Based on observation, record review, and interview, the facility failed to identify a significant change for one (#42) of thirteen sampled residents assessments reviewed. The Resident Census and Conditions of Residents report, dated 06/28/23, documented the census was 49. Findings: Resident #42 had diagnoses which included, high blood pressure, chronic bronchitis, and dementia. A Quarterly Assessment, dated 03/17/23, documented Resident #42 had severe cognitive impairment, and needed limited assistance of one staff for bed mobility, transfer, dressing, toilet use, and personal hygiene. A Quarterly Assessment, dated 06/17/23, documented Resident #42 had severe cognitive impairment and needed extensive assistance with the assistance of one staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. There was no documentation in the clinical health record a significant change assessment had been completed when the resident had a significant decline in their activities of daily living. On 06/30/23 at 10:21 a.m., the MDS Coordinator was shown the MDS data from 03/17/23 and 06/17/23. They were asked why the resident had a decline in ADLs. They stated the resident had a UTI at the time. On 06/30/23 at 10:39 a.m., the MDS coordinator was asked if the MDS assessment, dated 06/17/23, accurately reflected the residents status. They stated, No. On 06/30/23 at 3:27 p.m., the MDS coordinator was asked when the significant change had been identified. They stated the system showed a significant change and flagged it as a potential change and I had chosen not to do it.

Based on observation, record review, and interview, the facility failed to ensure palatable food was served for one (#17) of six sampled residents reviewed for food services. The Resident Census and Conditions of Residents report, dated 06/28/23, documented the census was 49. LPN #1 identified all 49 residents received their meals from the kitchen. Findings: Resident #17 had diagnoses which included high blood pressure, diverticulitis of intestine, chronic kidney disease stage three, and major depressive disorder. A Physician Order, dated 05/13/19, documented Resident #17 was on a diverticulitis texture, regular consistency diet. A Quarterly Assessment, dated 04/25/23, documented Resident #17 had mild cognitive impairment. On 06/28/23 at 12:10 p.m., Resident #17 was asked how was the food. They stated, It's not any good, my hamburger was cold, and I couldn't hardly chew it. On 06/30/23 at 11:38 a.m., Resident #17 was observed in their room with a lunch meal of mashed potatoes with white gravy, chicken strips, apple pie, and cottage cheese. They were observed to be holding a chicken strip in their hand and were asked how the chicken strips tasted. They stated, They are hard, I can't hardly eat them. On 06/30/23 at 1:44 p.m., the CDM was asked if they'd had any complaints about the food. The CDM stated they were aware some residents did not care for the chicken strips that were being served, but had been unable to order the chicken strips that the residents preferred.