**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a care plan was developed for a resident with exit seeking behaviors to decrease the risk of elopement (an individual who was incapable of adequately protecting themselves who left a health care facility undetected and unsupervised) for 1 (Resident #12) of 6 (Resident #4, Resident #12, Resident #58, Resident #72, Resident #80, and Resident #90) sampled residents reviewed for accidents hazards.Findings: Review of the facility's Care Plan Process policy and procedure, dated 06/2015 and revised on 12/2024, revealed, in part, the care plan was driven by a resident's unique needs. Further review revealed a well-developed and executed care plan would provide information regarding how the causes and risks associated with issues and/or conditions were addressed to provide for a resident's highest practicable level of well-being. Further review revealed the facility would re-evaluate the resident's status annually and then modify the individualized care plan as appropriate and necessary. Review of Resident #12's Annual Minimum Data Set (MDS) with an Assessment Reference Date of 05/06/2025 revealed, in part, Resident #12 had a Brief Interview of Mental Status score of 10 which indicated Resident #12 had moderate cognitive impairment. Further review revealed Resident #12 had a diagnosis of dementia and used a security bracelet/elopement alarm. Review of Resident #12's Nursing Data Collection and Screening dated 05/06/2025 revealed, in part, Resident #12 was at risk for elopement and a security bracelet/elopement alarm was in place. In an interview on 07/23/2025 at 2:12PM, S5Licensed Practical Nurse indicated Resident #12 was at risk for elopement and had a history of asking for his truck keys so he could leave the facility. In an interview on 07/23/2025 at 2:23PM, S6Certified Nursing Assistant indicated Resident #12 would ask for his keys to go home once or twice a week, and would ask which door he could get out of. Review of Resident #12's Care Plan revealed no evidence, and the facility did not present any evidence a care plan was developed to include measurable objectives and timeframes when Resident #12's security bracelet/elopement alarm was initiated on 10/08/2024 and/or when it was documented on his Annual MDS dated [DATE]. In an interview on 07/23/2025 at 2:33PM, S4Registered Nurse indicated Resident #12 was at risk for elopement and he did not have a care plan developed that addressed Resident #12's risk for elopement implemented into his care plan until today (07/23/2025). In an interview on 07/23/2025 at 2:53PM, S2Director of Nursing confirmed Resident #12 was at risk for elopement and a care plan was not developed to address this risk until today (07/23/2025), and should have been developed when the risk for elopement was initially identified.

Based on observation, interviews, and record reviews, the facility failed to ensure residents did not have cigarette lighters in their possession per facility policy for 1 (Resident #90) of 6 (Resident #4, Resident #12, Resident #58, Resident #72, Resident #80, Resident #90) sampled residents investigated for accident hazards.Findings:Review of the facility's Smoking Policy and regulations, dated 04/2006 and revised on 10/2024, revealed, in part, cigarette lighters and matches were not permitted in a resident's room and would be kept at the nursing station. Visitors were not permitted to smoke in the facility, nor were they permitted to give or leave matches or lighters with any resident.Review of Resident #90's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/09/2025 revealed, in part, Resident #90 was a current tobacco user. Review of Resident #90's Care Plan initiated on 05/28/2025, with a goal date of 09/05/2025, revealed, in part, residents smoking supplies were stored per the facility policy. Observation on 07/22/2025 at 10:12AM, of the smoker's patio, revealed Resident #90 removed a lighter from his front left pants pocket and lit a cigarette.In an interview on 07/22/2025 at 12:20PM, S3Licensed Practical Nurse (LPN) indicated she was not aware Resident #90 had a cigarette lighter. In an interview on 07/22/2025 at 1:00PM, S9Regional Administrator confirmed residents should not have cigarette lighters in their possession.

Based on Interviews and record reviews the facility failed to administer a medication as ordered for 1 (Resident#1) of 3 (Resident#1, Resident#2, Resident #3) sampled residents reviewed for unnecessary medications. Findings: Review of the facility's policy and procedure on Medication Administration with an effective date of 10/04/2024, revealed, in part, nursing personnel shall ensure the safe and effective administration of medications. Further review revealed, prior to administration, the nursing staff member administering the medication shall ensure medications match the physician's orders and label, and that the proper dose was administered. Review of Resident #1's medical record revealed, in part, an admission date of 11/18/2024. Further review revealed Resident #1 had the following diagnoses, in part, chronic obstructive pulmonary disease (COPD) gastric esophageal reflux disease (GERD) and unspecified psychosis. Review of Resident #1's physician orders revealed, in part, an order dated 01/31/2025 for Ondansetron 4 milligrams (mg) by mouth p.o. every 6 hours for 3 days. In an interview on 05/22/2025 at 10:00 a.m., S1 Director of Nursing (DON) and S2 Assistant Director of Nursing (ADON) both acknowledged Resident #1 did not receive Ondansetron as ordered by her physician, and she should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a resident and the resident's representative was issued a written notice of discharge prior to discharging a resident. This deficient practice was identified for 1 (Resident #1) of 2 (Resident #1 and Resident #2) sampled residents reviewed for discharge requirements. Findings: Review of Resident #1's clinical record revealed Resident #1 was admitted to the facility on [DATE]. Further review revealed Resident #1 was discharged from the facility on 05/27/2024 because Resident #1's representative was unable to make the bed hold payments. In an interview on 07/31/2024 at 10:30 a.m., S2Assistant Director of Nursing (ADON) indicated the cost of the facility's bed hold price and amount was given and explained at length to Resident #1's representative. S2ADON further indicated Resident #1's representative knew the cost to hold Resident #1's bed, and Resident #1's representative did not make payments to the facility. There was no documented evidence and the facility did not present any documented evidence that Resident #1 and/or Resident #1's representative was issued a written notice of discharge prior to discharging Resident #1. In an interview on 07/31/2024 at 10:35 a.m., S1Administrator offered no explanation as to why Resident #1 and/or Resident #1's representative was not issued a written notice of discharge prior to Resident #1's 05/27/2024's discharge as required.

Based on record reviews, observations, and interviews, the facility failed to assess a resident for self-administration of medications for 2 (Resident #22 and Resident #97) of 20 (Resident #2, Resident #13, Resident #16, Resident #17, Resident #22, Resident #25, Resident #26, Resident #39, Resident #44, Resident #61, Resident #64, Resident #67, Resident #69, Resident #70, Resident #79, Resident #77, Resident #80, Resident #88, Resident #95, and Resident #97) sampled residents reviewed. Findings: Review of the facility's Self-Administration of Medications policy with a revision date of 11/2017 revealed, in part, residents would be allowed to self-administer medications only if a physician order was obtained allowing residents to keep a medication at bedside for the purpose of self-administration, and the interdisciplinary team deemed resident to be clinically appropriate to self-administer medications. Review of the facility's Drug Administration and Documentation policy with a revision date of 12/2023 revealed, in part, under no circumstances is medication to be left at the bedside or given to the resident without him/her swallowing it in the nurses presence unless a physician had written an order to, and the facility had determined the resident is mentally and physically capable of self-administration. Resident #22 Review of Resident #22's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/20/2024 revealed, in part, Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #22 was cognitively intact. Observation on 07/15/2024 at 9:13 a.m. revealed a disposable medication cup with 7 tablets and/or capsules on Resident #22's bedside table. In an interview on 07/15/2024 at 9:13 a.m., Resident #22 indicated the nurse left her medications at her bedside for her to self-administer when she was feeling better. In an interview on 07/15/2024 at 9:15 a.m., S5Licensed Practical Nurse (LPN) confirmed the disposable medication cup on Resident #22's beside table contained 7 tablets and/or capsules. S5LPN indicated she did not ensure Resident #22 swallowed her medications during medication administration, and should have. In an interview on 07/17/2024 at 11:35 a.m., S6Certified Nursing Assistant indicated she had occasionally noticed medication cups containing medications left at resident's bedsides. Review of Resident #22's record revealed no documented evidence and the facility was unable to present any documented evidence Resident #22 had physician orders to self-administer medications and/or allowed to keep medications at the bedside. In an interview on 07/17/2024 at 12:00 p.m., S1Director of Nursing (DON) indicated Resident #22 did not have a physician's order to self-administer medications and S5LPN should not have left Resident #22's medications at the bedside to self-administer. Resident #97 Review of Resident #97's MDS with an ARD of 05/09/2024 revealed, in part, Resident #97 had a BIMS score of 15 which indicated Resident #97 was cognitively intact. Observation on 07/17/2024 at 10:35 a.m. revealed a clear plastic container on Resident #97's bed which contained a box of medication labeled Betamethasone Valerate 0.1% ointment (a medication used to relieve redness, itching, or swelling caused by skin conditions) apply to affected area twice daily. In an interview on 07/17/2024 at 10:35 a.m., Resident #97 stated she previously used the above mentioned ointment for a fungal infection on her ear and she kept the ointment in case she needed it again. Review of Resident #97's record revealed no documented evidence and the facility was unable to present any documented evidence Resident #97 had a physician's order to self-administer medications and/or allowed to keep medications at the bedside. In an interview on 07/17/2024 at 12:00 p.m., S1DON confirmed Resident #97 did not have a physician's order to self-administer medications and/or allowed to keep medications at the bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident with a mental illness had an accurate PASARR (Preadmission Screening and Resident Review) for 1 (Resident #67) of 2 (Resident #17, Resident #67) residents reviewed for PASARR. Findings: Review of Resident #67's Medical Record review revealed, in part, Resident #67 was admitted to the facility on [DATE] with a diagnosis of PTSD (Post-Traumatic Stress Disorder). Review of Resident #67's Quarterly MDS (Minimum Data Set) dated 05/30/2024 revealed, in part, Resident #67 had a diagnosis of Post-Traumatic Stress Disorder (PTSD). Review of Resident #67's Level I PASARR dated 10/07/2020 revealed, in part, Resident #67's diagnosis of PTSD was not selected on Section III as a mental illness. In an interview on 07/17/2024 at 10:03 a.m., S3Social Service Director indicated Resident #67 did not have a Level II PASARR, and the facility could not produce any documented evidence that a Level II PASARR for a diagnosis of PTSD was completed and submitted to the required agency for resident review. In an interview on 07/17/2024 at 10:007 a.m., S2Assistant Director of Nursing (ADON) indicated a Level II PASARR was not completed, and the facility could not produce any documented evidence that a Level II PASARR for a diagnosis of PTSD was completed and submitted to OBH for resident review.

Based on observation, interview, and record review, the facility failed to ensure staff implemented their Policy & Procedure for abuse for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for abuse. Findings: Review of the facility's Elder Justice Act policy with a revision date of 04/2022 revealed, in part, it is the facility's policy to comply with the Elder Justice Act (EJA) about reporting a reasonable suspicion of a crime, under Section 1150B of the Social Security Act, as established by the Patient Protection and Affordable Care Act. Further review revealed staff must report the suspicion of an incident to the administrator. Resident #2 Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/12/2023 revealed, in part, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact. In an interview on 11/06/2023 at 9:08 a.m., S2Housekeeper asked the state surveyor to talk Resident #2 stating the resident wanted to report something. In an interview on 11/06/2023 at 9:09 a.m., Resident #2 stated S3Certified Nursing Assistant (CNA) screamed at her earlier in the morning which upset her. Resident #2 further stated she told S2Housekeeper that S3Certified Nursing Assistant (CNA) screamed at her and upset her. In an interview on 11/06/2023 at 9:10 a.m., S2Housekeeper acknowledged that Resident #2 reported to her that S3Certified Nursing Assistant had hollered at her and she was insulted. S2Housekeeper further stated she just tried to console Resident #2 from crying but did not report the incident to anyone. S2Housekeeper stated she should have reported to the nurse or administrator immediately that Resident #2 alleged S3CNA had hollered at her and insulted her. S2Housekeeper further stated Resident #2 had reported the above mentioned verbal abuse to her before breakfast on 11/06/2023. S2Housekeeper stated breakfast is at approximately 7:30 a.m. daily. In an interview on 11/06/2023 at 9:31 a.m., S1Administrator acknowledged he was not aware that Resident #2 had alleged that S3CNA screamed at her and insulted her. S1Administrator further acknowledged S2Housekeeper did not immediately report Resident #2's allegation of verbal abuse as required.

Based on observation, interview, and record review, the facility failed to notify the physician and responsible party of a resident's onset of loose stools and bilateral buttock wounds for 1 (Resident #79) of 1 (Resident #79) sampled residents reviewed for skin conditions. Findings: Review of Resident #79's departmental notes, revealed, in part, the following: 1. 08/19/2023 the Certified Nurse Assistant (CNA) reported one episode of loose stool; and, 2. 08/30/2023 the CNA reported loose stools this shift; and, 3. 08/31/2023 the CNA reported one episode of loose stool. Further review revealed no documented evidence the physician or responsible party was notified of Resident #79's loose stools. Review of Resident #79's August 2023 Physician's orders revealed, in part, orders dated 08/24/2023 to cleanse left and right buttock moisture associated skin damage (MASD) with normal saline, pat dry and apply calmoseptine ointment (moisture barrier that protects and helps heal skin irritations) daily until resolved. Review of Resident #79's departmental notes, revealed, in part, no documented evidence the physician or responsible party was notified of Resident #79's left and right buttock moisture associated skin damage and the initiation of wound care to the left and right buttocks. Observation on 08/30/2023 at 12:45 p.m. revealed S12CNA removed Resident #79's diaper and the diaper was soiled with loose stool and the skin to Resident #79's left and right buttocks was open and bright red. Further observation revealed, Resident #79 continued to have a bowel movement with loose stool during incontinence care. In an interview on 08/30/2023 at 12:45 p.m., S12CNA stated as she cleaned Resident #79's buttocks loose stool would continuously come from Resident #79's rectum. S12CNA stated Resident #79 had loose stool since last week. In an interview on 08/31/2023 at 2:10 p.m., S9Licensed Practical Nurse (LPN) stated she was aware Resident #79 had episodes of loose stool yesterday, and was not aware Resident #79 had any episodes of loose stool today. S9LPN confirmed she did not notified the physician of Resident #79's multiple episodes of loose stool or the moisture associated skin damage to left and right buttocks. In an interview on 08/31/2023 at 2:40 p.m., S16CNA stated Resident #79 had one episode of loose stool earlier this morning on her shift and the nurse was notified. In an interview on 08/31/2023 at 3:08 p.m., Resident #79's Nurse Practitioner stated she was only made aware a few minutes ago by the facility of Resident #79's episodes of loose stools and she ordered medication for treatment. Resident #79's Nurse Practitioner stated she had no knowledge of Resident #79's moisture associated skin damage to her left and right buttocks. Resident #79's Nurse Practitioner confirmed she had not been notified by the facility of Resident #79's left and right buttock moisture associated skin damage or the initiation of treatment to the wounds. In an interview on 08/31/2023 at 3:22 p.m., Resident #79's daughter and responsible party stated she had not been notified by the facility of Resident #79's episodes of loose stool, moisture associated skin damage to her bilateral buttocks, or the initiation of treatment on 08/24/2023 to her bilateral buttock wounds. Record review revealed no evidence and the facility did not produce any evidence the physician or responsible party was notified at the onset of Resident #79's episodes of loose stool and moisture associated skin damage to left and right buttocks.

Based on observation, interview, and record review, the facility failed to: 1) Ensure a residents wounds were assessed; and, 2) Ensure a resident was provided treatment for loose stools for 1 (Resident #79) of 1 (Resident #79) sampled residents reviewed for skin conditions. Findings: Review of the facility's prevention and treatment of skin issues policy revealed, in part, the facility should properly identify and assess residents whose clinical conditions increase the risk for impaired skin integrity to implement preventative measures and to provide appropriate treatment. Further review revealed, for newly identified skin issues staff should implement weekly wound documentation in the Wound Assessment Manager (WAM) to include: type of wound, location, date, length, width, depth, wound base description, and wound edge description. 1. Review of Resident #79's August 2023 Physician's orders revealed, in part, an order dated 08/24/2023 to cleanse left and right buttock moisture associated skin damage (MASD) with normal saline, pat dry and apply calmoseptine ointment (moisture barrier that protects and helps heal skin irritations) daily until resolved. Review of Resident #79's departmental notes revealed, in part, no documented assessments of Resident #79's left and right buttock moisture associated skin damage. Review of the facility's Wound Assessment Manager (WAM) revealed, in part, no documented assessments of Resident #79's left and right buttock moisture associated skin damage. In an interview on 08/30/2023 at 11:45 a.m., S5Treatment Nurse stated she did not complete a wound assessment on Resident #79's left and right buttock moisture associated skin damage. In an interview on 08/31/2023 at 2:58 p.m., S2DON stated they did not have documented evidence of Resident #79's wound assessments on the left and right buttock moisture associated skin damage. Record review revealed no documented evidence and the facility did not produce any documented evidence Resident #79's moisture associated skin damage to the left and right buttock was assessed. 2. Review of Resident #79's departmental notes, revealed, in part, the following: 1.) 08/19/2023 the Certified Nurse Assistant (CNA) reported one episode of loose stool, 2.) 08/30/2023 the CNA reported loose stools this shift, and 3.) 08/31/2023 the CNA reported one episode of loose stool. Review of Resident #79's August 2023 physician orders, revealed, in part, no medication ordered for treatment of Resident #79's loose stools. Observation on 08/30/2023 at 12:45 p.m. revealed S12CNA removed Resident #79's diaper and the diaper was soiled with loose stool. In an interview on 08/30/2023 at 12:45 p.m., S12CNA stated when she cleaned Resident #79's buttocks during incontinence care loose stool would continuously come from Resident #79's rectum. S12CNA stated Resident #79 had loose stool since last week. In an interview on 08/31/2023 at 2:10 p.m., S9Licensed Practical Nurse (LPN) stated she was aware Resident #79 had episodes of loose stool yesterday. S9LPN confirmed she did not notify the physician of the multiple episodes of loose stool and Resident #79 had no current orders to treat her loose stool. In an interview on 08/31/2023 at 2:40 p.m., S16CNA stated Resident #79 had one episode of loose stool earlier this morning on her shift and the nurse was notified. In an interview on 08/31/2023 at 3:08 p.m., Resident #79's Nurse Practitioner stated she was only made aware a few minutes ago by the facility of Resident #79's episodes of loose stool and she ordered medication for treatment. Record review revealed no documented evidence and the facility did not produce any documented evidence treatment was provided for Resident #79's episodes of loose stool.

Based on observations, interviews, and record reviews the facility failed to: 1.) Ensure resident's interventions were updated after a fall for 1 (Resident #44) of 3 (Resident #19, Resident #44, and Resident #78); and, 2.) Ensure a resident's intervention listed in the Comprehensive Care Plan was implemented for 1 (Resident #78) of 3 (Resident #19, Resident #44, and Resident #78) sampled residents reviewed for falls. Findings: 1. Resident #44 Review of Resident #44's Minimum Data Set (MDS) with and Assessment Reference Date (ARD) revealed, in part, Resident #44 had a Brief Interview of Mental Status (BIMS) of 8 (a score of 8-12 indicated a resident had moderately impaired cognition). Review of Resident #44's care plan with a target date of 09/30/2023 revealed Resident #44 was at risk for falls with a fall on 06/02/2023. Review revealed a new intervention for the fall on 06/02/2023 was not initiated. In an interview on 08/29/2023 at 3:04 p.m., S8Liscensed Practical Nurse (LPN) stated Resident #44 had a fall last week. S8LPN stated Resident #44 was recently moved to this room and was unaware of any previous falls. S8LPN further stated she was unaware of any interventions that were in place prior to the fall. In an interview on 08/30/2023 at 4:03 p.m., S2Director of Nursing (DON) stated Resident #44 had a fall on 06/02/2023. S2DON further stated the intervention for Resident #44's fall on 06/02/2023 was initiated on 06/05/2023 by transferring Resident #44 to the hospital. 2. Resident #78 Review of Resident #78's MDS with an ARD of 07/04/2023 revealed, in part, Resident #78 had a BIMS of 5 which indicated severely impaired cognition. Further review of Resident #78's MDS revealed Resident #78 had 2 or more falls with injury since admission. Review of Resident #78's Comprehensive Care Plan revealed Resident #78 was at risk falls. Further review of Resident #78's approaches revealed, in part, a full size mattress next to bed when in bed at all times. Observation on 08/28/2023 at 10:00 a.m. revealed Resident #78 lying in bed with fall mattress propped up against Resident #76's bed. Observation on 08/29/2023 at 3:04 p.m. revealed Resident #78 lying in bed asleep with a fall mattress propped up against Resident #76's bed. In an interview on 08/29/2023 at 3:18 p.m., S9LPN stated Resident #78 has had falls. S9LPN stated the interventions for Resident #78 included placing a fall mattress next to the bed when Resident #78 was in bed. Observation on 08/30/2023 at 1:52 p.m. revealed Resident #78 lying in bed with fall mattress leaning on the bed held in place by the nightstand. Observation on 08/31/2023 at 12:30 p.m. revealed Resident #78 lying in bed with fall mattress propped against the wall. In an interview on 08/31/2023 at 12:36 p.m., S2DON stated Resident #78 should have a fall mattress on the floor next to the bed at all times when he was in the bed. S2DON confirmed Resident #78 was lying in the bed and the fall mattress was propped against the wall. S2DON further stated the fall mattress should have been on the floor next to Resident #78's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to monitor the oral intake of 2 (Resident #63 and Resident #106) of 2 residents investigated for nutrition. Findings: Review of the facility's Food Intake Records policy revealed, in part, the intake of each resident should be documented at each meal. Resident #63 Review of Resident #63's Registered Dietician (RD) Nutrition assessment dated [DATE] revealed, in part, to monitor Resident #63's oral intake. Review of Resident #63's log of percentage of meals eaten revealed, in part, no documentation of the percentage of breakfast eaten 08/17/2023, 08/22/2023, 08/23/2023, 08/24/2023, 08/26/2023, and 08/27/2023, no documentation of the percentage of lunch eaten on 08/17/2023, 08/22/2023, 08/23/2023, 08/24/2023, and 08/27/2023 and no documentation of the percentage of dinner eaten on 08/15/2023, 08/17/2023, 08/19/2023, 08/21/2023, 08/22/2023, 08/24/2023, 08/25/2023, 08/26/2023, 08/27/2023, and 08/29/2023. In an interview on 08/31/2023 at 10:13 a.m., S11Liscensed Practical Nurse (LPN) stated Certified Nursing Assistants (CNA) were to document a resident's meal intake after every meal. In an interview on 08/31/2023 at 10:48 p.m. S15CNA stated the residents' oral intakes should be checked after every meal. In an interview on 08/31/2023 at 11:13 a.m., S4Registered Dietician (RD) stated staff were supposed to document Resident #63's meal intake for every meal. S4RD further stated a resident's meal intake should be documented accurately because it was part of what she used to make decisions regarding RD recommendations. In an interview on 08/31/2023 at 12:50 p.m., S2Director of Nursing (DON) stated Resident #63's meal intake should have been assessed and documented after breakfast, lunch, and dinner, and it was not. Resident #106 Review of Resident #106's RD Nutrition assessment dated [DATE] revealed, in part, to monitor Resident #106's oral intake. Review of Resident #106's RD Nutrition assessment dated [DATE] revealed, in part, to monitor Resident #106's oral intake. Review of Resident #106's log of percentage of meals eaten revealed, in part, no documentation of the percentage of breakfast eaten on 07/18/2023, 07/19/2023, 07/20/2023, 07/21/2023, 07/22/2023, 07/29/2023, 08/02/2023, 08/05/2023, 08/06/2023, 08/07/2023, 08/11/2023, 08/12/2023, 08/13/2023, 08/16/2023, 08/19/2023, 08/26/2023, 08/29/2023, and 08/30/2023, no documentation of the percentage of lunch eaten on 07/18/2023, 07/19/2023, 07/20/2023, 07/21/2023, 07/22/2023, 07/29/2023, 08/02/2023, 08/05/2023, 08/06/2023, 08/07/2023, 08/11/2023, 08/12/2023, 08/13/2023, 08/16/2023, 08/17/2023, 08/19/2023, 08/26/2023, and 08/29/2023, and no documentation of the percentage of dinner eaten on 07/20/2023, 07/21/2023, 07/22/2023, 07/23/2023, 07/28/2023, 07/29/2023, 08/01/2023, 08/04/2023, 08/09/2023, 08/10/2023, 08/11/2023, 08/13/2023, 08/14/2023, 08/15/2023, 08/16/2023, 08/18/2023, 08/27/203, and 08/28/2023. Further review revealed documentation that Resident #106 ate 75% of her lunch on 08/30/2023. Observation on 08/30/2023 at 12:05 p.m. revealed Resident #106 being fed by S2DON and another aide. Further observation of resident's lunch tray revealed that she ate less than 10% of her lunch. In an interview on 08/30/2023 at 4:35 p.m., S2DON stated Resident #106 only ate less than 10% of her lunch, and Resident #106's percentage of lunch eaten was inaccurately documented on 08/30/2023. In an interview on 08/31/2023 at 10:05 a.m., S13CNA stated the residents' meal intakes needed to be documented after every meal. In an interview on 08/31/202 at 10:13 a.m., S11LPN stated Certified Nursing Assistants (CNA) were supposed to be monitoring Resident #106 oral intake after every meal. In an interview on 08/31/2023 at 11:13 a.m., S4Registered Dietician (RD) stated staff were supposed to document Resident #106's meal intake for every meal. S4RD further stated a resident's meal intake should be documented accurately because it was part of what she used to make decisions regarding RD recommendations. In an interview on 08/31/2023 at 12:50 p.m., S2DON stated Resident #106's meal intake should have been assessed and documented after breakfast, lunch, and dinner, and it was not.