The Buckingham

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to keep the medication error rate below 5 percent. Surveyors identified a 14% medication error rate, based on 5 errors out of 34 opportunities, involving 3 of 6 residents and 3 of 3 staff observed during medication administration. The errors included medications not administered as ordered, medications given at the wrong time, and incomplete administration practices during the observed medication pass. Resident #47 had diagnoses including pneumonia due to MRSA, acute respiratory failure, generalized weakness, dysphagia, cognitive communication deficit, type 2 diabetes, Alzheimer's disease, dementia, COPD, hyperlipidemia, GERD, and other chronic conditions. The resident's BIMS score was 05, indicating severe cognitive impairment. The physician ordered Ipratropium Bromide nasal solution 0.03% 21 mcg, 2 sprays to each nostril twice daily, and Rosuvastatin 10 mg daily. During observation, RN B administered only 1 spray to each nostril of the nasal solution and did not administer Rosuvastatin. When interviewed, RN B stated she would need to call the physician to verify Rosuvastatin because she believed it should be given at bedtime. Resident #76 had diagnoses including urinary tract infection, neurogenic bladder with Foley catheter, hemiplegia and hemiparesis following cerebral infarction, dysphagia, generalized weakness, malnutrition, asthma, hypertension, GERD, constipation, and rheumatoid arthritis. The resident's BIMS score was 10, indicating moderate cognitive impairment. Orders included Centrum Silver Gel 1 tablet daily and Bactrim 400-80 mg daily for 2 days. During observation, RN C did not administer either medication. RN C later stated Centrum Silver was borrowed from another medication cart and Bactrim was taken from the emergency kit, but she had not signed the emergency kit form. The ADONs later checked the emergency kit and stated Bactrim was not among the drugs available there and that Centrum Silver should not be taken from another cart. Resident #167 had diagnoses including a displaced left fibula fracture, hyperlipidemia, CHF, GERD, hypertensive heart disease with heart failure, glaucoma, dysphagia, muscle wasting, weakness, gait abnormalities, and spinal stenosis. The resident's BIMS score was 15, indicating intact cognition. Pantoprazole sodium 40 mg was ordered to be given before breakfast. During observation, LVN A administered Pantoprazole after breakfast had already been served and after the resident reported having eaten about an hour earlier. The blister packet instructions also stated to take the medication before breakfast. LVN A acknowledged the timing was not correct and stated she knew the medication should be given at the right time for therapeutic effect.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Drugs and biologicals were not consistently labeled or stored in accordance with accepted professional principles. During observation, LVN A left a medication cart unlocked in the hallway while administering medications, and later stated she forgot to lock it and that leaving it unlocked could allow residents and non-licensed staff access to the cart. The facility also reviewed three medication carts and found multiple opened medications that were not dated, including inhalers, eye drops, nasal sprays, creams, and a vial of heparin. On Nurse Cart 1B, surveyors observed opened and undated medications including albuterol sulfate inhalation aerosol, heparin sodium injection, fluticasone propionate nasal spray, ipratropium bromide nasal spray, timolol maleate eye drops, and latanoprost eye drops. RN C stated nursing staff were expected to check carts daily for expired and inappropriately labeled medications and that multi-dose containers should be labeled with the date opened to track beyond-use dates. On Nurse Cart 2A, surveyors observed opened and undated nystatin cream, metronidazole gel, lidocaine and prilocaine cream, estradiol vaginal cream, nystatin and triamcinolone acetonide cream, and fluticasone propionate nasal sprays. On Nurse Cart 2B, surveyors observed opened and undated fluticasone propionate nasal sprays, lidocaine HVL 1% that was also expired, Voltaren Arthritis Pain cream, albuterol sulfate inhalation aerosol, and hydrocortisone cream. LVN B stated the medications should be dated after opening, and LVN D stated she would place an open date on medications when opened for therapeutic effectiveness.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish and maintain an infection prevention and control program for 3 residents reviewed for infection control. Resident #119 had multiple chronic conditions including severe cognitive impairment, bowel incontinence, hemiplegia, diabetes, vascular disease, heart failure, and dependence on renal dialysis. The resident’s care plan directed staff to keep the resident clean, dry, without odor, and comfortable. On observation, the resident was lying in bed with Enhanced Barrier Precautions (EBP) posted outside the room, and staff entered without the required PPE. A CNA entered without PPE, and an LVN responded to reposition the resident without donning PPE or clean gloves. The LVN picked up a blanket from the floor and placed it on the resident. Later, neither staff member washed their hands or used hand sanitizer, and the CNA carried the resident’s lunch tray to the hallway food cart. During interview, the CNA stated she did not gown up because she thought the resident did not use the toilet, and the LVN stated she did not don PPE because she was in a hurry and needed to administer eye drops. Resident #153 had severe cognitive impairment, bowel incontinence, and diagnoses including infective endocarditis, sepsis, stroke, respiratory failure, pneumonia, dysphagia, and a gastrostomy tube. The resident’s care plan noted the need for assistance with ADLs and tube feeding. During observation, an RN entered the room with EBP signage posted, performed hand hygiene, and put on gloves, but did not put on a PPE gown. PPE supplies were observed outside the room. In interview, the RN stated she did not really understand the importance of EBP and had intended to ask the DON but had not done so. Resident #182 had severe cognitive impairment, an indwelling Foley catheter, and diagnoses including stage 4 sacral pressure ulcer, heel pressure ulcers, hypertension, hypothyroidism, and cerebral infarction. The resident’s care plan stated the resident required assistance with ADLs and should remain clean, dry, without odor, and comfortable. During observed incontinent and Foley catheter care, a CNA picked up a clean brief and placed it on the bed, changed gloves multiple times, and donned clean gloves without washing hands or using hand sanitizer. The resident had a large pasty bowel movement, and the CNA did not open the labia to clean and did not clean around the buttocks before placing and fastening the clean brief. In interview, the CNA stated she knew she should clean around the buttocks but did not do so during this care because she was nervous. The ADONs stated residents with wounds, contact isolation, gastrostomy tube feeding, or Foley catheters were placed on EBP and that contact with a resident with a catheter required gown and gloves.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

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. Resident #182 was admitted with diagnoses including a history of stage 4 sacral pressure ulcer, stage 2 right heel pressure ulcer, unstageable left heel pressure ulcer, depression, hypertension, hypothyroidism, vitamin D deficiency, hyperlipidemia, obstructive and reflux uropathy, glaucoma, and cerebral infarction. The resident’s quarterly MDS reflected severe impairment in thinking, an indwelling catheter, and dependence on staff for care needs per the care plan, which stated the resident was totally dependent on staff for all ADLs and was to remain clean, dry, without odor, and comfortable each shift. During observation of incontinent and Foley catheter care, C.NA A and C.NA B assisted Resident #182, who had a large pasty bowel movement. C.NA A opened the labia to clean the resident but did not clean around the buttocks before placing a clean brief and fastening it. When interviewed, C.NA A stated she did not clean around the buttock and acknowledged that inadequate cleaning could cause itchiness, skin breakdown, urinary tract infection, and odors. The ADON stated that poor incontinent care could result in infection, skin breakdown, and UTI, and the facility policy on perineal care stated the purpose was to provide cleanliness and comfort, prevent infections and skin irritation, and observe the resident’s skin condition.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure appropriate incontinent and Foley catheter care for a resident with an indwelling catheter and severe cognitive impairment. Resident #182 was admitted with multiple diagnoses including a history of stage 4 sacral pressure ulcer, stage 2 right heel pressure ulcer, unstageable left heel pressure ulcer, obstructive and reflux uropathy, glaucoma, and cerebral infarction. The resident’s MDS reflected an indwelling catheter, and the care plan stated the resident was totally dependent on staff for all ADLs and was to remain clean, dry, without odor, and comfortable each shift. During observation of incontinent care, CNA A and CNA B transferred the resident from a recliner to bed, and CNA A performed Foley catheter and incontinent care. CNA A did not wash hands or use hand sanitizer, donned clean gloves, removed the soiled brief, and cleaned the resident’s groin, but did not secure the Foley catheter. CNA A cleaned visible parts of the catheter but did not open the labia to clean from the insertion site, and after the resident had a large bowel movement, CNA A cleaned in between the buttocks but did not clean around the buttocks before applying a clean brief. CNA A stated she was nervous and did not open the labia to clean the catheter insertion site; CNA B stated CNA A did not clean from the insertion site as required. The facility policy for female catheter care directed staff to cleanse around the meatus and catheter from the insertion site outward.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Pharmaceutical services were not provided to meet the needs of each resident when RN B administered two nasal sprays to Resident #47 without waiting the required time between them. During medication administration on 8/27/25, RN B gave oral medications and then administered Ipratropium Bromide nasal solution 0.03% 1 spray to each nostril at 8:23 AM, followed by Azelastine Hydrochloride nasal solution 0.1% 1 spray to each nostril at 8:24 AM. In an interview immediately afterward, RN B stated she should have waited 5 minutes between the nasal sprays and said she was very nervous. Resident #47 was a male admitted and re-admitted to the facility with diagnoses including MRSA pneumonia, acute respiratory failure, dysphagia, cognitive communication deficit, type 2 diabetes mellitus, Alzheimer's disease, unspecified dementia, atherosclerotic heart disease, hypertensive heart disease, insomnia, COPD, osteoarthritis, hyperlipidemia, GERD, adult failure to thrive, and other conditions. His admission MDS showed a BIMS score of 05, indicating severe cognitive impairment, and his care plan noted he required assistance with ADLs due to Alzheimer's dementia, decreased physical and functional mobility secondary to weakness, and multiple medical comorbidities.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. Surveyors observed that necessary interventions to manage existing pressure ulcers were not consistently provided, and preventive practices such as regular repositioning, skin assessments, or use of pressure-relieving devices were not adequately documented or performed. This resulted in residents being at risk for worsening of existing ulcers and the development of new pressure injuries.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the exact nature of the records involved are provided in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident with multiple complex medical conditions. The resident, a cognitively intact female with diagnoses including cancer, coronary artery disease, heart failure, hyperlipidemia, GERD, protein calorie malnutrition, anxiety disorder, and respiratory failure, was admitted and assessed as occasionally incontinent of bladder and continent of bowel. Her assessment triggered care areas such as incontinence, pressure sore, pain, falls, ADLs, and psychotropic medications. Despite these identified needs, the care plan did not address all triggered areas, specifically omitting the anti-anxiety medication Sertraline prescribed for anxiety. Interview with the MDS Coordinator confirmed that the care plan did not include the anti-anxiety medication and acknowledged the oversight, attributing it to challenges with a new program and the need to address all care areas promptly, especially for short-stay residents. Review of facility policy indicated that a comprehensive, person-centered care plan should be developed within seven days of the required MDS assessment, involving the interdisciplinary team and the resident or their representative. The failure to include all triggered care areas in the care plan was identified through record review and staff interview.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as intended, based on their documented preferences and medical directives.

Penalty

Inspection fine: $14,069

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to immediately notify the resident, the resident's physician, and the resident's representative after a significant change in condition following an unwitnessed fall. A male resident with a history of Alzheimer’s disease, frequent falls, abnormal gait, seizures, atrial fibrillation, and insomnia was found on the floor by nursing staff during midnight rounds. The resident was holding his head, appeared confused, and was unable to answer questions about pain or the circumstances of the fall. Despite these findings, the nurse assessed the resident, found no visible injuries, and monitored his vital signs, which were within normal limits. Instead of making an immediate phone call to the nurse practitioner (NP) on call, the nurse sent a text message reporting the fall and the resident’s confusion. The NP did not see the text until several hours later and responded that the resident should be sent to the emergency room for evaluation. The nurse did not attempt a follow-up phone call after not receiving a timely response to the text message. The resident was eventually sent to the hospital approximately six hours after the fall, where he was diagnosed with a subarachnoid hemorrhage and admitted to the intensive care unit. Interviews with staff confirmed that the nurse was trained to notify the physician by phone in the event of a significant change in condition, such as an unwitnessed fall with confusion and possible head injury. Facility policy required immediate phone notification to the physician and family in such cases. The nurse relied on her judgment that the resident was stable and did not perceive the confusion as a change in condition, resulting in delayed notification and delayed emergency services.

Removal Plan

• All facility residents were assessed for any Change in Condition.
• 1:1 education was provided to RN A by the Director of Nursing and Administrator.
• Education was provided to all licensed nursing staff and CNAs.
• Direct care staff (PRNs, new hires, from vacation) will not be allowed to render care until in-service is completed.
• Test questions were given and taken by all registered and licensed nurses to ensure understanding of the policies and procedures.
• Education included Policy & Procedure on Notification - Physician Notification, Policy & Procedure on Quality of Care - Change in a Resident's Condition, and use of the Interact SBAR Communication Form.
• Physician and Nurse Practitioner Notification Call Tree was completed and posted in all Nurses stations.
• All direct care staff were educated on the location and use of the Call Tree during in-service.
• Audit tools/checklists were developed to monitor provider notification and change-in-condition documentation.
• Registered and licensed nurses were educated on these audit tools.
• A Notification Report audit on Change in Condition for residents was reviewed and completed.
• These tools will be reviewed for compliance.
• Staff in-services were started on Physician Notification and all clinical staff on Changes in condition; this in-servicing will continue until all clinical staff have been trained.
• Staff will not be allowed to start on the floor or give care until this training has been completed.
• All new clinical staff will receive the in-services as part of the onboarding orientation process prior to being assigned and providing care to residents.
• Post tests were conducted and completed to ensure understanding and competency.
• All current residents were assessed to determine if there is any change in status and/or condition, and the physician will be made aware of any noted changes from the resident's normal baseline.

Penalty

Inspection fine: $14,069

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A facility failed to ensure that a resident received timely treatment and care in accordance with professional standards, the resident's care plan, and the resident's preferences following an unwitnessed fall. The resident, who had a history of Alzheimer’s disease, frequent falls, abnormal gait, seizures, atrial fibrillation, and insomnia, was found on the floor by nursing staff during midnight rounds. The resident was confused, holding his head, and unable to clearly explain what had happened. Initial assessments showed no visible injuries and stable vital signs, and the resident was assisted back to bed and monitored throughout the night. Despite the resident’s confusion and the unwitnessed nature of the fall, the RN on duty notified the nurse practitioner (NP) by text message rather than by phone, as required by facility policy. The NP did not see the text message until several hours later, as she was asleep, and instructed that the resident be sent to the emergency room (ER) for evaluation. The RN did not attempt further notification after not receiving a response, relying on her judgment that the resident was stable. This resulted in a delay of approximately six hours before the resident was transported to the hospital. Upon arrival at the hospital, the resident was found to have a subarachnoid hemorrhage and was admitted to the intensive care unit. Interviews with facility staff, including the RN, NP, DON, and administrator, confirmed that the RN did not follow the required notification procedures, which included making a phone call for urgent changes in condition and, if necessary, escalating the notification up the chain of command. Facility policies required immediate phone notification of the physician for significant changes in condition, especially after unwitnessed falls with possible head injury and confusion.

Removal Plan

• All facility residents were assessed for any Change in Condition.
• 1:1 education was provided to RN A by the Director of Nursing and Administrator.
• Education was provided to all licensed nursing staff and CNAs.
• Direct care staff (PRNs, new hires, from vacation) will not be allowed to render care until in-service is completed.
• Test questions were given and taken by all registered and licensed nurses to ensure understanding of the policies and procedures.
• Education included Policy & Procedure on Notification - Physician Notification, Policy & Procedure on Quality of Care - Change in a Resident's Condition, and use of the Interact SBAR Communication Form.
• Physician and Nurse Practitioner Notification Call Tree was completed and posted in all Nurses stations.
• All direct care staff were educated on the location and use of the Call Tree during in-service.
• Audit tools/checklists were developed to monitor provider notification and change-in-condition documentation.
• Registered and licensed nurses were educated on these audit tools.
• A Notification Report audit on Change in Condition for residents was reviewed and completed.
• These tools will be reviewed for compliance.
• The Administrator notified the Medical Director of the Immediate Jeopardy.
• A QAPI meeting was held to review policies/protocols for Change in Condition and Physician Notification.
• The Director of Nursing and the ADON were in-serviced by the Medical Director on Change in Condition and Physician Notification.
• Staff in-services for all registered nurses, licensed clinical staff, and CNAs on Physician Notification and Changes in Condition were started and will continue until all clinical staff have been trained.
• Staff will not be allowed to start on the floor or give care until this training has been completed.
• All new clinical staff will receive the in-services as part of the onboarding orientation process prior to being assigned and providing care to residents.
• Post tests were conducted and completed to ensure understanding and competency.
• All current residents were assessed to determine if there is any change in status and/or condition, and the physician will be made aware of any noted changes from the resident's normal baseline.
• After completion of the residents' audits, no other residents were found to be at risk of having a change in condition and at their normal baseline.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident, who was dependent on staff for activities of daily living (ADLs) such as bathing, grooming, and personal hygiene, did not receive scheduled showers or baths for a two-week period following admission. The resident, who has diagnoses including hypertensive heart disease, chronic kidney disease, and chronic respiratory failure, was found to require substantial assistance for bathing and was unable to walk. Review of records revealed that no shower sheets had been completed for the resident since arrival, and the baseline care plan indicated a need to keep the resident's skin clean and dry to prevent breakdown. Interviews with the resident confirmed that she had not received a bath or shower as scheduled and had repeatedly requested assistance, which was not provided. The resident reported feeling unclean and embarrassed, and stated that her requests to the CNA were ignored. Staff interviews revealed inconsistent practices regarding resident hygiene, with some CNAs stating that residents should be awakened for showers and refusals documented, while the CNA responsible for the resident admitted to not providing showers or baths and could not specify which nurse had been informed of the missed care. Further interviews with facility leadership and other staff confirmed that the expectation was for residents to receive showers or baths on scheduled days, with refusals to be documented and communicated to nursing staff. The facility's policies emphasized the importance of maintaining resident dignity, self-esteem, and individualized grooming preferences. Despite these policies, the resident did not receive the necessary assistance with hygiene and grooming, and required services were not documented or provided as outlined in her care plan.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement comprehensive person-centered care plans for two residents, Resident #25 and Resident #86, as required by regulations. For Resident #25, the care plan did not include measurable objectives and timeframes related to his communication methods, ADL needs, and preferences. Additionally, there was no documented care plan for his use of a catheter, despite nursing notes indicating he was admitted with a Foley catheter. Observations confirmed the presence of the catheter, yet the care plan lacked any mention of it, potentially leading to unrecognized care needs and preferences. Resident #86's care plan also lacked completion in several areas, including her ADL self-care needs and communication methods. Although the care plan had prefilled sections for various levels of assistance and preferences, none of these were completed. This oversight could result in staff being unaware of the specific care requirements and preferences of Resident #86, as she was rarely or never understood, according to her MDS assessment. Interviews with facility staff, including LVNs, the ADON, the Temp MDS Nurse, the DON, and the Admin, revealed systemic issues contributing to the incomplete care plans. Staff reported a lack of training and familiarity with the facility's EHR system, which was necessary for creating and updating care plans. The MDS Nurse admitted to not knowing how to complete care plans in the EHR, and there was no staff responsible for oversight of the care plans. The facility's policy required care plans to be completed within seven days of the MDS assessment, but delays in MDS assessments led to delayed care plans, exacerbated by a high workload and insufficient training for the MDS team.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct quarterly MDS assessments for two residents, Resident #27 and Resident #35, within the required three-month timeframe. Resident #27, a woman with severe cognitive impairment and multiple health conditions, had her quarterly MDS assessment completed one month late due to the heavy caseload of the MDS Nurses. The assessment documented her severe cognitive impairment and dependency on staff for all activities of daily living (ADLs), but it was not completed within the required period. Resident #35, a man with minimal cognitive impairment and significant physical limitations, also did not have his quarterly MDS assessment completed and transmitted on time. His assessment was incomplete, with several sections not filled out, and it was not submitted to the receiving agency as required. The MDS Nurse was unaware of this oversight, attributing it to the IDT not completing their sections of the MDS and the lack of a system to flag incomplete assessments. The MDS Nurse cited a heavy workload, multiple admissions and discharges, and external factors such as an internet outage and a hurricane as contributing factors to the delay in completing and transmitting MDS assessments. The facility had previously identified a backlog of over a thousand MDS assessments that had not been transmitted timely, which was discovered in January 2024. This backlog was addressed by transmitting the assessments between May and June 2024, but the focus on clearing the backlog may have contributed to the oversight in Resident #35's assessment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to professional standards for food service safety in one of its walk-in freezers. During an observation, a five-gallon container of ice cream was found without a lid, with only plastic film touching the ice cream. The surface of the ice cream had black-brown areas and was covered with ice crystals. This improper storage was identified during a survey, and the ice cream was subsequently removed and disposed of by the Dietary Director (DD). Interviews with the DD and the Dietary Manager (DM) confirmed that the ice cream should have been stored with a lid to prevent contamination. The DM also stated that all items in the freezer should have two dates: the date obtained and the date for disposal. The facility's undated Standard Storage Procedure policy emphasized proper food storage, rotation, and date marking to ensure safety and quality. However, the ice cream's improper storage could have led to contamination, posing a risk of illness to residents consuming it.