Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable and attractive. Specifically, the facility failed to consistently ensure: -Foods were palatable in temperature; and, -Always available alternative menus were available for residents. Findings include: I. Facility policy and procedure The Food and Beverage Operation Guide, dated 2024, was received from the nursing home administrator (NHA) on 9/19/24 at 8:00 a.m. It documented in pertinent part, All food and display units maintain proper temperature to avoid contamination and deterioration. Appropriate times/temperature include: hot food display units must maintain food above 135 degrees Fahrenheit (F). Harmful microbes grow best in the temperature danger zone at 41 to 135 degrees Fahrenheit. II. Individual resident interviews Resident #16 was interviewed on 9/16/24 at 11:26 a.m. She said the food was always served cold when it was served to her in her room. She said she always ate toast for breakfast, and it was served cold and rock hard. She said she did not enjoy the toast when it was served hard. She said she enjoyed chocolate ice cream with her meals and it often was served melted. She said it took a while to get her meals and they never came at the same time each day. Resident #17 was interviewed on 9/16/24 at 12:04 p.m. He said the food tasted terrible, there was no flavor in the food served and there was no variety. He said he was served chicken frequently and the facility did not mix it up. He said the food could be served hotter. He said he did not know how to get another option if he did not want what they were serving and there was no always available menu in his room. Resident #7 was interviewed on 9/16/24 at 2:43 p.m. He said he did not have access to the weekly menu. He said he did not have an always available menu. He said the food was served cold and did not taste right. He said the quality of food started changing when they changed to a new chef. Resident #13 was interviewed on 9/16/24 at 3:12 p.m. He said he generally did not eat lunch, however his main meals were breakfast and dinner. He said for the past several weeks the food was served cold. He said he complained to the staff about it but nothing so far had been done. He said he did not know there was an always available menu. He said when he did not like the food that was served, the staff told him to order a sandwich. Resident #13 was interviewed on 9/16/24 at 3:15 p.m. He said the food was served cold. Resident #4 was interviewed on 9/16/24 at 3:22 p.m. He said he usually would eat everything that was served. He said he ate his meals in his room and were sometimes served cold, but he did not ask the staff to heat it up. He said when the food was bad, it was bad at every meal that day. He said he was not aware he could order food from an always available menu because he did not know there was an always available menu. He said he was the resident council president and the residents had complained about the food quality and temperature during recent meetings. Resident #7 was interviewed again on 9/17/24 at 4:30 p.m. She said her lunch meal was served cold and did not taste right. She said she complained about the food at the resident council meeting a while back. She said the food quality changed when they hired a new chef. Resident #16 was interviewed again on 9/18/24 at 1:10 p.m. She said she had the chicken, eggplant parmesan, soup and chocolate ice cream for lunch on 9/18/24. She said the chicken, eggplant and soup were served cold. She said the ice cream was served melted. She said she did not enjoy the meal when it was served cold and the ice cream was melted. Resident #15 was interviewed on 9/18/24 a 1:15 p.m. She said the food was served cold and she could not eat it because it tasted so bad. She said she got the eggplant parmesan and chicken with mashed potatoes and gravy for lunch on 9/18/24. She also had soup that she said was served cold. She said the food sometimes was served warm but today it was served cold Resident #17 was interviewed again on 9/18/24 at 1:20 p.m. He said he had the chicken and eggplant parmesan for lunch on 9/18/24. He said it was served cold and he did not enjoy the chicken since he ate it almost daily. He said he was not aware there was an alternative menu or how to order something different. Resident #10 was interviewed on 9/18/24 at 4:17 p.m. He said he did not like chicken. He said he was told by a staff member to write a ham sandwich on the menu card if there was nothing else he would like from the daily menu options. He said there was not an always available menu on the menu card he was provided. III. Meal service and test tray observations Lunch meal service was observed on 9/17/24 beginning at 11:30 a.m. and ending at 1:05 p.m., the following was observed: Line cook (LC) #1 placed the pans that contained the food in the hot air wells table to maintain temperature through the end of the service to all residents. LC #1 took the temperatures of the food at 12:00 p.m. prior to leaving the main kitchen for meal service. LC #1 took the food cart to the memory care unit and served the residents. LC #1 then took the food cart to the assisted living unit and served the units. At 12:55 p.m. she started serving food to residents on the SNF unit. She did not recheck the food temperatures. A test tray for a regular diet was evaluated by two surveyors immediately after the last resident had been served their meal for lunch on 9/18/24 at 1:05 p.m. The test tray consisted of rosemary and garlic chicken, grilled flank steak with red wine sauce, roasted broccoli, sauteed shiitake mushrooms and mashed potatoes with gravy: -The chicken was 120 degrees F. -The beef was 115 degrees F. The beef tasted salty. -The broccoli was 105 degrees F. -The mushrooms were 105 degrees F. IV. Resident council meeting minutes The 6/4/24 resident council minutes revealed the residents reported if the temperature of the food they were served varied. They said the food served in the dining room was warm, but could be warmer. -There was no documentation indicating the steps the facility took to resolve the residents' concerns. The 7/2/24 resident council minutes revealed the residents reported the food was often served cold. -There was no documentation indicating the steps the facility took to resolve the residents' concerns. The 8/6/24 resident council minutes revealed the residents reported the food was not always hot, but they understood that the food had to be delivered from another building. The residents said the cold food was more of a problem for the residents who ate in their rooms. -There was no documentation indicating the steps the facility took to resolve the residents' concerns. V. Culinary council meeting minutes The February 2024 culinary council meeting minutes documented the residents said the food was often served too cold and items were missing from the tickets, the food could be warmer, and they would like the food hotter when it was served. They said the food was cold when delivered as room trays and sometimes food was served cold in the dining room. -There was no documentation indicating the steps the facility took to resolve the residents' concerns. The April 2024 culinary council meeting minutes documented the residents said hot food should be served hot and cold food should be served cold. -There was no documentation indicating the steps the facility took to resolve the residents' concerns. The June 2024 meeting minutes documented the residents said sometimes there were long wait times between courses and the food gets cold in the dining room. -There was no documentation indicating the steps the facility took to resolve the residents' concerns. VI. Staff interviews Line cook (LC) #2 was interviewed on 9/19/24 at 8:05 a.m. LC #2 said he was aware of the new convection ovens were installed in the kitchen about two months ago, however he did not know how to use it and was not trained on this appliance. Dietary aide (DA) #1 was interviewed on 9/19/24 at 8:25 a.m. DA #1 said the dietary staff took a weekly menu to the residents on Thursdays and asked the residents to choose food for next week. She said there was no always available menu the staff could use when residents did not like the food that was on the weekly menu. She said she usually suggested a variety of cold sandwiches to the residents if they did not like the menu options. The NHA was interviewed on 9/19/24 at 10:45 a.m. The NHAsaid he was not aware the residents did not have access to an always available menu. He said he was aware of the concerns regarding food being served cold to the residents and had been working on ways to improve the food temperature by making changes, renovations to the kitchen and working on a process improvement plan. He said there were residents that had grievances and concerns regarding the cold food that were discussed in the culinary council and resident council. The executive chef (EC) was interviewed on 9/16/24 at 10:15 a.m The EC said the food was stored, prepared and cooked in the main kitchen. He said the main kitchen was in the independent living facility. He said the food was then distributed by a vehicle to the skilled nursing facility (SNF). He said that one line cook was assigned to cook food for residents in the SNF in the main kitchen, then transported the ready to serve food to the care center, placed in the hot air wells table. The line cook served food to the residents in the kitchen in the SNF. He said the kitchen was remodeled approximately two months ago and the steam table was replaced with a new hot air table. He said two new convection ovens were installed so when the food got cold during the serving process the line cook could warm it up. The EC was interviewed again on 9/19/24 at 12:30 p.m. the EC said he was aware of residents being served cold meals. He said there were ovens in the kitchen that could be utilized to heat food and keep it hot until serving it. He said the expectation would be to serve foods at safe and palatable temperatures and if a food is lower, then before serving they should heat it up to the proper temperature.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the August 2021 computerized physician orders (CPO), the diagnoses included rheumatoid arthritis, acute respiratory failure, vascular dementia, lower back pain, unsteadiness on feet, attention and concentration deficit, and Parkinson's Disease. The 9/10/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of five out of 15. She required extensive assistance with bed mobility, transfers, locomotion off the unit, dressing, toilet use, and personal hygiene. It was very important for the resident to do things with groups of people, read, listen to music, and do her favorite activities. B. Observations On 12/9/21 at 2:40 p.m. Resident #3 was in her room lying on her bed. She was calling out hello, hello, help, can someone please take me to activities? On 12/9/21 at 3:09 p.m. certified nurse aide (CNA) #2 entered Resident #3's room. The resident asked when the activity started. CNA #2 told her it had begun at 3:00 p.m. CNA #2 helped the resident out of her bed and into her wheelchair. CNA #2 took the resident to the bathroom. The CNA and Resident #3 left the room at 3:18 p.m. to go to the elevator to attend the activity that had begun at 3:00 p.m. C. Resident interview Resident #3 was interviewed on 12/9/21 at 2:40 p.m. She said there was a group activity going to start at 3:00 p.m. downstairs. She said someone should take her when it started. She said she would turn on her call light to get staff to help get her out of bed. She said she loved attending the activities in the facility. She said she did not get invited by the staff to go to activities. She said when she wanted to go to an activity she had to ask someone to help take her to all of the events. She said sometimes she would forget an activity was happening. She said it was up to her to remember when events happened. She said she must turn on her call light to get help to attend an activity or she did not get to go. D. Record review The care plan revised 12/8/21 revealed: Resident #3 identifies activities of interest and participates in all group programming we offer. However, Resident #3 does not self initiate independent leisures of her choice, and often states she has nothing to do and is bored, forgetting she just attended programming. -However, there was no mention in the care plan the resident required assistance and reminders to attend activities. There was no documentation of Resident #3's November 2021 to 12/14/21 participation in activities provided by the activity department when requested during survey. E. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 12/9/21 at 3:19 p.m. She said the residents received the monthly activity calendar. She said the residents must read the calendar and decide if they want to go to an activity during the day. She said the residents must ask to be taken to the activity. She said that was how the facility provided activities to the residents. She said the residents were not invited to activities. She said if the residents asked to be taken to an activity then they get to go to an activity. She said the activities happen on the third and first floor and there were no activities on the second floor which was the skilled nursing floor where Resident #3 resided. She said all residents on the second floor were escorted in an elevator to other floors when they wanted to attend an event. The activity assistant (AA) was interviewed on 12/13/21 at 4:00 p.m. She said the residents must read the activity calendar on their own and then tell staff they want to be taken to an event. She said if someone had vision impairment and could not read a calendar they would need reminders from the staff. She said she did not invite people to activities because the residents read the calendars. She said a printout of the daily events were given to residents at breakfast and they should read it. She said she was aware that many of the residents had short term memory. She said the Activity Department staff did not coordinate with the staff to know who was invited, or who refused an invite. She said it was not documented by the activity department. She said she had been a CNA and she knew the CNAs did not always have time to invite the residents to group activities. She said CNAs were often busy with giving showers or feeding residents. She said she understood that the CNAs may not have time to invite the residents to groups. She said there were no activities on the second floor. She said the residents from the second floor must be escorted into an elevator to attend groups on the first or third floor where events were held. She said Resident #3 enjoyed activities almost daily. She said Resident #3 needed assistance to get to events. She said Resident #3 must remember to ask for help from the staff to get to activities. The activity director was interviewed on 12/14/21 at 1:00 p.m. via the phone. She said the activity staff do not conduct any group activities on the second floor because the second floor common area was noisy. She said all groups were provided on the first and third floors. She said a daily sheet of events was given to each resident with their breakfast. She said it was difficult to invite residents individually. She said the residents were responsible to read the calendars and tell the floor staff that they wanted to attend a group. She said the activity staff know who came regularly and take those individuals to the activity, but they did not go room to room to invite people. She said the nursing home administrator (NHA) told her it was the CNAs job to get people to activities, not the activity department staff. Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (#3 and #6) of five out of 19 sample residents. Specifically, the facility failed to offer and invite Resident #3 and #6 to activities of choice. Finding include: I. Facility policy The Lifestyle/Activity policy, revised October 2017, was provided by the nursing home administrator (NHA) on 12/13/21. It read in pertinent part, the ongoing activities/lifestyle is designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. These programs shall provide residents with recreational, social and educational opportunities. Appropriation activities/lifestyle programs for residents include, but are not limited to: cognitive stimulation/intellectual/educational activities, community involvement, social activities and music. II. Activity schedule 12/8/21-Catholic Mass with Monsignor [NAME]-9:00 a.m., Daily chronicle-10:00 a.m., Senior weekly news discussion 10:15 a.m., Bingo-1:30 p.m and Watch mash (television show) with [NAME]-3:30 p.m. 12/9/21- Daily chronicle-10:00 a.m., National Park series-extreme Alaska-10:15 a.m., Nutrition talks with [NAME]-3:00, Watch mash with [NAME]-3:30 p.m. and Resident run bridge-6:30 p.m. 12/13/21- Daily chronicle-10:00 a.m., Visit & Fit exercise-10:15, Brain games and Trivia-10:45 a.m., Discover the unknown country of Futuna with [NAME]-2:00 a.m., Watch mash with [NAME]-3:30 p.m. 12/14/21- Daily chronicle-10:00 a.m., Visit & Fit exercise-10:15, Who am I? What am I?-10:45 a.m., Live piano with [NAME] Christmas carols-2:00 p.m., Watch mash with [NAME]-3:30 p.m. and Resident run Yahtzee-6:30 p.m. III. Resident #6 A. Resident status Resident #6, age [AGE], was admitted on [DATE]. According to the December 2021 computerized physician's orders (CPO), diagnosis of vascular dementia without behavioral disturbance. The 9/20/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of zero out of 15. She had clear speech and usually made herself understood and sometimes understands others. She had no rejection of care documented. She required extensive assistance with bed mobility and transfers. B. Observations On 12/8/21, at 10:30 a.m. the resident was lying on her back looking towards the ceiling without stimulation. There was a television (TV) in her room and it was not turned on. On 12/9/21 from 10:00 a.m. to 11:30 a.m., the resident was observed lying on her back looking toward the ceiling without stimulation. The TV was not turned on. There was no radio in her room for her to listen to her favorite music as indicated in her assessments (see below). On 12/9/21 from 2:23 p.m. to 3:30 p.m., the resident was observed lying on her back in bed without stimulation. There was an activity scheduled at 3:00 p.m. (see activity schedule above) no staff invited the resident to the activity. On 12/13/21, a continuous observation was done from 9:47 a.m. to 10:50 a.m. At 9:47 a.m., the resident was observed sitting at the table in the dining room. There were three residents and two staff members in the dining room. The activity assistant (AA) walked into the dining room. She invited two of the residents in the dining room to the activity. She did not invite Resident #6. At 9:55 a.m., the certified nurse aide (CNA) #3 asked the resident if she was finished with her drink. She said she would take the resident to her room. She pushed the resident via her wheelchair out of the dining room. She did not offer the resident to go to the activity. She took the resident to her room and put her in her bed. She did not turn the TV on or put her favorite music on as documented in her assessments. C. Record review The 6/17/2020 MDS assessment, Section F (Interview for Activity Preferences) revealed it was very important to listen to music she likes, keep up with the news and do her favorite activities. The comprehensive care plan, revised on 9/20/21, identified the resident chose activities of interest at her own leisure and joined many activities. Interventions included, lifestyles and staff will notify, ask and escort resident to programming of her choice. The resident will observe if she does not want to participate. She enjoys being around people. The December 2021 activity participation log was reviewed. The participation log documented the December 2021 calendar (see above schedule activities) with the resident's name and room number documented at the bottom of the calendar. -The log did not document that the resident participated in any activities on 12/8/21, 12/9/21, 12/13/21 and 12/14/21. D. Staff interviews CNA #3 was interviewed on 12/13/21 at 10:25 a.m. She said the activity and nursing staff usually invite and take the residents to the activity. She said Resident #6 had finished her breakfast and she believed the resident was tired. She said at times the resident will refuse. (however, during observation the resident was never offered/invited to activity). She said she took the resident to her room. The activity assistant (AA) was interviewed on 12/13/21 at 3:15 p.m. She said the activity director was not present in the facility at the moment and she was the only person running the activity program. She said she was responsible to invite all residents and bring them to activity. She said sometimes the nursing staff would help. She said Resident #6 usually sits in the common area by the nurse station because she likes to socialize and observe people walking around. She said she did not invite Resident #6 because she believed she was still having breakfast (during observation the resident was not eating breakfast). She said due to the absence of the activity director, inviting all residents was too much to do. She said sometimes she did not invite all residents. She said she was not aware Resident #6 was in her room all the time and was never invited to activities. She said she would communicate with the nursing staff to invite and bring all residents who want to attend to activities. The activity director (AD) was interviewed on 12/14/21 at 2:00 p.m. She said she had been out for two days. She said Resident #6 liked to sit in the common area and watch the staff walk by. She said if the resident was invited to an activity, she would come even if she did not actively participate. She liked to observe the activity program. She said the nursing staff and activity staff should have invited the resident to activity or play her favorite music while in her room. She said she would provide education to the activity assistant to ensure she invited all residents to the activity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide one (#17) of two residents reviewed for pressure injuries out of 19 sample residents with the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing. Specifically, the facility failed to offer protective boots for Resident #17 to prevent skin breakdown according to the physician's order. Findings include: I. Facility policy and procedure The Medical, Nursing and Personal Care policy, revised October 2017, was provided by the nursing home administrator via email on 12/14/21 at 2:21 p.m. It revealed in pertinent part: General nursing care is provided 24 hours per day, 7 days per week and includes, but is not limited to: Medication administration; Personal care, per resident preference, including skin care. Programs to treat skin and prevent pressure injuries and/or other impairments in skin integrity; Treatment and procedure administration. II. Resident #17 A. Resident status: Resident #17, over age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the November 2021 computerized physician orders (CPO), the diagnoses included cerebral infarction (stroke), hypertension (high blood pressure), anemia, vascular dementia, muscle weakness, unsteadiness on feet, edema, adult failure to thrive, and age related osteoporosis. The 11/3/21 annual minimum data set (MDS) assessment revealed the resident refused to conduct a brief interview for mental status score (BIMS). The resident had short and long term memory problems. The resident was moderately impaired with daily decision making. The resident did not exhibit any behaviors including rejecting cares. The resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident required total dependence with bathing, and for locomotion on the unit. The resident was dependent on staff to put on and off footwear. The resident was at risk of developing pressure ulcers. III. Observations On 12/9/21, 12/10/21 and 12/13/21, at 9:30 a.m., 11:30 a.m., 12: 30 p.m., 3:00 p.m., and 4:30 p.m., Resident #17 was observed in her wheelchair in her room watching television, in the dining room in her wheelchair eating lunch, and in her bed napping. On these three days the resident was not wearing protective boots on her feet according to the physician order. IV. Record review The 2/16/21 physician order revealed, Please make sure the resident has on protective boots (brand name) at all times except for transfers and showers to protect heels. Every shift, shift one 6:00 a.m. - 6:00 p.m., shift two 6:00 p.m. - 6:00 a.m. The 11/11/21 care plan revealed, Resident #17 was at risk for pressure injuries due to a history of anemia, fragile skin, and decreased mobility. Blanchable (non pressure ulcer) and non blanchable skin (discoloration of the skin) was noted on numerous areas on both feet including heels, and toes. The goal was to keep Resident #17's skin integrity intact. The 12/9/21, 12/10/21, and 12/13/21 treatment administrative record (TAR) documented the resident had on the protective boots. The resident was observed not wearing their protective boots on all three days during shift one (see observations above). The TAR did not document that the resident refused to wear the boots. (see below under interviews) V. Resident interview On 12/9/21 at 11:03 a.m. Resident #17 said she did not know why she was not wearing her protective boots. She said the boots were somewhere in her room but she did not know where they were. VI. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 12/13/21 at 3:22 p.m. She said she was unaware that the resident did not wear her protective boots last week. CNA #1 opened the resident's dresser and pulled out two protective boots. She said the resident refused to wear her boots today. She said she notified nursing that the resident refused. She said the CNAs did not mark refusals in the electronic medical records. She said they were to notify a nurse to record the refusal in the electronic medical records Licensed practical nurse (LPN) #1 was interviewed on 12/13/21 at 3:57 p.m. She said in the resident's TAR the nursing staff had a system for recording events if a resident refused treatment. She said the nurse would put their initials in parenthesis for the shift if a resident refused a treatment. She said then below on the same page the nurse would write the resident refused and explain why they refused. The director of nursing (DON) was interviewed on 12/14/21 at 11:50 a.m. She said Resident #17 had poor circulation in her feet. She said the resident's feet turn dark, almost purple so the staff put on protective boots to prevent skin breakdown. She said even though the resident did not walk she had fragile skin that needed protection. She said she would address with the staff to record in the TAR correctly, whether the resident wore the boots or document if the resident refused to wear the boots. She said the staff should not record the resident had her boots on when she did not have them on. She said the resident should wear her protective boots in accordance with the physician's order. VII. Facility follow-up The DON was interviewed on 12/14/21 at 12:45 p.m. She said she called today and had the order changed for Resident #17. She said the facility would try a different type of boots to protect the resident's skin. She said the order was changed to, offer and encourage the resident to wear the boots as tolerated. She said she left a message with the resident's provider and the resident's husband. She said she also educated the staff on marking refusals in the electronic medical records.