Health inspection·June 11, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, the facility ensured that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of five residents (Resident #2) reviewed for quality of care. Residents Affected - Some 1. The facility failed to ensure that Resident #2 was prepared for his scheduled eye doctor appointments. 2. The facility failed to ensure Resident #2 did not eat prior to his scheduled eye surgery on 7/15/2024. 3. The facility failed to ensure Resident #2 received an exam for medical clearance prior to his eye procedure on 5/21/2025. 4. The facility failed to have Resident #2 at his scheduled appointment on 3/3/2025 and resident was a no call/no show for this appointment. These failures could place residents at risk for unassessed changes in conditions that could lead to permanent impairment, including decreased quality of life, or further vision deficits. Findings included: Record review of Resident #2's face sheet, dated 5/22/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnosis which included unspecified vision loss, unspecified glaucoma (a group of eye conditions that can cause blindness), Type D Diabetes Mellitus without complications (blood sugar disorder) and Hyperglyceridemia (elevated level of fat in the blood) Record review of Resident #2's quarterly MDS, dated [DATE] reflected a BIMs of 10, which indicated mild cognitive impairment. Section B; Vision reflected Resident #2 was severely impaired and did not wear corrective lenses. Record review of Resident #2's care plan, dated 5/22/2025, reflected the focus: [Resident #2] is legally blind unspecified glaucoma. Also, the focus [Resident #2] refuses to attend appts at [location outside current city], also refuses to attend appointments d/t weather or if resident isn't agreeable to treatment plans; Goal: The resident will cooperate with care through next review date; and allow the resident to make decisions about treatment regime, to provide sense of control, Educate Page 1 of 14 675360 675360 06/11/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident/family/caregivers of the possible outcome(s) of not complying with treatment or care, Provide resident with opportunities for choice during care provision, Spoke with Staff at [eye doctor] regarding resident refusing additional tx and refusal of appointments in [location outside current city]. During an interview on 5/21/2025 at 4:10 pm, Resident #2 stated he did not remember missing any eye appointments, but he didn't always know when they were. He stated the facility took care of that for him. He stated he was legally blind in his left eye and had poor vision in his right eye. He stated he did remember missing an eye procedure because he ate but no one at the facility told him he couldn't eat, and they took him to the dining room for breakfast and lunch that day. He stated he was not aware the eye doctor needed medical clearance for his most recent surgical procure earlier this month, but they [the facility] keep track of all that, I don't. he stated the staff with him was supposed to check him out and make his next appointments and he was not aware of any problems with not showing up for a scheduled appointment. During an interview on 5/22/2025 at 9:30 AM, the EYD stated they had been treating Resident #2 for over a year and often had issues with the nursing facility following instructions for surgery and getting the resident to appointments. The EYD stated one surgical procedure had to be canceled at the last minute, delaying care because Resident #2 had eaten meals prior to the procedure and was supposed to be NPO. He stated his office had to fit in an appointment the next day to prevent the resident from further vision deterioration. He stated for another procedure to help the resident with his vision, he required medical clearance from the NF doctor and the medical clearance was never completed by the NF doctor. He stated he and the anesthesiologist had to complete the medical clearance right before the procedure so it would not be canceled - further delaying critical vision treatments for Resident #2. The EYD stated he was concerned Resident #2 would have further deterioration in his vision without timely attendance at follow up appointments and surgical procedures. He stated it was important that all appointments and procedures be completed on time as scheduled to prevent further potential loss of the vision Resident #2 had remaining in his one eye and to prevent blindness. During an interview on 5/24/2025 at 1:24 PM, the ADM stated his expectation was that residents would get to their appointments at the date and time of their scheduled appointment. He stated they would try to get the resident to appointments at the doctor's office unless the resident refused. He stated he was not aware of any transportation problems getting residents to and from appointments. He stated he was aware one appointment had to be rescheduled for Resident #2 because he ate breakfast, and they asked the EYD office if they could change the appointment and they were able to change it. The ADM stated he was not aware the EYD faxed the NF asking for medical clearance for Resident #2 for a surgical procedure - he stated this was a medical/clinical question for the DON. During an interview on 5/25/2025 at 1:45 PM, the DON stated once the facility was aware of the appointment date and time they coordinated with the ADM, activities director and designees to ensure the completion of the appointment. If the resident refused an appointment the team encouraged them to go, educated them why they needed to go, and alerted the family and physician of the missed appointments. The NF attempted to get any rescheduled refusals or conflicting appointments rescheduled as the clinic allowed. The ADM DON and activities staff get residents to their appointments and submit any follow up information to the charge nurse and medical records. She stated they did not have a designee for coordinating appointments it was a collaborative effort by the DON, the ADM and Activities - they all worked together to get them to their appointments. The DON stated they did have residents who refused to go to appointments - there were various reasons why they did not want to go. She stated the NF might have conflicting appointments which could cause an appointment already scheduled to 675360 Page 2 of 14 675360 06/11/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0684 Level of Harm - Minimal harm or potential for actual harm have to be rescheduled. She stated she did not recall a resident being taken to the dining room for breakfast and lunch when he was NPO and his procedure having to be canceled. She stated she was aware a surgical clearance that had a delay in return of completion by a physician - but clearance so the procedure would not cancel, and risk further delay to Resident #2. Residents Affected - Some Record review of an email from the EYD surgical coordinator, dated 5/22/205, reflected Resident #2: After patient's appointment on 2/20/2025 the patient was never checked out and left his appointment, so our office had to call to request to schedule his follow up appointment (reference 4). This would be in reference to the 3/3 no showed appointment. Our office attempted to schedule multiple times with no answer. We left multiple voicemails and finally spoke with someone on 2/27/2025 who scheduled the appointment [for 3/3/2025]. For his procedure July 15th [2024] it was rescheduled because he ate. We were not notified by the patient or nursing facility. We were notified by the surgery center that he ate breakfast and lunch after being told to be NPO. For his procedure scheduled for May 21, 2025, the patient was scheduled and given instructions on May 14, 2025. These were physically given and emailed. When the facility was called to request the patient's pre-operative clearance, we were notified that they were not aware it was needed. Record review of eye doctor records reflected: Audio recordings were provided and revealed Multiple messages were left for the NF between 2/20/2025 and 2/27/2025 requesting NF contact eye doctor for follow up appointment. Email dated 7/16/2024 reflected Resident #2's procedure from yesterday 7/15 [24] was cx-ed [canceled]. He ate breakfast and lunch. Fax confirmation dated 7/1/2024 to NF with pre-surgery instructions patient has surgery scheduled for July 15th [2024] and we are missing information regarding the patient's demographics. The attached documents need to be filled out signed and faxed back to [Eye doctor] at [fax number provided] Communication note dated 5/20/2025 at 1:46 pm requested clearance. Communication note dated 5/21/2025 at 9:43 am [NF staff] said she is looking into where it is Communication note dated 5/21/2025 I spoke to nurse [staff name], she stated that they were not aware that he had to have medical clearance prior to surgery, that the person that brought him was not the regular transportation person, it was someone in admissions. She said that if we call [local family medicine clinic] that they could possibly clear him for surgery, since he was already fasting. Communication note dated 5/21/2025 at 10:06 am for Resident #2 Spoke with [NF staff] on her personal number [phone number]. She is one of the nurses at [NF]. I informed her that since the facility was unable to get his pre-op done for surgery, we will have someone do it at the facility so he could still proceed today. She confirmed with me that he has been fasting and did have transportation to have him at [name] Surgery Center at 11:45AM. Review of facility policy Transportation, Diagnostic Services revised [DATE] reflected: 675360 Page 3 of 14 675360 06/11/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0684 Level of Harm - Minimal harm or potential for actual harm Our facility will assist residents in arranging transportation to/from diagnostic appointments when necessary. Should it become necessary to transport a resident to a diagnostic service outside the facility, the Social Service Designee or Charge Nurse shall notify the resident and inform them of the appointment. Residents Affected - Some 2. The resident's representative (sponsor) will be responsible for transporting the resident to his or her lab appointment. 3. Should it become necessary for the facility to provide transportation, nursing/administration will be responsible for arranging the transportation. 4. A member of the Nursing Staff, or Administration, will accompany the resident to the diagnostic center when the resident's family is not available. 5. Requests for transportation should be made as far in advance as possible, so as to not have conflicting scheduled appointments. 6. The use of volunteers to transport residents to appointments must be approved by the Administrator. 675360 Page 4 of 14 675360 06/11/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of four residents (Resident #1) reviewed for accidents hazards. The facility failed to ensure Resident #1, who received anticoagulant therapy, received adequate supervision when she experienced blunt trauma on 05/14/25 when she hit her head and, approximately 10 hours later, on 05/15/25, was transferred to the hospital due to vomiting and subsequently passed away. An Immediate Jeopardy (IJ) situation was identified on 05/22/25. While the IJ was removed on 05/26/25, the facility remained out of compliance at a scope of isolated that with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of injury, hospitalization and death. The findings include: Record review of Resident #1's face sheet, dated 05/21/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] and 05/12/25. Resident #1 had diagnoses which included hemiplegia and hemiparesis (hemiplegia and hemiparesis both refer to weakness or paralysis on one side of the body), morbid (severe) obesity due to excess calories (refers to having a Body Mass Index [BMI] of 40 or higher, or a BMI of 35 or higher with at least one obesity-related health condition), and cellulitis of left lower limb (a bacterial skin infection that can cause redness, swelling, warmth, and pain in the affected area). Record review of Resident #1's admission MDS assessment, dated 03/24/25, reflected a BIMS of 11, which indicated moderate cognitive impairment. Section N (Medications) reflected she was taking an anticoagulant (blood thinner). Record review of Resident #1's admission care plan reflected: Resident #1, care plan focus, dated 02/07/22, had potential for bleeding related to anticoagulant therapy. Resident #1, care plan focus, dated 03/15/25, was at risk for injury, falls related to excessive clutter in room. Resident #1, care plan focus, revision dated 05/08/25, required extensive-total assist with intervention, dated 05/08/25, provide assist as needed check q 2 hrs. & prn. Resident #1, care plan focus, revision dated 05/03/22, Resident #1 had ADL self-care performance deficit related to pain and hemiplegia and hemiparesis following cerebral infarction (a type of stroke that occurs when blood flow to the brain is interrupted leading to a lack of oxygen and nutrients to brain tissues) affecting left non-dominant side with intervention revised on 05/08/24 Transfer: 675360 Page 5 of 14 675360 06/11/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0689 The resident requires extensive to total assistance by 2 staff to move Level of Harm - Immediate jeopardy to resident health or safety between surfaces as necessary. ***mechanical lift*** and Resident #1 is also able to do a self-transfer if she isn't feeling weak Residents Affected - Few Resident #1 care plan focus revision, dated 04/08/25, reflected Resident #1 has a history of verbally aggressive behavior. Observation on 05/23/25 at 1:48 PM of facility video footage of Resident #1's hallway on 05/14/25 beginning at 2:00 PM revealed at 2:49 PM on 05/14/25, CNA A entered Resident #1's room alone with a mechanical lift. No other staff member was observed entering or leaving Resident #1's room with CNA A and the mechanical lift. At 2:56 PM, CNA A left Resident #1's room and put the mechanical lift next to the wall outside of Resident #1's room. Record review of Police Incident Report, dated 05/17/25, reflected a police officer received a call from the hospital about a questionable death and a judge ordered an autopsy on a female who was believed to be a victim of abuse or neglect which caused her death. The report reflected Resident #1 was sent to the hospital due to nausea and vomiting that started around 3:00 AM. Hospital staff reported Resident #1 was coherent and alert and told them she hit her head on the cabinet the day prior 'during repositioning in bed on a sling.' Resident #1 reported to the hospital that she, 'was laid back and struck her head on the cabinet very hard.' Record review of the preliminary autopsy report, dated 05/17/25, reflected preliminary cause of death: blunt force trauma to the head, subdural hematoma of right cerebral hemisphere (a condition where blood collects between the skull and the surface of the right side of the brain. This occurs due to a head injury or other causes) and evidence of uncal herniation (a type of brain herniation where a portion of the temporal lobe [the uncus] is forced downwards and through the tentorial incisura due to increased intracranial pressure. It's a serious condition that can cause significant neurological damage and is often a life-threatening emergency.) Record review of hospital records, dated 05/15/25, reflected Emesis [vomiting] per EMS nausea/vomiting since 3:00 AM given Reglan (treats symptoms of gastroesophageal reflux disease [a condition where stomach acid and sometimes stomach contents flow back into the esophagus, the tube connecting your mouth to your stomach]), Zofran (prevents nausea and vomiting) at nursing home. 'PT states she hit head at NH (no LOC); H/O CVA, LT- sided weakness, [hospital] transport. Pt. reports that she hit her head on a cabinet yesterday Record review of hospital records Medical Decision Making, dated 05/15/25, reflected CT (computed tomography) did reveal a chronic appearing hygroma with acute intracranial hemorrhage (a situation where a patient presents with a long-standing subdural hygroma (a collection of cerebrospinal fluid) that is suddenly complicated by a fresh hemorrhage in the subdural space (a layer of cells called [NAME] border cells). Patient observations: PT alert and oriented X4 [someone who is alert and oriented to person, place, time, and event], cooperative, frequent request for nausea/pain meds [medication] upon arrival. Record review of hospital records, dated 05/15/25, reflected Injury Type: blunt trauma PT states she, 'hit her head on a wooden cabinet 05/14/25 while being lifted into a WC at NH' Record review of hospital records, dated 05/15/25, Brief History - she reports that yesterday 675360 Page 6 of 14 675360 06/11/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0689 Level of Harm - Immediate jeopardy to resident health or safety during repositioning in bed on sling, she was asked to lay back and struck her head on a cabinet very hard. She had a cephalohematoma (an accumulation of blood under the scalp) but otherwise no issues related to this. She was found to have had an acute chronic subdural hematoma in the setting of recent acute mild traumatic brain injury secondary to her recent head trauma (the patient had a recent head trauma that caused initial bleeding, and then later, the blood clot organized into a chronic subdural hematoma) while at the care facility. Residents Affected - Few Record review of hospital course/summary records, dated 05/17/25, reflected Resident #1 was a [AGE] year-old female with a past medical history of diabetes mellitus type II (blood sugar regulation disorder) and cerebrovascular accident (a medical condition where blood flow to the brain is suddenly disrupted leading to brain cell death and potential neurological damage) left sided and lower extension deficits (often associated with specific muscle imbalances or conditions), who was at her care facility when she developed nausea and vomiting. She said she reportedly struck her head on a cabinet. She was on chronic anticoagulation Lovenox (a medication that helps prevent blood clots from forming and is a type of anticoagulant) 100 mg twice a day for diabetes mellitus type II and cerebrovascular accident who was at her care facility when she developed persistent nausea and vomiting. The patient was unable to use or move her left upper and left lower extremity. She was found to have an acute on chronic subdural hematoma in the setting of recent acute mild traumatic brain injury secondary to her recent head trauma (refers to a situation where there is a new [acute] bleeding within an existing [chronic] subdural hematoma) while at the care facility. She is non-ambulatory due to prior cerebrovascular accident. The patient required intubation (a flexible tube is inserted into a person's airway to help them breath) in the emergency department for depressed Glasgow Coma Scale (a neurological scale used to assess the level of consciousness in people with head injuries) and was evaluated by the neurosurgery team who decided that her prognosis was exceedingly poor. She had a fixed and dilated right pupil (can be a serious sign, potentially indicating a neurological issue like stroke, brain injury or intracranial [within the skull] bleeding) as well as decerebrate posturing (a neurological sign indication severe brain damage, characterized by abnormal extensor responses (a reflex in which the big toe extends upward and the other toes fan outward when the sole of the foot is stroked) specifically in the upper and lower limbs. The patient did not make any neurologic recovery. Palliative care was consulted, and the patient was transitioned to comfort care on 05/17/25. She passed away at 12:48 AM on 05/17/25. Record review of LVN C's Nurses Note, dated 05/14/25 at 10:38 PM, reflected CNA'S reported to this nurse while they were transferring the resident from bed to shower chair the resident started to sliding down and they eased the resident down to the floor. I asked resident what happened the resident stated while they were transferring her, she was sliding down and they eased her to the floor. I assessed the resident head to toe and all body parts no injury noted resident denies pain. Vital signs - blood pressure 106/61, pulse 75, temperature 97.3, respiratory rate 18, oxygen saturation 97% room. Record review of LVN D's Nurses Notes reflected dated created 05/15/25 at 6:00 AM reflected, Resident noted to have nausea/vomiting. PRN zofran and reglan administered. C/O headache as well. PRN APAP administered. Resident noted to be diaphoretic (sweating heavily). VS: 97.0 [temperature] 132/57 [blood pressure] 72 [pulse]18 95% on room air [oxygen saturation] Increased weakness noted as well. Resident cleaned up and vomited two more times. Call returned by [MD], made aware of change in condition. New order received to transfer to ER for evaluation and tx. Call placed to daughter made aware of transfer to [hospital]. On call notified of transfer. Record review of resident #1's orders reflected aspirin oral capsule 81 mg (aspirin) give 81 mg by 675360 Page 7 of 14 675360 06/11/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0689 Level of Harm - Immediate jeopardy to resident health or safety mouth one time a day related to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side start date 01/31/2024 no discontinued dated. Record review of Resident #1's Neurological Check Assessment forms beginning 05/14/25 at 5:36 PM through 05/14/25 at 8:30 PM by LVN C and 05/14/25 at 10:30 PM through 05/15/25 at 5:15 AM by LVN D reflected: Residents Affected - Few 05/14/25 at 5:36 PM, temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 5:50 PM, temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/14/25 at 6:07 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk both eyes, pupil size bilateral equal. 05/14/25 at 6:25 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk both eyes, pupil size bilateral equal. 05/14/25 at 7:00 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk both eyes, pupil size bilateral equal. 05/14/25 at 7:30 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk both eyes, pupil size bilateral equal. 05/14/25 at 8:30 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk both eyes, pupil size bilateral equal. 05/14/25 at 10:30 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk both eyes, pupil size bilateral equal. 05/14/25 at 11:15 PM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, 675360 Page 8 of 14 675360 06/11/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk - both eyes, pupil size bilateral equal. 05/15/25 at 12:30 AM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk both eyes, pupil size bilateral equal. 05/15/25 at 1:30 AM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk both eyes, pupil size bilateral equal. 05/15/25 at 4:15 AM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk both eyes, pupil size bilateral equal. 05/15/25 at 5:15 AM, normal temperature within normal range, pulse within normal range, respiration readings within normal range, blood pressure within normal range, full consciousness (awake, aware, oriented), movement all four extremities, hand grip equal and strong, speech clear, pupil reactions brisk both eyes, pupil size bilateral equal. Record review of CNA A's Employee Warning Report dated 05/16/25 reflected supervisor's/employer's statement, staff member suspended pending investigation of incident involving resident that occurred 05/14/25. During investigation, staff member was observed violating facility safety/nursing policies. Staff member has given multiple different accounts of incident, making it difficult to verify what actually occurred discussed with CNA A by phone and employee declined to sign document. Interview on 5/21/25 at 2:30 PM with CNA A revealed CNA A and CNA B were transferring Resident #1 together using a gait belt from Resident #1's bed into a shower chair and Resident #1 began to wiggle and she and CNA B eased Resident #1 to the floor. After Resident #1 was on the floor, CNA B got the mechanical lift and both CNA A and CNA B transferred Resident #1 into the shower chair using the mechanical lift. CNA A said when the nurse came into assess Resident #1, Resident #1 was in bed. She said Resident #1 did not hit her head and if Resident #1 hit her head, she would have told the nurse. Interview on 05/21/25 at 5:35 PM with CNA B reflected she worked the 2:00 PM - 10:00 PM shift on 05/14/25 and she and CNA A went into Resident #1's room to assist Resident #1 with her shower. CNA B said she thought it was about 3:30 PM on 05/14/25. CNA B said Resident #1 was wearing a gait belt and when she and CNA A were transferring Resident #1 from her bed to her shower chair Resident #1 became weak and they gently sat Resident #1 down on the floor of her room. CNA B said Resident #1 did not fall and she did not hit her head. She said after Resident #1 sat on the floor, they used a mechanical lift to transfer Resident #1 from the floor to her shower chair and they wheeled Resident #1 into the shower using the shower chair. CNA B said after Resident #1 was in her bed after her shower, LVN C came to assess Resident #1 . Interview on 05/21/25 at 1:16 PM with LVN C revealed CNA A and CNA B reported to her they were transferring Resident #1 from her bed to the shower chair and Resident #1 began to slide down and the 675360 Page 9 of 14 675360 06/11/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few CNAs eased Resident #1 down to the floor of Resident #1's room. The CNAs informed LVN C of the incident after Resident #1 was in her bed. LVN C said she did not know how the CNAs got Resident #1 from the floor to the bed. LVN C thought the CNAs used a mechanical lift, but she did not witness them using a mechanical lift to transfer Resident #1 from the floor to her bed. She said after the CNAs informed her Resident #1 slide to the floor, she assessed Resident #1. LVN C said Resident #1 was not a mechanical lift transfer prior to this incident but Resident #1 had been declining and just returned from the hospital. CNA C said she assessed her from head to toe and did not find any trauma to Resident #1's head. She said Resident #1 denied pain and was talking without difficulty. LVN C said the CNAs should have called her to assess Resident #1 before they moved Resident #1 because she was the charge nurse and residents were not to be moved when they were on the floor. Interview on 05/23/25 at 1:24 PM with LVN D revealed LVN D worked the 10:00 PM - 6:00 AM shift beginning 05/14/25 and conducted neurological checks on Resident #1 that evening. LVN D said on 05/15/25 Resident #1 had vomited, and she cleaned her up and gave her PRN nausea medication. LVN D stated Resident #1 had a fall during the 2:00 PM - 10:00 PM shift from a chair and this occurred before LVN D's shift started. LVN D said she was not told Resident #1 hit her head. LVN D said Resident #1 was not herself, not at baseline and she was sweating. Interview on 05/22/25 with a FP G at 9:05 am who was employed with the autopsy company that conducted Resident #1's autopsy, revealed Resident #1's injures were consistent with a fall and the injuries could have occurred even from a minor fall. He said her subdural hemorrhage was caused by trauma and it would have been exceedingly rare for her to have had those injuries if she had not had a fall. He said if she received treatment sooner, potentially, she might have survived or at least had a better chance of survival. He said because Resident #1 was on anticoagulants, a fall would work in tandem for causing catastrophic bleeding. He said the autopsy photos were consistent with a fall and there was a pretty significant contusion (an injury to soft tissue that causes bleeding without breaking the skin) of the frontal scalp and the back of the scalp. He said her trauma exhibited in the autopsy was from a fall and not a natural death. Interview on 06/11/25 at 9:15 am with a FP G at 9:15 am who was employed with the autopsy company that conducted Resident #1's autopsy and was the FP who conducted Resident #1's autopsy revealed that Resident #1's had an acute bleed that was a day or two old but could not say that it was not an older bleed. She stated there was a subdural contusion (a lift threatening condition where blood collects between the brain and its outer covering) underneath the scalp at the hairline and it did look like she hit her head. Interview on 05/21/25 at 12:36 PM with the DON reflected CNA A and CNA B reported to her that during a transfer with Resident #1, from her bed to a shower chair they broke a fall meaning the CNAs repositioned a person to prevent a fall from happening. The DON said most days Resident #1 did well with staff assisting her with transfers, but she was weak. The DON said she told the CNAs when in doubt, use a mechanical lift and sometimes Resident #1 needed a mechanical lift. The DON said after the CNAs, broke the fall Resident #1 was upset and cursing. She said that when the staff, broke her fall she decided to treat it like a fall and LVN C assessed Resident #1 and the DON wanted close attention paid to Resident #1 because Resident #1 could be difficult. The DON said they used the buddy system to care for Resident #1 because Resident #1 was challenging. The DON stated Resident #1 had a history of calling 911 to come to the facility to take her to the hospital. She said she wanted the nurses to conduct neurological checks on Resident #1 because she wanted to treat the situation where the CNAs broke her fall as if it were a fall and because of Resident #1's history of calling 911 and telling them she needed treatment. The DON stated she wanted the staff to go above and beyond, and 675360 Page 10 of 14 675360 06/11/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0689 they conducted the neurological checks to be on the safe side. Level of Harm - Immediate jeopardy to resident health or safety Interview on 05/26/25 at 11:23 AM with the Administrator revealed, after observing on 05/23/25 the facility video footage of Resident #1's hallway on 05/14/25 at 2:49 PM, CNA A entered Resident #1's room alone with a mechanical lift. The Administrator said if CNA A was transferring Resident #1 using a mechanical lift, there should have been two people transferring Resident #1 to prevent any accidents and for the safety of Resident #1 . Residents Affected - Few Interview on 05/22/25 at 5:30 PM with MD E revealed she received a call from the facility on 05/15/25 about Resident #1's nausea and vomiting. She said she did not remember the call very well and did not document the call in her records which she usually did. MD E said if Resident #1 was given PRN medication for the vomiting and she was still vomiting, she needed to go to the ER. She said she did not remember if they discussed Resident #1 falling or any discussion that Resident #1 hit her head. Record review of the facility's, undated, policy Safe Lifting and Movement of Residents, , reflected: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and movement of residents. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include residents' preferences for assistance, residents' mobility, resident size, weight bearing ability, cognitive status, whether the resident is usually cooperative with staff and the residents' goals for rehabilitation, including restoring and maintaining functional abilities. Record review of the facility's, undated, policy Neurological Assessment, reflected: The purpose of this procedure is to provide guidelines for a neurological assessment 1. upon physician order 2. when following an unwitnessed fall 3. subsequent to a fall with a suspected head injury 4. when indicated by resident condition When assessing neurological status, always include frequent vital signs. Particular attention 675360 Page 11 of 14 675360 06/11/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0689 Level of Harm - Immediate jeopardy to resident health or safety should be paid to widening pulse pressure (often a sign of increased arterial stiffness or a decreased ability of the heart to pump effectively) a difference between systolic pressure (the higher number in the blood pressure reading and diastolic pressure (the pressure in your arteries when your heart is at rest between beats, allowing the heart to refill with blood). This may be indicative of increasing intracranial pressure. Record review of the facility's, undated, policy Falls-Clinical Protocol reflected all should be categorized as Residents Affected - Few 1. those that occur while trying to rise from a sitting or lying to an upright position for an individual who has a fall, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. 2. those that occur while upright and attempting to ambulate and 3. other circumstances such as sliding out of a chair or rolling from a low bed to the floor Falls should also be identified as witnessed or unwitnessed events. This was determined to be an Immediate Jeopardy (IJ) on 05/22/25 at 5:27 PM. The ADM was notified. 5:. The ADM was provided with the IJ template on 05/22/25 at 5:27 PM . The following Plan of Removal submitted by the facility was accepted on 05/24/25 at 4:02 PM: Plan of Removal Immediate Jeopardy On 05/22/2025 an abbreviated survey was initiated. On 05/22/25, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate jeopardy states as follows: The facility failed to ensure Resident #1 received adequate supervision when she experienced trauma to the head, and approximately 10 hours later was transferred to the hospital due to vomiting and subsequently passed away. Action: The DON was in-serviced by Corporate Consultant on safe transfers, mechanical lift safety guide, falls clinical protocol, incident and accident reporting via a conference call on 5/22/25, 6:22 PM. The DON will educate the ADON/ADM/designee and all direct care staff, PRN, new staff and agency staff upon hire: safe transfers, mechanical lift use, falls-clinical protocol, and incident and accident reporting before the beginning of next scheduled shift. All current staff, PRN, agency and new hires will receive this training prior to working their next shift. The retention of the training will be monitored by performing a pre/post test. 675360 Page 12 of 14 675360 06/11/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0689 Start Date: 05/22/2025 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Action: All current and new residents that require the use of the mechanical lift/2 person assist will have the care plan KARDEX reviewed to ensure they are up to date. Seventeen residents have been identified that currently use the lift or 2 person assist. Responsible: DON/ADON/Therapy/designee Start Date: 05/22/2025 Responsible: MDS/designee Action: The DON/ADON/Therapy to help conduct lift competencies on all current, PRN, and new nursing staff and will be maintained in the employee file. The retention of the training will be monitored by performing a pre/posttest and will be maintained in the employee file. This will be conducted prior to working the next shift. All agency staff will complete a competency prior to working a shift. The DON/designee will monitor conduct three random observations of transfer with lifts and/or 2-person assists a week for the next 4 weeks then three random observations of transfer w/lifts and/or 2-person assists monthly thereafter. All findings will be reported to the QAPI team. Start Date: 05/22/2025 Responsible: Therapy/designee The charge nurse/DON/ADON will assess each resident that has been identified to use a mechanical lift to determine if any other residents have had any injury related to use of a lift. This will be completed on 5/23/25. Seventeen residents have been identified that use a mechanical lift. A facility-wide survey was completed 05/23/25, all residents deny that they have suffered any accidents or hazards. The DON was in-serviced by RN Corporate Consultant on 05/22/25 on safety and supervision. This in-service was then provided to the nursing staff, CMA's and CNA's on 05/23/25. All in-services will be provided to the two agency companies and will be required before working their next shift and future shifts. This will be ongoing. The agencies will provide signed confirmation on their electronic platform. The DON/ADON/ADM will be responsible for ensuring the education is completed prior to working a shift. A QAPI plan is being initiated with this POR , the DON and Administrator will carry out the plan and monitoring. The Corporate consultants will monitor the plan monthly with each site visit for the next 6 months . Monitoring of the POR included the following: 675360 Page 13 of 14 675360 06/11/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on 05/24/25 at 4:45 PM with the CC revealed she in-serviced the DON on the facility policy regarding safety and supervision, safe transfers, mechanical lift safety guidelines, falls clinical protocol, incident and accident reporting via a conference call on 5/22/25 at 6:22 PM. The CC discussed with the DON the safety and supervision of residents in general and during transfers and the falls protocol and using the mechanical lift for safe transfers and safety during 2-person non-mechanical lift transfers. The CC in-serviced the DON on educating her staff that even if they suspected there was an injury to the head, or any injury, nurses needed to notify the MD and send the resident to the hospital at that time. She in-serviced the DON on educating CNAs to report in a timely manner to the nurses anything out of the ordinary that occurred during transfers or during CNA involvement with resident care and safety. Interview on 05/24/25 with the DON at 4:00 pm revealed she was in-serviced by the CC and together they reviewed the facility policy procedures on safety and supervision, safe transfers, mechanical lift guidelines, falls clinical protocol, incident and accident reporting via a conference call on 5/22/25 at 6:22 PM. They discussed ensuring the safety of residents who used a mechanical lift and residents who were a two person assist. The DON said during the in-service they discussed the requirement for nurses to call the MD and get an order for the resident to go to the hospital if there was even a suspicion of the resident hitting their head or had any safety issues. CNAs were to report to their charge nurse any type of fall, incident, or accident even if they thought it was minimal. It needed to be reported to the charge nurse because it was the responsibility of the charge nurse to follow up with the resident and escalate as needed. It was the responsibility of the charge nurse to report any suspected head injury to the MD. It was the responsibility of the Abuse and Neglect coordinator to report any concerns of abuse and neglect and the responsibility of the DON to assist with investigations as directed and follow up with any reported suspicion of head injury. It was the responsibility of the charge nurse to make sure CNAs were reporting to the nurses any and all concerns about resident care and safety and problems or concerns with resident transfers and the nurse's responsibility to follow up with those concerns to the MD and to notify on call staff. Interview on 05/25/25 at 9:26 AM with the DOR reflected 675360 Page 14 of 14