**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and facility policy review, the facility failed to maintain complete and accurately documented medical records in accordance with accepted professional standards of practice for three (Residents #329, #330, and #332) of 31 sampled residents, by failing to include medical diagnoses to the resident electronic medical record. The findings include: 1. A medical record review of Resident #329 revealed he was admitted on [DATE], with diagnoses including muscle weakness, difficulty walking, and other signs & symptoms involving skeletal system. A review of Resident #329's Agency for Healthcare Administration Form 5000-3008 revealed his medical diagnoses included atrial fibrillation, gastroesophageal reflux disease, cardio myopathy, alcohol cirrhosis, peripheral artery disease, coronary artery disease, hypertension, and asthma. A review of Resident #329's admission/Medicare minimum data set (MDS) assessment noted it was in progress showing a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. 2. A medical record review of Resident #330 revealed she was admitted on [DATE], with no diagnoses listed on the medical diagnosis page. A review of Resident #330's MDS assessment noted it was in progress with a BIMS score of 12, indicating the resident was cognitively intact. 3. A medical record review of Resident #332 revealed he was admitted on [DATE], with diagnoses including muscle weakness (generalized), difficulty in walking, not elsewhere classified, and other lack of coordination. A review of Resident #332's Agency for Healthcare Administration Form 5000-3008 revealed his medical diagnoses included severe anemia, diabetes mellitus, atrial fibrillation, chronic kidney disease, and pressure ulcer. A review of Resident #332's admission/Medicare 5-day MDS assessment noted it was in progress with no BIMS score indicated. On 12/11/24 at 10:07 AM, an interview was conducted with the MDS Coordinator/Registered Nurse (RN). She confirmed she was responsible for updating resident diagnoses in the electric medical record. She said, The DON will sometime add resident's initial and quarterly updates. When asked, how soon medical diagnoses were added to the electronic medical record. She replied, Within 24 hours of a resident's admission to the facility. The RN/MDS Coordinator confirmed that resident diagnoses needed to be added to the electronic medical record. On 12/11/24 at 10:14 AM, the MDS Coordinator/RN confirmed that only the therapy diagnoses had been added for Residents #332 and #329, and that Resident #330 had no diagnoses and stated the medical diagnoses would be added. She said, I was going back and forth between the pressure ulcer and the fracture. I hadn't had a chance to go back to update the electronic medical record. Diagnoses are pulled from the 3008 form, history and physical, physician progress notes, wound care notes, psych notes, and Dietitian notes. I try my best to add diagnoses within 24 hours of admission. Review of the facility's policy titled: Health Records Policies, date approved: 11/15/2018, read: II. Procedure: .5. The health records shall be maintained according to commonly-accepted standards. (Copy obtained) .