Based on record review, interviews and facility policy review, the facility failed to complete medication administration records (MARs) for 1 of 3 residents sampled for intravenous therapy. (Resident #316) The findings include: A review of Resident #316's medical record was conducted. A physician's order was found for Merrem (meropenem) intravenous solution reconstituted 500 mg (an antibiotic) every 8 hours for prophylaxes with a start date of 2/6/24 and a discontinue date of 2/28/24. Another physician's order stated that Cubicin (daptomycin) solution reconstituted 500 mg (another antibiotic) use 500 mg intravenously every 24 hours for prophylaxis related to right knee revision was to be started on 1/29/24 and discontinued on 2/28/24. A review of the MAR revealed Cubicin 500 mg was not documented on 2/7/24 at 5:00 pm and on 2/21/24 at 5:00 pm. Additionally, Merrem 500 mg was not documented on 2/7/24 at 10:00 pm, 2/16/24 at 2:00 pm, 2/21/24 at 10:00 pm, and on 2/23/24 at 10:00 pm On 7/10/24 at 4:05 pm, an interview was conducted with Staff A, a Licensed Practical Nurse (LPN) and unit manager. Staff A walked the surveyor through the process of documenting the MARs and stated there was a facility policy to fully documented whether the medication is given or not given. On 7/10/24 at 4:19 pm, an interview was conducted with Director of Nursing (DON). She stated it was facility's expectation to fully document on MARs. Facility policy titled Charting errors/omissions dated November 2001 was reviewed. Policy stated accurate medical records shall be maintained by the facility. Bullet 4 stated any hole or omitted documentation is considered an error/omission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure residents were seen by a physician or other delegated licensed health care professional at least every 60 days for 2 of 5 sampled residents (Residents #1 and #2). The findings include: Resident # 1 was admitted on [DATE], with diagnoses of Alzheimer's Disease, late onset, Heart Failure, Congestive Heart Failure, Osteoarthritis, Essential Hypertension, Atrial Fibrillation, and Type 2 Diabetes. Resident #1 has a Brief Interview for Mental Status (BIMS) of 02 indicating severely impaired cognition. Extensive Assistance with one-person physical assist with transfers, dressing, eating, and personal hygiene. The last documented physician assessment was dated 11/10/2022. There was no other documentation to support the physician, physician assistant, nurse practitioner or clinical nurse specialist had assessed the resident since that date. Resident #2 was admitted on [DATE], with diagnoses of Type 2 Diabetes, Hypothyroidism, Hypertensive Heart Disease, Atrial Fibrillation, Osteoarthritis, Gout, Glaucoma, Hyperlipidemia, Major Depressive Disorder, and generalized Anxiety. Resident #2 has a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. She required extensive assistance with a two+ person assist with bed mobility, transferring, dressing, toileting, and personal hygiene. The last documented physician assessment was dated 11/17/2022. There was no other documentation to support the physician, physician assistant, nurse practitioner or clinical nurse specialist had assessed the resident since that date. An interview was conducted on 02/16/2023 at approximately 2:00 PM, with the Regional Facility Consultant. He stated that he was aware that there may be some residents who have not been seen timely. He stated the Medical Director was having some computer problems and may have missed seeing some residents. He stated the facility is trying to adjust and correct any problems for the Medical Director. An interview was conducted on 02/16/2023 at approximately 2:30 PM, with the Medical Director of the facility. The Medical Director stated that there is a glitch in the computer system. He stated the facility had a medical chart upgrade to all of the facilities. He stated, I used to be able to see a list of who I needed to see in the facilities. But now, they all run together, and I cannot tell who I have seen and who I have not seen. When they had the new version upgrade, I was in the middle of a resident assessment and lost that information. The process is broken. I know I have probably missed seeing some patients. A review of the Physician's Visit policy date November 2017 states the resident should be seen by his/her attending physician at least once every sixty days. The policy states the resident's attending physician must review the resident's total program of care, including medications and treatments at least quarterly. The policy states a physician assistant or nurse practitioner may make alternate visits after the initial visit.