physician Orders dated 11/8/22 for resident #84 documented in part: Foley catheter for diagnoses urinary retention ; Foley Care every shift; Change catheter and drainage bag as needed for leakage or obstruction. Observation on 11/9/22 at 7:00AM revealed Resident #84 had catheter bag hanging on the rail of his bed with the head of his bed elevated 90 degrees. The resident's wife was sitting at his bedside. An observation and interview on 11/9/22 at 11:30 AM that the catheter tubing had no urine in it and the catheter tubing was hanging down on the right side of the bed. The head of the resident's bed remained elevated. The Surveyor asked resident #84 if he had a leg strap to keep the catheter securely in place and he stated no. The surveyor asked who positioned the catheter on the side of he bed and Resident #84's wife replied that Hospitality Aide B hung the catheter bag on the bed rail above the resident's bladder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676212 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 676212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE College Park Rehabilitation and Care Center 1715 Martin Dr Weatherford, TX 76086 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview and observation on 11/9/22at 11:40 AM, LVN A stated she was responsible for monitoring to see that foley catheters bags were positioned correctly on the resident's beds. She stated catheters should be secured to the resident's leg to prevent trauma to the resident and the catheter should be placed below the level of the bladder. She stated Hospitality aide B was currently on break and should have checked the catheter bag before leaving his hall. LVN A accompanied the surveyor to Resident #84's room and observed the catheter bag hanging on the bed rail above the resident's bladder and stated it was not positioned correctly and stated she would have the Hospitality Aide B report to her before returning to duty on the floor. Resident #244 Record review of the admission Record for resident #244 dated 11/9/22, documented he was an [AGE] year-old male with an initial admission date of 10/31/22. The following diagnoses were documented: urinary tract infection, hypertension, retention of urine, acute kidney failure, and prostate enlargement with lower urinary tract symptoms. Review of Resident #244's admission MDS (Minimum Data Set) dated 11/4/22 revealed the resident had a BIMS of 12 which indicated moderate cognitive impairment and he required minimal assist of one person with bed mobility and transfers, dressing, and personal hygiene; total assistance of two persons with transfers; assistance to stabilize with toileting and, the resident had an Indwelling catheter, and was continent of bowel. Review of Care Plan last reviewed on 10/21/22 for resident #84 documented in part: Resident has a urinary catheter and is has a urinary tract infection and trauma. Approaches: Position catheter bag and tubing below the level of the bladder, secure catheter bag with a leg strap, may use a leg bag when up. Review of the admission Physician Orders dated 11/8/22 for resident #84 documented in part: Foley catheter for diagnoses urinary retention ; Foley Care every shift; Change catheter and drainage bag as needed for leakage or obstruction. Secure catheter with a leg strap to prevent pulling. An observation and interview on 11/9/22 at 11:45:M by the surveyor and LVN A revealed Resident #244 had his catheter laying on the floor approximately 2 feet from his bedside with his bedside table sitting on top of the catheter bag. The tubing was attached to the bag and was pulled taut while the resident lay in his bed. The resident stated he transferred himself from his wheelchair to his bed. In an interview on 11/9/22 at 11:45 AM, LVN A stated she was responsible for monitoring to see that foley catheters bags were positioned correctly on the resident's beds. She stated catheters should be secured to the resident's leg to prevent trauma and/or infection to the resident and the catheter should be placed below the level of the bladder. She stated Hospitality Aide B was currently on break and should have checked the resident and his catheter bag before leaving his hall. LVN A had accompanied the surveyor to Resident #244's room and observed the catheter bag laying on the floor underneath the wheel of the resident's bedside table. She stated it was not positioned correctly and stated she would have the Hospitality Aide B report to her before returning to duty on the floor. Hospitality aide B had left the facility and was not available for an interview after his lunch break. Review of Hospitality Aide B's employee file revealed that he had been competency checked on foley (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676212 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 676212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE College Park Rehabilitation and Care Center 1715 Martin Dr Weatherford, TX 76086 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 0690 catheter care with satisfactory performance documented by the ADON. Level of Harm - Minimal harm or potential for actual harm In an interview on 11/9/22 at 12:00 PM the DON stated her expectation was that aides should check their residents frequently and always before leaving the floor on breaks and at the end of their shift. She stated the failure occurred because the Hospitality aide did not perform his job duties as he had been trained to do. Residents Affected - Some Review of the facility's Policy & Procedure on Foley Catheter Guidelines revised on 9/2014 provided by DON on 11/10/22 documented in part: Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. The urinary bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the bladder. Be sure the catheter tubing and drainage bag are kept off the floor. Ensure the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. Catheter tubing should be strapped to the resident's inner thigh. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676212 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 676212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE College Park Rehabilitation and Care Center 1715 Martin Dr Weatherford, TX 76086 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 food was stored in accordance with professional standards for 1 of 3 refrigerators reviewed for food storage. Residents Affected - Few One refrigerator contained expired one-half gallon buttermilk. This failure by the facility could have caused residents who ate food prepared with outdated product to acquire foodborne illnesses. Findings include: Observation on 11/09/2022 at 11:40 AM revealed an open container approximately one-third full of low-fat cultured buttermilk in the two-door refrigerator next to the serving line was observed to have a use by date of 11/04/2022. In an interview on 11/09/2022 at 11:45 AM the Dietary Manager (DM) said that somebody probably missed the expired buttermilk during their routine inspections and that it should not have been there. In an interview on 11/10/2022 at 10:35 AM the Dietitian said TCS food per facility policy should be discarded no later than three days beyond the expiration date and said the staff must have missed the expired buttermilk when they were doing their routine sweep. 11/10/2022 3:30 PM Record review of a facility policy titled Policy & Procedure Manual, Food Storage dated 3/22 revealed in part: Procedure: .7. c. Date marking should be visible on all high-risk food to indicate the date by which a ready-to-eat, TCS food should be consumed, sold or discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676212 If continuation sheet Page 10 of 10