**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet each resident's needs identified in the comprehensive assessment for one of 16 sampled residents. (Resident 15) Findings include: Clinical record review revealed that Resident 15 was admitted to the facility on [DATE], and had diagnoses that included depression. The Minimum Data Set Care Area Assessment summary dated March 23, 2025, noted that the resident's psychotropic drug use was to be addressed in the care plan. Review of the medication administration record in March and April 2025, revealed the resident was receiving an antidepressant. There was no documented evidence that interventions to address Resident 15's psychotropic drug use were included in the current care plan. In an interview on April 9, 2025, at 2:40 p.m., the Director of Nursing confirmed there was no documented evidence that the care area was addressed in the Resident 15's current care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in two of two kitchenettes (Great Oak and Elm) and in the main kitchen of the dietary department. Findings include: Review of the facility's policy entitled, Date Marking for Food Safety, dated March 20, 2025, revealed that staff were to label food items with the date the item was opened and the items were to be discarded by the use-by date. Observations during the tour of the two kitchenettes and the main kitchen on April 8, 2025, at 10:30 a.m., revealed the following: In the Great Oak kitchenette reach-in cooler, there was an opened container of cottage cheese with a use-by date of March 21, 2025, and had an opening date of April 8, 2025, written on the lid. In the deli cooler, there was a pan of egg salad with a use-by date of April 4, and a bagel with a use-by date of December 24, 2024. There was a pan of lettuce and a cut wrapped sweet potato that were both not dated. In the Elm kitchenette reach-in cooler, there was a dished pan of pears labeled use-by April 4, and a dished pan of pureed fruit cup labeled use-by April 3. In the deli cooler, there was a container of chicken salad with a use-by date of April 6, a container of tuna salad labeled use-by April 6, a package of six hot dogs labeled use-by April 6, a container of lemon slices labeled use-by March 15, a package of cream cheese labeled use-by March 28, and a package of sliced provolone cheese labeled use-by March 14, and all items were opened. There was a container of 10 eggs, a cut wrapped onion, and an opened package of sliced cheese that were not dated. In the Main Kitchen reach in cooler, there was a package of cheese slices that was open to air and an opened package of whipped topping that was not dated. In the walk-in cooler, there was a container of cottage cheese with a use-by date of March 21, 2025. There was a container of 17 eggs and a large container of 30 peeled potatoes in water that were not dated. In dry storage, there was an opened package of walnuts that was not dated. In an interview on April 8, 2025, at 11:30 a.m., the Assistant Director of Dining confirmed these items should have been dated, expired items should have been removed, and the food items were for use in the skilled areas. 28 Pa. Code 201.14(a) Responsibility of licensee.