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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455416 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Ridge Wellness & Rehabilitation 8001 Western Hills Blvd Fort Worth, TX 76108 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)