Health inspection·August 29, 2025

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. 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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of five residents reviewed for pharmacy services. The facility failed to prevent a diversion of Resident #1's Hydrocodone-Acetaminophen Oral 10-325 MG tablet, 60 tablets reported missing on 08/18/2025. The failure could place residents at risk for medication error and delay therapy. Findings include:Record review of Resident #1's face sheet, printed 08/28/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] and discharged on 08/27/2025 to Oceans Behavioral Hospital. His diagnoses included mild cognitive impairment of uncertain or unknown etiology (Mild cognitive impairment is the in-between stage between typical thinking skills and dementia), type 2 diabetes mellitus without complications (a stage of the disease where a person has elevated blood sugar levels but has not developed any chronic complications), hyperlipidemia (excess of lipids or fats in your blood), gout (a disease in which defective metabolism of uric acid causes arthritis, especially in the smaller bones of the feet, deposition of chalkstones, and episodes of acute pain). Record review of Resident #1's comprehensive MDS assessment, dated 07/16/2025, Section C (Cognitive Patterns) reflected a BIMS score of 09, which indicated moderately impaired.Record review of Resident #1's physician's order reflected an order, dated 03/18/2025 for Hydrocodone-Acetaminophen Oral 10-325 MG tablet. Give 1 tablet by mouth every 4 hours as needed for pain. Record review of Resident #1's Medication Administration Record (MAR) for Hydrocodone-Acetaminophen Oral 10-325 MG tablet revealed the medication was scheduled to be given PRN for pain. The MAR revealed that staff gave the resident the medication on the following dates and times:Charted Date Time Pain Level (a scale is used to measure his or her pain so that the doctor can plan how best to manage it)8/17/2025 3:32 PM/7:43 PM 78/18/2025 05:14 AM/9:20 PM 5/78/19/2025 8:24 PM 88/20/2025 05:21 AM 88/25/2025 10:33 PM 08/26/2025 06:00 AM/10:00 AM 10Record Review or the resident electronic health records revealed Resident #1 was discharged out of the facility as of 08/27/2025Record review of the Provider Investigation Report, dated 08/18/2025, reflected, On 08/18/2025 at 09:30 AM, by the ADON that Resident #1 were missing 60 tabs out of 180 tabs of Hydrocodone /APAP 10/325 from the facility's med cart. We started a facility wide search immediately. The Administrator and nursing staff were not able to locate the drugs. They have started a formal investigation. Consultant pharmacy, regional nurses notified. Incident reported to Police Department. In-serviced started on control substance documentation and storage., interviewed the nursing staff that worked on the cart the day before up to when the medication went missing, an audit of the medication carts were done to make sure no other medications were missing and all other counts were accurate. After the investigation was completed, the medication was not found and the administrator and nursing staff wan unable to determine who took the medication. During an interview with the ADON on 8/28/2025 at 5:20 PM Residents Affected - Few Page 1 of 3 675360 675360 08/29/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed she stated she worked the medication cart on 8/17/2025 from 6 am to 2 pm. She handed the med cart and keys to an agency worker who worked the cart from 2 pm to 10 pm. She stated the narcotic medication count was accurate, and they signed off once it was switched over. She stated whenever there was a shift change, staff were to count the cart with the person they were giving the cart to and if there were any discrepancies, they were to report it to the ADON, DON or the ADM. The ADON stated when the staff came in on Monday 8/18/2025 morning, the nurse that was supposed to take over the cart was late, and another nurse took over the cart. Once the LVN came in, they counted the meds, and it was allegedly accurate. The LVN came to her about 8:30 AM and advised her that the Hydrocodone-Acetaminophen Oral 10-325 MG table was missing and the medication count sheet in which the medications was listed was also missing. She stated there was an investigation conducted, and they viewed cameras, drug tested staff that had access to the cart, they notified the doctor and the pharmacy consultant. The ADON stated the nurse that reported the medication missing was no longer with the company due to being terminated because of excessive tardiness and missing days. The other nurse was agency, and she was no longer allowed to return to the facility. She stated Resident #1's medication was PRN, and he had enough medication that he did not miss a dosage. She stated with the drug diversion it could have cause the resident not to have his meds and could have been left in pain. During an interview with the SC on 8/29/2025 at 10:18 AM revealed the drug diversion happened between agency nurses. On 8/18/2025, LVN B noticed the missing meds and it was reported. She stated when drug diversion occurred, policy stated to call whoever was on call, the ADON, DON or Administrator and they would come in and began an investigation on the missing medication and report it to state, drug screen staff involved, get statement from nurse/MA involved. An interview with MA A on 8/29/2025 at 11:05 AM revealed when drug diversion occurs, the policy is to report to charge nurse and the DON for them to investigate. She stated she has not had any issues with the count being off. She stated when she gets the cart from another med tech or nurse, they count the medication cart together, and they sign off that the count is correct, and they sign the narcotic book and hand off the keys. She stated if she had any issues with the count she knows to report it. An interview with LVN A on 8/29/25 at 12:52 PM revealed narcotic count is done with off going and ongoing nurse, and both sign off together. She stated if the count is off, she doesn't accept the cart, she will call management which is the DON, ADON, Administration. She stated a negative outcome will be the resident missed their medication and based on the type of medication; they can have an adverse reaction. Record review of a statement dated 8/20/2025 taken from LVN B stated she worked on 8/17/2025 the night shift 10 PM to 6 AM. She stated when she came on shift, she counted the carts with the nurse leaving and the count was correct. She stated when she got off, she counted with the oncoming nurse, and the count was correct. She stated she do not know of any missing narcoticsAn interview with the ADM on 8/29/2025 at 1:08 PM revealed he was notified about the narcotics missing. He stated he notified the doctor about the missing medication and the quantity on hand for Resident #1. He stated Resident #1 was assessed and there was no negative outcome and there was enough medication for Resident #1. He stated that medication cart that was worked by all nurses and a MA that day and they were drug tested. He stated the last nurse, which was an agency nurse whom is no longer working for the company and was not able to be interviewed,, whom was the last person to work the cart was asked not to return to the facility. There were agency nurses that worked the 2 PM to 10 PM and the 10 PM to 6 AM shift were agency nurses. He stated the last dosage of medication Resident # 1 was administered was 8/18/2025 at 5:15 AM and again on 9:21 AM and that is when it was found missing. He stated law enforcement was notified and provided an item number. He stated they have watched the cameras and were not able to determine what 675360 Page 2 of 3 675360 08/29/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few happened to the medication. He stated the way the nurses are positioned with the med cart, the cameras did not show anyone taking medication from the cart or the pages out of the book. All the other medications carts were counted to make sure no other medications were missing. He stated a negative outcome that can happen is there will be missing medication, and the resident could miss a dose of their medication. Record review of the undated policy of Injection Safety - Drug Diversion, revealed drug diversion is referring to the theft or other deviation that removes a prescription drug from its intended path from the manufacturer to the patient. 1. All drugs and biologicals, including controlled substances, are stored in lock compartments and only authorized personnel have keys to locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms). 2. Staff with access to medications are trained on their responsibilities for safe storage and administration of medications, including documentation and disposition of medications. 3. Staff with access to controlled medications are trained on the facility's policy for the administration and accountability of controlled substances. Each employee is required to report suspicion or known diversion of a controlled substance to the Director of Nursing or Administrator. 675360 Page 3 of 3