Health inspection·June 9, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviewsm the facility failed to maintain medical records on each resident that are accurate for 1 of 5 residents (Resident #1) reviewed for resident records. CNA A failed to accurately document in Resident #1's EHR on 06/06/25 when she documented her care using CNA B's log-in credentials. This failure could lead to incorrect documentation of resident care. Findings included: Record review of Resident #1's undated admission Record reflected the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Alzheimer's, dementia, and high blood pressure. Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 3 indicating he had severe cognitive impairment. His Functional Status assessment indicated he was dependent on staff for all of his ADLs. Record review of Resident #1's care plan, dated 05/30/25, reflected he had an ADL self-care deficit, and impaired cognition being non-verbal. Record review of Resident #1's Tasks in her EHR reflected on 06/06/25 CNA B had documented all of the resident's cares as being completed. In an interview on 06/08/25 at 2:20 PM, CNA B stated she had not worked with Resident #1 on 06/06/25 because she had been assigned to another unit. She stated CNA A had been assigned to work with Resident #1 on that date. In a phone interview on 06/08/25 at 2:47 PM, CNA A stated she had provided Resident #1 with care on 06/06/25. She stated she had documented under CNA B's log-in credentials. She stated her log-in kicked her out all the time, so she used CNA B's log-in. She stated CNA-B was logged into the EHR when she tried to log-in, so she just used CNA B's log-in. She stated she had told people about the issue but nothing had been done. She stated she knew she was not supposed to use someone else's log-in. In a follow up interview on 06/08/25 at 3:06 PM, CNA B stated she must not have signed off the computer at the end of her shift, which was how CNA A was able to chart under her name. She stated she Page 1 of 2 455416 455416 06/09/2025 Willow Ridge Wellness & Rehabilitation 8001 Western Hills Blvd Fort Worth, TX 76108

F 0842 Level of Harm - Minimal harm or potential for actual harm knew not to share her log-in credentials with anyone. She stated the DON was responsible for re-setting credentials when needed. In an interview on 06/09/25 at 3:08 PM, CNA C stated it was not allowed to use someone else's log-in to chart and it was also not allowed to share your log-in with anyone else. Residents Affected - Few In an interview on 06/09/25 at 3:10 PM, RN D stated it was not allowed to use someone else's log-in to chart, or to share your log-in with anyone else. She stated the risk to the resident was another discipline, such as a CNA, charting as a nurse or incorrect information being documented. In an interview on 06/09/25 at 3:13 PM, RN E stated they were not allowed to document using someone else's log-in. She stated there was a risk of incorrect documentation being done and difficulty identifying who had documented something. In an interview on 06/09/25 at 3:18 PM, RN F stated staff were not allowed to share log-ins or document using someone else's log-in. She stated the risk was someone documenting as a nurse when they were not. In an interview on 06/09/25 at 3:20 PM, the ADON stated it was absolutely not allowed to share log-ins or document as someone other than oneself. She stated it would be considered false documentation and there were multiple risks with that. In an interview on 06/09/25 at 3:35 PM, the DON stated it was not allowed to share log-ins with anyone else. She stated if a staff member had an issue with their log-in, she could reset it in a few minutes. She stated anyone documenting using another person's log-in was creating a false document. In an interview on 06/09/25 at 3:30 PM, the Administrator stated she did not have a policy addressing not using other staff member's log-in credentials. She stated it was common sense not to do that. 455416 Page 2 of 2