Health inspection·July 9, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete notable changes or observations. Problem #3: The resident has an ADL self-care performance deficit r/t had surgical procedure of right hip, previous right shoulder replacement, chronic pain, OA of right shoulder, and weakness. Intervention: SKIN INSPECTION: The resident requires SKIN inspection per facility protocol Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Record review of Resident#3's MDS dated [DATE] revealed, Section M- Skin Conditions revealed, Determination of Pressure Ulcer/Injury risk Formal assessment instrument/tool and Clinical Assessment. Yes, this resident is at risk of developing pressure ulcers/injuries. No, this resident does not have one or more unhealed pressure ulcers/injuries. Other Ulcers, Wounds, and Skin Problems: E: surgical wounds Skin and Ulcer/injury treatments: E: Pressure ulcer/injury care; F: Surgical wound care; H: Applications of ointments/medications. In an observation 7/8/25 at 3:17 pm Resident #3's catheter bag was half full of a pale-yellow liquid visible from the hallway. There was not a cover on the catheter bag to disguise or cover the fact Resident #3 had a catheter bag. In an interview on 7/9/25 at 3:54PM the ADON revealed a catheter bag should have a cover over it or not be visible to the public. They should have privacy bags/covers. The ADON said it is the CNA and nurses' responsibility to ensure all catheter bags are covered. The ADON stated it is the responsibility of all staff members to ensure each resident's dignity is intact to prevent embarrassment or quality of life. Record review of Resident#4's admission Record updated 7/9/25 revealed, Resident #4 was an [AGE] year-old male with no listed diagnosis. Record review of Resident#4's care plan updated 7/8/25 revealed, Problem: The resident has potential/actual impairment to skin integrity of the (specify location) r/t. Intervention: Educate Resident/family/caregivers of causative factors and measures to prevent skin injury. Record review of Resident#4's MDS dated [DATE] revealed, No mention of any skin related problems. In an observation 7/8/25 at 3:15 pm Resident #4's catheter bag was half full of a pale-yellow liquid visible from the hallway. The bag did not have a cover to disguise and prevent any dignity issues for Resident #4. In an interview on 7/9/25 at 4:05 PM RN B revealed a catheter bag should have a cover over it or not be visible to the public. They should have privacy bags/covers. RN B said it is the CNA and nurses' responsibility to ensure all catheter bags are covered. RN B stated it is the responsibility of all staff members to ensure each resident's dignity is intact to prevent embarrassment or quality of life. n an interview on 7/9/25 at 4:15 PM CNA C revealed a catheter bag should have a cover over it or not be visible to the public. They should have privacy bags/covers. CNA C said it is the CNA and nurses' responsibility to ensure all catheter bags are covered. CNA C stated it is the responsibility of all staff members to ensure each resident's dignity is intact to prevent embarrassment or quality of life. In an interview on 7/9/25 at 4:25PM The DON revealed a catheter bag should have a cover over it or not be visible to the public. DON said it is all staff's responsibility to ensure all catheter bags are covered. The DON stated it is the responsibility of all staff members to ensure each resident's dignity is intact to prevent embarrassment or quality of life. The DON stated the facility did not have a policy regarding privacy bags to disguise/cover catheter bags. Event ID: Facility ID: 675546 If continuation sheet Page 2 of 7 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 675546 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Care Center 1000 E Main St Round Rock, TX 78664 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 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for three (Resident #1, Resident #2, and Resident #17) of 18 residents reviewed for resident call system in that: The facility failed to ensure call lights were within reach for Resident #1, Resident#2, and Resident #17.This failure could have placed residents at risk of being unable to obtain assistance when needed Findings included:Record review of Resident#1's admission Record updated 7/9/25 revealed, Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. She had diagnosis of nontraumatic intracerebral hemorrhage (stroke), acute respiratory failure (difficulty breathing), dysphagia following cerebral infarction (difficulty swallowing after stroke).Record review of Resident#1's care plan updated 7/8/25 revealed, Problem: The resident has an ADL self-care performance deficit r/t CVA with hemiplegia of left side and weakness. Intervention revealed Resident #1 required 1 person assist with bathing, dressing, bed repositioning, and eating.Record review of Resident#1's MDS dated [DATE] revealed, Resident #1 was dependent on oral hygiene, toileting, upper and lower body dressing, and putting on/off footwear.In an observation and interview on 7/8/25 at 12:02 pm Resident #1 revealed she did not know where the call light was. She was looking on the wall but the plug for the call light was behind her head on her left side. She reached for the wall but was unable to locate the call light on her own. The call light itself was observed on the floor under her bed. She further stated when she needed assistance she yells out for help because she did not know where the call light was located. She stated last night she yelled for help for a long time before someone finally came to assist her.In an interview on 7/8/25 at 2:08 PM the DON stated the facility does not have a policy regarding call lights.Record review of Resident#2's admission Record updated 6/6/25 revealed, Resident #2 was a [AGE] year-old female with a diagnosis of unspecified dementia (memory loss); essential hypertension (elevated blood pressure); sarcopenia (age related muscle loss).Record review of Resident#2's care plan updated 7/8/25 revealed, Intervention for fall risk; Be sure Resident#2's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Intervention for ADL self-care encourage Resident #2 to use bell to call for assistance.Record review of Resident#2's MDS dated [DATE] revealed, supervision or touching assistance for transfers and not applicable or not attempted for walking 10 feet.In an observation 7/8/25 at 3:25 pm Resident #2 the call light was on the floor behind the bed where Resident #2 could not locate without assistance. In an interview on 7/8/25 at 3:25 pm Resident #2 said the staff always put the call light where she cannot reach it. She said she has asked them multiple times to leave it where she can push it when she needs help, but they never do as she asked.Record review of Resident#17's admission Record updated 7/9/25 revealed, Resident #17 was an [AGE] year-old female with diagnosis of unspecified dementia (memory loss) hyperlipidemia (elevated cholesterol), essential tremor (rhythmic shaking)Record review of Resident#17's care plan updated 7/8/25 revealed, an ADL self-care performance.deficit r/t dementia, parkinsonism, tremors, gait with Intervention: Encourage the resident to use bell to call for assistance. High risk for falls intervention; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.In an observation 7/9/25 at 10:10 am Resident #17 the call light was on the floor behind the bed where Resident #17 could not locate without assistance. In an observation on 7/9/25 at 10:17 am RN A came into Resident #17's room. RN A located the call button tangled up off the left-hand side of bed, not within reach of resident. RN A untangled the call button. In an interview on Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675546 If continuation sheet Page 3 of 7 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 675546 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Care Center 1000 E Main St Round Rock, TX 78664 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 7/9/25 at 3:54 pm ADON stated the expectation for a call light is that a call light should be placed where a resident can reach the button in case care is needed. The ADON stated it is all staff's responsibility to place call light within resident's reach. The ADON stated if a call light is not within reach, then a resident would have to yell out if they can, to notify staff care is needed, but staff should be verifying call light placement prior to leaving the room.In an interview on 7/9/25 at 4:05 pm RN B stated the expectation for a call light is that a call light should be placed where a resident can reach the button in case care is needed. RN B stated it is all staff's responsibility to place call light within resident's reach. RN B stated if a call light is not within reach, then a resident would have to yell out if they can, to notify staff care is needed, but staff should be verifying call light placement prior to leaving the room.In an interview on 7/9/25 at 4:15 pm CNA C stated the expectation for a call light is that a call light should be placed where a resident can reach the button in case care is always needed. CNA C stated it is all staff's responsibility to place call light within resident's reach. CNA C stated if a call light is not within reach, then a resident would have to yell out if they can, to notify staff care is needed, but staff should be verifying call light placement prior to leaving the room.In an interview on 7/9/25 at 4:25pm the DON stated the expectation for a call light is that a call light should be placed where a resident can reach the button in case care is needed. The DON stated it is all staff responsibility to place call light within resident's reach. The DON stated if a call light is not within reach, then a resident would have to yell out if they can, to notify staff care is needed. The DON stated there is not a facility policy or procedure regarding call lights.Record review of Resident#17's MDS dated [DATE] revealed, Resident #17 required extensive assistance with bed mobility, transfers, and toilet use. Event ID: Facility ID: 675546 If continuation sheet Page 4 of 7 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 675546 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Care Center 1000 E Main St Round Rock, TX 78664 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 - Some 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 ensure maintain medical records on each resident that are- Complete and accurately documented, for 3 (Resident #1, Resident #9, and Resident #10) of 5 residents reviewed for assessments in that: -The facility did not ensure Resident #1, Resident #9, and Resident #10's wound assessments accurately reflected current wound locations, measurements, or wound typeThis failure could place residents needing wound care at risk of not receiving proper care, treatments, and interventions.Findings included:Record review of Resident#1's admission Record updated 7/9/25 revealed, Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. She had diagnosis of nontraumatic intracerebral hemorrhage (stroke), acute respiratory failure (difficulty breathing), dysphagia following cerebral infarction (difficulty swallowing after stroke).Record review of Resident#1's care plan updated 7/8/25 revealed, IN INTERVENTION: The resident requires SKIN inspection per facility protocol. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse.Record review of Resident#1's MDS dated [DATE] revealed, Resident #1 has a stage 2 pressure ulcer that was present upon admission. Resident#1 is receiving Ulcer/Injury treatment: pressure reducing device for bed; pressure ulcer/injury care; applications of ointments/medications.Record review of Weekly Skin Observation dated 6/11/25 for Resident#1 revealed, Location 14 abdomen, peg tube site; location 38 left knee (front) scar; location 53 Sacrum, Pressure, Measurements 1x0.5x0.1, Stage II; Other IC/Sub q/implanted port; neck trach removed 0.5x0.4x0.1.Record review of Weekly Wound Progress dated 6/12/25 for Resident#1 revealed, Wound#1 Pressure ulcer to Sacrum 100% Epithelial, Stage II to Sacrum measuring 1x0.5x0.1.Record review of Weekly Skin Observation dated 6/18/25 for Resident#1 revealed, location 14 abdomen peg tube; location 31 right buttock pressure depth 0; location 34 left thigh (front) blister; Anterior neck surgical incision.Record review of Weekly Wound Progress dated 6/19/25 for Resident#1 revealed, pressure ulcer 100% epithelial, stage II, sacrum, 1x0.5x0.Record review of Weekly Skin Observation dated 6/25/25 for Resident#1 revealed, document is marked yes for Does resident have any observed skin issues? The rest of the document is blank.Record review of Weekly Wound Progress dated 6/26/25 for Resident#1 revealed, pressure ulcer 100% epithelial, stage II, sacrum, 2x2x0.Record review of Weekly Skin Observation dated 7/2/25 for Resident#1 revealed, document is marked yes for Does resident have any observed skin issues? Then in notes it stated, wound to sacrum area.Record review of Weekly Wound Progress dated 7/3/25 for Resident#1 revealed, pressure ulcer 50% granulation 50% epithelial, stage II, sacrum, 2x2x0.Record review of Resident#9's admission Record updated 7/9/25 revealed, Resident #9 was a [AGE] year old male with HEMIPLEGIA (complete or severe paralysis to one side of the body) AND HEMIPARESIS (weakness on one side) FOLLOWING CEREBRAL INFARCTION affecting the right dominant side; Hepatic encephalopathy (serious brain condition caused by liver dysfunction, leading to the accumulation of toxins in the blood that affect brain function.).Record review of Resident#9's care plan updated 4/18/25 revealed, Weekly skin assessments started 12/9/21. Monitor/document/report PRN: Edema (swelling caused by too much fluid trapped in skin tissue), Bruising/discoloration of skin. Provide skin care to keep clean and prevent skin breakdown.Record review of Resident#9's MDS updated 5/13/25 revealed, Skin and Ulcer/Injury Treatments: Pressure reducing device for bed; Applications of ointments/medications other than to feet; Application of dressings to feet (with or without topical medications).Record review of Weekly Skin Observation dated 6/16/25 for Resident#9 revealed, wound to left heel (location 50), pressure without measurements; left shin open area without location # or measurements; left forearm skin tear without location # or measurements.Record review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675546 If continuation sheet Page 5 of 7 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 675546 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Care Center 1000 E Main St Round Rock, TX 78664 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 - Some of Weekly Wound Progress dated 6/19/25 for Resident#9 revealed, 1 wound to Sacrum with measurements 4.5 X 4 X 0.1 with 100% granulation for deep tissue wound.Record review of Weekly Skin Observation dated 6/23/25 for Resident#9 revealed, under notes section left heel wound, scabs to BLE (bilateral lower extremities), skin tear both arms. There was no site location # or measurements. Record review of Weekly Wound Progress dated 6/26/25 for Resident#9 revealed 1 wound pressure ulcer to Sacrum with measurements 4 X 2.8 X 0.1 with 100% granulation for deep tissue wound. Record review of Weekly Skin Observation dated 6/30/25 for Resident#9 revealed, under notes section left heel wound, scabs on BLE (bilateral lower extremities), scabs on arms.Record review of Weekly Wound Progress dated 7/3/25 for Resident#9 revealed, 1 wound pressure ulcer to Sacrum with measurements 3.5 X 2.5 X 0.1 with 100% granulation for stage II ulcer.Record review of Weekly Skin Observation dated 7/7/25 for Resident#9 revealed, under notes section wound to left heel.Record review of Skin Monitoring: comprehensive CNA shower review dated 7/8/25 for Resident#9 revealed, a diagram of the back of the body with a circle to the left arm stating, scabbed 1,2 and the left heel circled stating pressure.Record review of Resident#10's admission Record updated 7/9/25 revealed Resident #10 was a [AGE] year-old male with VASCULAR DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL DISTURBANCE (memory loss), hyperlipidemia (elevated cholesterol), type 2 diabetes mellitus (frequently elevated blood sugar).Record review of Resident#10's care plan updated 1/7/25 revealed, Intervention: skin care to keep clean and prevent skin breakdown; Monitor/document/report PRN any s/sx (signs and symptoms) of poor wound healing; Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: Inform the resident/family/caregivers of any new area of skin breakdown. Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection, wound size (length X width X depth), stage. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Monitor skin rashes for increased spread or signs of infection.Record review of Resident#10's MDS updated 7/8/25 revealed, Resident #10 Skin Conditions included: Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Formal assessment instrument/tool (e.g., Braden, [NAME], or other). Clinical assessment. Resident #10 had 1 Stage 2 pressure ulcers: 1 Stage 3 pressure ulcers. Other problems: Skin tears. Skin and Ulcer/injury treatments: Pressure reducing device for bed, Nutrition, or hydration intervention to manage skin problems, Pressure ulcer/injury care, Application of nonsurgical dressings (with or without topical medications) other than to feet, Applications of ointments/medications other than to feet.Record review of Weekly Skin Observation dated 6/12/25 for Resident#10 revealed, location 13 vertebrae (upper-mid) shear; location 26 left trochanter (hip) pressure wound; location 53 Sacrum pressure wound. Notes: LAL mattress in place, treatment in place for wounds.Record review of Weekly Wound Progress dated 6/12/25 for Resident#10 revealed, wound #1; pressure ulcer left hip 100% granulation, Stage 2, minimal exudate measurements 2.5x2.5x0.1. Wound #2: sacrum 50% granulation 50% slough, Stage 3 minimal exudate, measurements 4x2.5x0.1. Wound #3 abrasion upper back left side 100! Granulation 2x2x0.1 scant red exudate.Record review of Weekly Skin Observation dated 6/19/25 for Resident#10 revealed, observed skin issue at site #53 sacrum pressure; left hip pressure.Record review of Weekly Skin Observation dated 6/26/25 for Resident#10 revealed, location 13 vertebrae (upper-mid) pressure wound; location 26 left trochanter (hip) pressure wound; location 53 Sacrum pressure wound. Notes: Tx in progress LAL mattress . improvement to areas noted.Record review of Weekly Wound Progress dated 6/26/25 for Resident#10 revealed, wound #1; pressure ulcer left hip 50% epithelial 50% granulation, Stage 2, scant tan exudate measurements 2x0.5x0.1. Wound #2: sacrum 50% granulation 50% slough, Stage 3 minimal exudate, measurements 4x2.5x0.1. Wound (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675546 If continuation sheet Page 6 of 7 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 675546 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Trinity Care Center 1000 E Main St Round Rock, TX 78664 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete #3 abrasion upper back left side 100! Granulation 2x2x0.1 Record review of Weekly Wound Progress dated 7/3/25 for Resident#10 revealed,Wound #1; pressure ulcer left hip 100% epithelial, Stage 2, scant red exudate measurements 2x2x0.1. Wound #2: sacrum 25% granulation 75% slough, Stage 3 moderate exudate, measurements 2x0.9x0.1. Record review of Weekly Skin Observation dated 7/7/25 for Resident#10 revealed, location 26 left trochanter (hip) pressure wound; location 53 Sacrum pressure wound. Notes: Tx in progress see wound care notes. improvement noted. In an interview on 7/9/25 at 3:54 pm the ADON revealed skin assessments are completed weekly by the charge nurses and the CNAs do a shower sheet with any abnormalities. The ADON stated anytime on an assessment where a body is seen the nurse is to indicate location with the number on the picture. Then under notes if you need to add more information you would use the notes section. The ADON stated when documenting any observed skin issues the nurse should document anything noted on the skin during an assessment. The ADON stated if a skin issue is documented on one skin assessment it should be documented on the following skin assessment. The ADON stated if a previous listed skin issue has healed it should be indicated on the notes section or in a progress note when care was discontinued. If documentation of wounds did not make it to the new assessment it could lead to the wound getting worse. In an interview on 7/9/25 at 4:05 pm RN B revealed she had been one of the nurses that documented the skin assessments on Resident #1, Resident #9, and Resident #10's wound assessments. She said skin assessments are completed weekly by the charge nurses and the CNAs do a shower sheet with any abnormalities. RN B stated anytime on an assessment where a body is seen the nurse is to indicate location with the number on the picture. RN B stated when documenting any observed skin issues the nurse should document anything noted on the skin during an assessment. RN B stated if a skin issue was documented on one skin assessment it should be documented on the following skin assessment. RN B stated if a previous listed skin issue has healed it should be indicated on the notes section or in a progress note when care was discontinued. RN B said the diagram of the body did not mark every part of the body and that measurements were not always documented on those forms even though they should have been. In an interview on 7/9/25 at 4:15 pm CNA C revealed she does a skin assessment every day because she knows what she saw the day before. CNA C stated anytime on an assessment where a body is seen the CNA is to indicate location with the number on the picture. CNA C stated when documenting any observed skin issues the nurse should document anything noted on the skin during an assessment. CNA C stated if a skin issue is documented on one skin assessment it should be documented on the following skin assessment. CNA C stated if a previous listed skin issue has healed it should be indicated on the notes section or in a progress note when care was discontinued. In an interview on 7/9/25 at 4:25pm the DON revealed skin assessments are completed weekly by nurses. The DON stated anytime on an assessment where a body is seen the nurse is to indicate location with the number on the picture. The DON stated when documenting any observed skin issues the nurse should document anything noted on the skin during an assessment. The DON stated if a skin issue is documented on one skin assessment it should be documented on the following skin assessment. The DON stated if a previous listed skin issue has healed it should be indicated on the notes section or in a progress note when care was discontinued. The DON stated there is not a policy or procedure related to skin assessments. She said if a wound goes without being documented correctly it could lead to a wound getting worse. Event ID: Facility ID: 675546 If continuation sheet Page 7 of 7