Health inspection·May 25, 2023

F 0684 weekly skin assessment for every Tuesday evening. Further review indicated a skin assessment was completed on 05/02/2023, 05/09/2023, and 05/16/2023. Level of Harm - Actual harm Residents Affected - Few Record review of Resident #1's Weekly Skin Observation Tool- (Licensed Nurse) dated 05/11/2023 at 8:38 a.m. revealed skin issue at right thigh (front). Record review of Resident #1's Nurse's note on 05/11/2023 at 6:24 p.m. revealed Resident has witnessed fall in lobby while attempting to stand. Lost balance and went to bottom. Witnesses report she did not strike her head . No signs of distress or pain however stated her 'hip hurt.' Resident has past injury to left hip from previous fall. PCP made aware and xray ordered to rule out injury. Record review of Resident #1's Nurse's note on 05/12/2023 at 11:06 a.m. revealed Reported left hip xray results to [resident #1's PCP], no new orders. Record review of Resident #1's Weekly Skin Observation Tool- (Licensed Nurse) dated 05/11/2023 at 6:26 p.m. revealed no skin issues. Record review of Resident #1's Nurse's note on 05/12/2023 at 1:49 a.m. revealed .Resident moan and will say NO NO NO when repositioning her, Bruising remain slight visible but fading . Record review of Resident #1's Nurse's note dated 05/12/2023 at 11:04 a.m. revealed Pharmacy recommendation to review use of Celebrex, [PCP] reviewed and stated to continue due to 'patient with chronic pain.' Record review of Resident #1's Weekly Skin Observation Tool- (Licensed Nurse) dated 05/12/2023 at 01:13 p.m. revealed no skin issues. Record review of Resident #1's progress notes revealed no notes regarding pain, bruising, or falls after 05/14/2023 or before 05/22/2023. Record review of Resident #1's Weekly Skin Observation Tool- (Licensed Nurse) revealed no documentation for the week of 05/15/2023. Record review of Task: ADL- Bathing dated 04/29/2023 to 05/22/2023 revealed Resident #1 was bathed on 05/18/2023 at 9:07 p.m. with no selected for resident having something on their skin requiring a protective dressing or nurse notified before or after for other skin issue. Bathing task documentation for 05/16/2023 and 5/20/2023 revealed question selections for bathing self-performance and support provided as not applicable and question selections for protective dressing and skin issues as response not required. Record review of Resident #1's Weekly Skin Observation Tool- (Licensed Nurse) dated 05/22/2023 at 12:35 p.m. revealed skin issue at right thigh (front) as surgical incision, right knee (front) as bruising, left shoulder (rear) as bruising, left forearm as bruising, and right forearm as bruising. Record review of Resident #1 Nurse's note dated 05/22/2023 at 1:45 p.m. revealed nurse's note text: Noted while doing weekly skin check resident had bruising being monitored from previous falls. Noted discoloration purple and yellow to right knee and lower thigh this nurse had not see before. Area to knee is swollen slightly and warm to touch . Pending STAT x-ray to the area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455533 If continuation sheet Page 2 of 8 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 455533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windcrest Nursing and Rehabilitation 8800 Fourwinds Dr Windcrest, TX 78239 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)

F 0684 Record review of Resident #1's Nurse's note dated 05/22/2023 at 1:58 p.m. revealed Notified RP he stated he saw that on Saturday but did not mention it to anyone. Level of Harm - Actual harm Residents Affected - Few Record review of Resident #1's x-ray fracture evaluation dated 05/22/2023 revealed findings of an acute transverse proximal tibial fracture [break straight across the upper part of the larger leg bone below the knee] as well as a fracture to the fibular neck [break in the upper portion of the smaller leg bone below the knee] .Osteopenic bones [bones are weaker than normal] . Record review of Resident #1's Nurse's note dated 05/22/2023 at 4:58 p.m. revealed proximal tibia/fibula fractures [break in the upper part of the leg bones below the knee] with mild displacement. Mild soft tissue swelling. Results from right knee x-ray. Interview with Resident #1's RP on 05/24/2023 at 3:58 p.m. revealed a concern that Resident #1's bruise was observed by himself on Saturday, 05/20/2023, but was not identified by the facility until Monday, 05/22/2023. He revealed that he did not report the bruise to facility staff. He revealed a concern that there was not a corresponding report from the facility of a fall or incident since 05/11/2023 and the possibility of Resident #1 having had an untreated fracture for 11 days. He revealed a nurse at the hospital stated the injury appeared 5-7 days old with the bruise going yellow and changing color. Interview with Resident #1's NP on 05/24/2023 at 4:59 p.m. revealed Resident #1 had multiple falls and her bruises took time to fade. The NP revealed Resident #1 took Aspirin which may delay bruising from fading. The NP revealed Resident #1's scheduled pain medications may have masked the pain. The NP revealed she was unaware of Resident #1 having a fall or injury occurring after Resident #1's fall on 05/11/2023 and before the knee bruise was identified on 05/22/2023. The NP revealed she did not know when or the circumstances that resulted in the knee fractures. Interview with Resident #1's PCP on 05/25/2023 at 09:39 a.m. revealed Resident #1 was on a blood thinner which would cause a bruise to form within a few hours after an injury. The PCP revealed he was not notified of Resident #1 having a fall or injury occurring after Resident #1's fall on 05/11/2023 and before the knee bruise was identified on 05/22/2023. The PCP revealed he did not know when or the circumstances that resulted in the knee fractures. Interview with LVN A on 05/25/2023 at 10:30 a.m. revealed there should have been a skin assessment completed for the week of 05/15/2023 and either the skin assessment or a progress note should have been completed if the resident refused. LVN A revealed a change in condition note should have been entered into the EMR if anything was found to be unusual or new for a resident. Interview with the DON on 05/25/2023 at 11:51 a.m. revealed if scheduled assessments were missed or late the EMR would trigger an alert and the ADONs monitor for those triggers. The DON revealed that she assumed the skin assessment was triggered for Resident #1 since the ADON completed the skin assessment on 05/22/2023. The DON revealed showers are scheduled for residents three times per week. The DON revealed a part of the CNA documentation for showers are notations for skin changes. The DON revealed staff had not reported Resident #1 indicating any unusual pain prior to the finding of the bruise and subsequent fractures. The DON revealed she would interpret a bruise described as purple and yellow as having been several days old. The DON revealed an injury not being identified for several days would result in a lot of consequences: including injury, delay of treatment, an even death. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455533 If continuation sheet Page 3 of 8 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 455533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windcrest Nursing and Rehabilitation 8800 Fourwinds Dr Windcrest, TX 78239 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 of 4 resident (Resident #2) reviewed for respiratory care. Residents Affected - Few 1. The facility failed to properly secure Resident #2's oxygen tubing off the floor. 2. The facility failed to obtain oxygen orders prior to providing non-emergent respiratory care. These failures could place the resident at risk for respiratory infections and not receiving an appropriate oxygen level. Findings included: Record review of Resident #2's face sheet dated 05/24/2023 revealed an [AGE] year-old male admitted on [DATE]. His diagnoses included pneumonia (a lung infection), dementia (a general term for impaired ability to remember, think, or make decisions), and chronic (long-lasting) respiratory failure with hypoxia (low levels of oxygen in the blood). Record review of Resident #2's BIMS evaluation dated 05/22/2023 revealed a score of 3.0 (out of 15.0), indicating he had severely impaired cognition. Record review of Resident #2's Functional Abilities evaluation dated 05/22/2023 revealed Resident #2 needed setup or clean-up assistance with eating, oral hygiene, and toileting; was independent for toilet transfer; and needed supervision or touching assistance with sit to lying, lying to sitting, sit to stand, and chair/bed to chair transfers. Record review of Resident #2's care plan reviewed 05/25/2023 revealed a problem, date initiated 05/20/2023, of altered respiratory status/difficulty breathing with inventions of: Administer medication/puffers as ordered . Record review of Resident #2's physician orders reviewed 05/24/2023 did not reveal an order for oxygen. Record review of Resident #2's progress notes, dated 05/22/2023 revealed a Physician H&P progress note with a date of service as 05/21/2023 .required supplemental O2 .COPD/O2 dependent . Observation on 05/24/2023 at 10:57 a.m. revealed a portion of the oxygen tubing connected to an oxygen concentrator on one side and a nasal cannula on the other side on Resident #2's floor. The oxygen was observed to be provided at the time of observation with a nasal cannula in place. Interview with CNA A on 05/24/2023 at 11:04 a.m. revealed Resident #2 was resident of her assigned hall. CNA A revealed Resident #2 had been receiving oxygen continuously since his admission. CNA A revealed the oxygen tubing should not be on the floor but was unsure on the interventions in place to keep Resident #2's tubing off the floor. CNA A revealed Resident #2 required longer oxygen tubing which allowed him to walk to the restroom without being limited. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455533 If continuation sheet Page 4 of 8 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 455533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windcrest Nursing and Rehabilitation 8800 Fourwinds Dr Windcrest, TX 78239 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm Interview with LVN B on 05/24/2023 at 11:12 a.m. revealed Resident #2 was a resident of her assigned hall. LVN B revealed it was at the request of Resident #2's family that Resident #2 have an extender for his oxygen tubing to allow him to be capable of walking to his restroom without restriction. LVN B revealed the extender must have come from Resident #2's family or the transferring hospital due to the facility not carrying them. LVN B revealed that having the oxygen tubing on the floor posed a fall risk to Resident #2. Residents Affected - Few Interview with the DON on 05/25/2023 at 11:51 a.m. revealed a physician order for Resident #2's oxygen provision was not in the EMR. The DON revealed she would look in the EMR for Resident #2's hospital transfer orders. The DON revealed the oxygen tubing on the floor was not a concern due to it being the extension on the floor versus the nasal cannula. The DON revealed that the expectation was for orders to be put into the EMR as soon as the nurses are given an order. The DON revealed the concern for not having an order is that the oxygen stats may not be monitored appropriately, and the concentrator and tubing may not be cleaned properly. Interview with the DON on 05/25/2023 at 12:50 p.m. The DON provided a printout of the Physician H&P progress note, dated 05/22/2023 with the notation for required supplementation highlighted. Record review of facility Oxygen Administration policy, dated revised October 2010, revealed .1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Record review of Lippincott procedures - Oxygen Therapy, Home Care revised 11/27/22 revealed Complications associated with oxygen therapy may include the following: . Infection (from contaminated equipment) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455533 If continuation sheet Page 5 of 8 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 455533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windcrest Nursing and Rehabilitation 8800 Fourwinds Dr Windcrest, TX 78239 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)

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 observation, interview, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 1 resident (Resident #1) reviewed for accuracy of medical records in that: 1. Resident #1's Weekly Skin Assessments were not completed on the dates that they were documented as completed and were not accurate. This failure could place residents at risk for inadequate care due to inaccurate assessments leading to a decline in physical and psychosocial wellbeing. The findings were: 1.Record review of Resident #1's face sheet dated 05/24/2023 revealed an [AGE] year-old female initially admitted on [DATE], readmitted on [DATE]. Her diagnoses included fracture of left femur (break of the bone that runs from the hip to the knee), fracture of the shaft of the left arm humerus (break in the center section of the bone that runs from the shoulder to the elbow), and dementia (a general term for impaired ability to remember, think, or make decisions). Record review of Resident #1's Significant Change MDS assessment dated [DATE] revealed the resident had a BIMS score of 00 (out of 15) indicating severely impaired cognition, required extensive assistance to total dependence with one-to-two-person physical assist for activities of daily living including toilet use and bathing, and had a history of one fall with a major injury during her admission. Record review of Resident #1's care plan, latest revision date 05/09/2023, revealed a problem of Acute Care Plan: Actual Fall, date initiated 05/09/2023, with goal of no major injuries from a fall over the next 90 days. Interventions included Monitor for changes in condition, document and report to MD/NP: localized swelling, c/o pain, increased lethargy, abnormal neuro vital signs, change in functional ability such as endurance, transfers, ambulation, etc. Further review revealed a problem of resident is on anticoagulant therapy r/t status post fracture to left hip and arm, date initiated 04/04/2023, with an intervention of Daily skin inspection. Report abnormalities to the nurse. Record review of Resident #1's MAR/TAR for June and July 2023 revealed scheduled weekly skin assessment: complete head to toe skin assessment and document findings on Weekly Skin Observation tool UDA in the evening every Thu[rsday] with a start date of 6/01/2023. The following dates were documented as completed: 6/01/2023 documented by LVN D, 6/08/2023 documented by LVN D, 6/15/2023 documented by LVN D, 6/22/2023 documented by LVN D, 6/29/2023 documented by an unidentified nurse, 7/06/2023 by an unidentified nurse. Record review of Resident #1's [EHR] Skin and Wound report [between 5/01/2023 to 7/11/2023] revealed Weekly Wound Progress note dated 5/04/2023: one wound to left hip, a surgical incision; Weekly Skin Observation dated 5/11/2023: right thigh (front) [no type listed, name of staff entering assessment not included]; Weekly Skin Observation 5/11/2023 documented by LVN D: no skin issues; Weekly Skin Observation dated 5/12/2023 documented by LVN V: no skin issues; Weekly Skin Observation dated 5/22/2023 documented by RN Q: Right thigh (front), surgical incision; Right knee (front), bruising; Left (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455533 If continuation sheet Page 6 of 8 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 455533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windcrest Nursing and Rehabilitation 8800 Fourwinds Dr Windcrest, TX 78239 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shoulder (rear), bruising; Left forearm, bruising; Right forearm, bruising; Weekly Skin Observation dated 6/02/2022 documented by LVN D: Left ankle, discoloration; Right hand, scab/abrasion; Weekly Skin Observation dated 6/12/2023 documented by an unidentified nurse: no skin issues; Weekly Skin Observation dated 6/19/2023 documented by RN Q: Right lower leg (front), bruising, noted, multicolored bruising to right lower leg up to hip due to fractures, in stages of healing; Weekly Skin Observation dated 6/26/2023 documented by LVN R: no skin issues; Weekly Skin Observation dated 7/03/2023 documented by LVN R: Left lower leg (front), discoloration and left lower leg (rear), discoloration, noted, discoloration to left lower leg; Weekly Skin Observation dated 7/11/2023 documented by RN P: Right lower leg (front), discoloration and left lower leg, discoloration, noted, resident with discoloration to LLE. Cast in place to LUE. Ace wrap in place to RLE. Record review of resident #1 MAR/TAR reavealed, in comparing the due dates from the June and July MARs/TARs to the Weekly Skin Observation forms revealed: assessment due 6/01/2023 was late, completed on 6/02/2023; assessment due on 6/08/2023 was late, completed on 6/12/2023; assessment due on 6/15/2023 was late, completed on 6/19/2023; assessment due on 6/22/2023 was late, completed on 6/26/2023; assessment due on 6/29/2023 was late, completed on 7/03/2023. Further review reveals intermittently inaccurate documentation attesting to no skin issues on 5/11/2023 by LVN D, 5/12/2023 by LVN V, 6/12/2023 documented by unidentified nurse and 6/26/2023 documented by LVN R after the initial injury on 5/11/2023 and expected continuation of skin issues due to severity of injury, and subsequent surgical repair.] Continued review of Resident #1 documentation on the MAR/TAR indicated LVN D completed the assessments dated 6/01/2023, 6/08/2023, 6/15/2023, and 6/22/2023; however, the assessment forms for those dates were not completed on those dates or by that nurse. The MAR/TAR indicated LVN V completed the assessment for 6/29/2023; however, the assessment for that date was not completed on that date or by that nurse.] In an observation on 7/11/2023 at 9:58 AM, Resident #1 was in bed with bed in the lowest position and fall mat at bedside with the left side of the bed against the wall. Resident #1 was lying in bed with the covers on and the call light within reach, talking to herself, did not respond to her name when spoken. [Bilateral lower extremities could not be observed, could not tell if either leg had a cast or an ace wrap applied.] In an interview on 7/12/2023 at 10:14 AM, RN P stated that it was possible she mis-documented where the skin issues on Resident #1 were located. RN P stated she did not remove the ace wrap on Resident #1 right lower leg. RN P stated the foot discoloration she documented was meant to indicate the top of the foot, at least what could be seen around the ace bandage. RN P stated the left lower extremity had discoloration more on the back of the calf but can be seen on the top of the left lower leg or shin area. RN P stated she would like to assess Resident #1 now to ensure she had documented her previous assessment correctly. [No corrections or addendums appeared in the EHR subsequently.] In an interview on 7/12/2023 at 10:47 AM, RN Q stated she could not recall if Resident # 1 had bruising to her left lower extremity. RN Q stated she could not recall if Resident # 1 had an ace wrap on at the time of the assessment she completed on 6/19/2023. RN Q stated that Resident #1 had bruising that went from mid-shin to mid-thigh and was patchy/mottled. RN Q stated Weekly Skin observation should include both known and any new skin concerns. In an interview on 7/11/2023 at 10:25 AM, LVN U stated she had been working at the facility for 3 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455533 If continuation sheet Page 7 of 8 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 455533 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windcrest Nursing and Rehabilitation 8800 Fourwinds Dr Windcrest, TX 78239 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few years. LVN U stated skin assessments were done weekly. Skin assessment assignments were done by the charge nurse and divided out by room and shifts. LVN U stated changes needed to be reported right away. LVN U stated she did not often work the hall where Resident #1 resided but knew there had been some issue a while back regarding the UDAs not being completed. In an interview on 7/11/2023 at 10:33 AM, LVN A stated she had been working at the facility about 30 days. LVN A stated she had been trained on resident rights, Stop and Watch. LVN A stated that she knew from that training that Skin Assessments were done weekly. LVN A stated she had been trained to report change in condition to the doctor, the family, and the DON. In an interview on 7/11/2023 at 11:05 AM, the DON stated LVN D had been out sick, LVN D worked on 7/10/2023, and was unsure if she had been trained prior to providing care to residents. The DON stated the nurses had been in-serviced to complete the UDAs which included the Skin Observation assessments when they were due. The DON did not address why the Weekly Skin Observations were not done on time. The DON did not address the accuracy of the documentation. In an interview on 7/11/2023 at 3:04 PM with LVN B, she stated she had not recently looked at the In-Service trainings that are kept at the front. LVN B stated she knew that the UDAs and Weekly Skin Observations were required, and she had entered the ones flagged as due when she worked. LVN B stated she had not had any late or missed assessments to the best of her recollection. LVN B stated that the assessments need to accurately reflect exactly what was observed at that time so the physician or wound care nurse could make treatment decisions. In an interview on 7/11/2023 at 3:13 PM, via telephone, LVN D stated she had been counseled by the DON to ensure that UDAs were completed timely. LVN D stated she was aware she had submitted some skin assessments late recently and the DON had advised her that they needed to be done when they are due. In an interview on 7/11/2023 at 4:30 PM, LVN C stated she had received training on making sure weekly skin assessments were done and to initiate a change of condition notification in the EHR if necessary. LVN C stated she had not been made aware if any of the assessments she was expected to do were late. LVN C stated she had not been made aware that she made a mistake on any of her documentation. In an interview on 7/12/2023 at 11:00 AM, LVN R stated she had only worked at this facility since 6/21/2023. LVN R stated she may have inadvertently documented something incorrectly when she first started. LVN R stated no one from management had told her documentation was incorrect and needed an addendum or correction. LVN R stated that as a part of her practice, since she was not yet familiar with the residents, she will review the documentation from previous shifts. LVN R stated that she had pointed out to the ADON and DON that she found obvious errors in the documentation. LVN R stated she could not recall which resident she found the errors in documentation, but she was certain it was not Resident #1. LVN R stated that as part of her first few shifts, much like an on-the-job training, she was told she needed to complete the UDAs and weekly skin assessments when they came due. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455533 If continuation sheet Page 8 of 8