Health inspection·December 30, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Resident #1) reviewed for rights. The facility failed to ensure Resident #1's doctors' orders were followed by not providing his antibiotic medications on 12/23/2025. This failure could place residents at risk for decreased quality of life, decreased self-esteem and diminished dignity. Findings included: Record review of Resident #1's face sheet dated 12/30/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses paraplegia, unspecified (paralysis affecting the lower half of the body (legs and sometimes trunk), but without specific details on the exact cause, severity (complete vs. incomplete), or level of spinal cord involvement provided in the medical record), stage four pressure ulcer or right buttock (a severe, deep open wound involving full-thickness tissue loss, where skin, fat, muscle, tendon, or even bone is exposed), other acute osteomyelitis, left ankle and foot (a sudden, serious bacterial or fungal infection in the bone, causing pain, swelling, redness, warmth, and possibly fever, often resulting from an injury, wound (especially with diabetes/poor circulation), or surgery, requiring urgent treatment with antibiotics and sometimes surgery to prevent permanent bone damage or amputation), scoliosis (a medical condition where the spine develops an abnormal sideways curve, often resembling a C or S shape, instead of being straight). Record review of Resident #1's most recent MDS, dated [DATE], reflected a BIMS score of 15, indicating cognition was intact. Record review of Resident #1's care plan, dated 12/29/2025, reflected Resident #1 had an infection and was on antibiotic therapy r/t sepsis (the body's extreme reaction to am untreated infection). Goal: Resident #1 would be free from complications related to infection through the review date 1/01/2026. Intervention/tasks included administering antibiotic as per MD orders, encourage po fluids if not contraindicated, monitored reactions and notify MD. Record review of Resident #1's care plan 12/22/2025 did not reflect he was receiving antibiotic therapy. Observation and record review of Resident #1's discharge orders, dated 12/23/2025, from a hospital stay revealed Resident #1 was discharged with two (2) antibiotics Linezolid 600 mg BID and Cipro 500 mg BID to be given 12/22/2025 through 12/27/2025. During an interview and observation on 12/30/2025 at 2:15 p.m., Resident #1 was asked if he was given his medication and he responded no. He stated he had antibiotics ordered when he was discharged from the hospital and the facility did not know until he asked about the medication. He stated he expected the nurses to have his medication. Resident appeared to be clean sitting in the wheelchair. During an interview on 12/30/2025 at 6:05 p.m., LVN A revealed when a resident was discharged from the hospital it was the responsibility of the charge nurse on duty to put the orders in the electronic system. LVN A stated Resident #1 was readmitted back into the facility after her shift. She stated she caught the Cipro 500 mg BID medication Resident #1 was prescribed. LVN A Page 1 of 4 675360 675360 12/30/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated Resident #1 asked about his discharge paperwork regarding his antibiotics the doctor prescribed for him, and she stated she was going to investigate it. The NP made rounds on the morning of 12/24. She notified the NP that Resident #1 did not receive his antibiotics and asked what to do next. LVN A stated he was supposed to be on the antibiotics for three days and he stated to extend it to five days, so she put the order in for five days. She stated the medication should have been in the e-kit (a small supply of medications kept in the home to quickly treat symptoms that may occur in a terminally ill patient). She thought Resident #1 received his medication on 12/25. Once she put it in the orders, he should have gotten the evening dose. The initial dose is given by the nurse and then the med tech can give medication. LVN A stated it was the residents' right to receive all their medications on time. During an interview on 12/30/2025 at 6:15 p.m., Charge Nurse A revealed it was everybody's responsibility to make sure orders were correctly put into the electronic system. Charge Nurse A stated the marketing person would bring the discharge paperwork to the nurses then the nurses will add the necessary documentation into the computer. The DON and ADON are supposed to go behind the nurse to make sure it is done. Sometimes the ADON or the DON would put the orders in. Charge Nurse A stated he does not know why the medications were missed. He stated Resident #1 returned to the facility about 9:20 p.m. after being gone for 72 hours and readmitted as a new admit. He stated he gave Resident #1 the initial medication for one of the medications and he had to call the pharmacy for the Linezolid medication. He stated the paperwork reflected what happened during resident hospital stay and not the medication. He stated the next morning, the paperwork that came reflected the doctors' medication orders. He stated he was advised by another nurse he had two medications on his discharge paperwork, and she went to see if they had it in their e-kit and the Cipro was the only one and he reached out to the pharmacy to get the medication sent in the Charge Nurse stated that it was the resident's right to get his medication. During an interview on 12/30/2025 at 7:05 p.m., The DON stated The Charge Nurse A did not put the orders in and when DON asked the charge nurse why they were not put in he stated he did not see them on the discharge medication list. DON stated once they realized the error, they notified the NP and did a medication error report. Resident #1 was given an order to restart the medication on 12/26/25. The DON stated Linezolid medication was on back order due to the holidays, and they did not have any in their ekit. The DON stated they tried to go through other pharmacies but did not have a contract with any other company. They have gone in the past to pick up the medications when it happens but the pharmacy they use is the company pharmacy. The DON stated they were waiting for the medication, no date was provided, and it showed a status out for delivery. The DON stated it was the residents' right to receive their medication on time. Review of facility resident rights policy dated December 2016 reflected: Employees should treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to: a. a dignified existence. b. be treated with respect, kindness, and dignity. 675360 Page 2 of 4 675360 12/30/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0760 Ensure that residents are free from significant medication errors. 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 residents were free of significant medications errors for one of three residents (Resident #1) reviewed for any significant medication errors, in that: The facility failed to ensure Resident #1 received his medications as prescribed by the physician. This failure affected residents by putting them at risk of exacerbation of their health conditions and deterioration of their health. Findings included: Record review of Resident #1's face sheet dated 12/30/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses paraplegia, unspecified (paralysis affecting the lower half of the body (legs and sometimes trunk), but without specific details on the exact cause, severity (complete vs. incomplete), or level of spinal cord involvement provided in the medical record), stage four pressure ulcer or right buttock (a severe, deep open wound involving full-thickness tissue loss, where skin, fat, muscle, tendon, or even bone is exposed), other acute osteomyelitis, left ankle and foot (a sudden, serious bacterial or fungal infection in the bone, causing pain, swelling, redness, warmth, and possibly fever, often resulting from an injury, wound (especially with diabetes/poor circulation), or surgery, requiring urgent treatment with antibiotics and sometimes surgery to prevent permanent bone damage or amputation), scoliosis (a medical condition where the spine develops an abnormal sideways curve, often resembling a C or S shape, instead of being straight). Record review of Resident #1's most recent MDS, dated [DATE], reflected a BIMS score of 15, indicating cognition was intact. Record review of Resident #1's care plan, dated 12/29/2025, reflected Resident #1 had an infection and was on antibiotic therapy r/t sepsis (the body's extreme reaction to am untreated infection). Goal: Resident #1 would be free from complications related to infection through the review date 1/01/2026. Intervention/tasks included administering antibiotic as per MD orders, encourage po fluids if not contraindicated, monitored reactions and notify MD. Record review of Resident #1's care plan 12/22/2025 did not reflect he was receiving antibiotic therapy. Observation and record review of Resident #1's discharge orders, dated 12/23/2025, from a hospital stay revealed Resident #1 was discharged with two (2) antibiotics Linezolid 600 mg BID and Cipro 500 mg BID to be given 12/22/2025 through 12/27/2025. During an interview and observation on 12/30/2025 at 2:15 p.m., Resident #1 was asked if he was given his medication and he responded no. He stated he had antibiotics ordered when he was discharged from the hospital and the facility did not know until he asked about the medication. He stated he expected the nurses to have his medication. Resident appeared to be clean sitting in the wheelchair. During an interview on 12/30/2025 at 5:35 p.m., the PCP revealed she was more familiar with Resident #1 in the hospital. She described his medical condition and stated healing was difficult for Resident #1. The PCP stated because of osteomyelitis the CT scan was inconclusive, and the 3rd toe amputee was the source control. Resident #1 had multiple rounds of antibiotics and was battling with the infection. The PCP stated the antibiotic was to make sure the infection cleared. The amputation cleared him, but the 2 antibiotics were just to make sure everything was clear. The PCP stated the antibiotics were given to ensure the infection was cleared. She stated the blood cultures they took while in the hospital did not reveal any growth. The PCP stated he could have a flare up of another infection. During an interview on 12/30/2025 at 6:05 p.m., LVN A revealed when a resident was discharged from the hospital it was the responsibility of the charge nurse on duty to put the orders in the electronic system. LVN A stated Resident #1 was readmitted back into the facility after her shift. She stated she caught the Cipro 500 mg BID medication Resident #1 was prescribed. LVN A stated Resident #1 asked about his discharge paperwork regarding his antibiotics the doctor prescribed for him, and she stated she was going to investigate Residents Affected - Some 675360 Page 3 of 4 675360 12/30/2025 Woodland Springs Nursing Center 1010 Dallas St Waco, TX 76704

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some it. The NP made rounds on the morning of 12/24. She notified the NP that Resident #1 did not receive his antibiotics and asked what to do next. LVN A stated he was supposed to be on the antibiotics for three days and he stated to extend it to five days, so she put the order in for five days. She stated the medication should have been in the e-kit (a small supply of medications kept in the home to quickly treat symptoms that may occur in a terminally ill patient). She thought Resident #1 received his medication on 12/25. Once she put it in the orders, he should have gotten the evening dose. The initial dose is given by the nurse and then the med tech can give medication. LVN A stated the adverse reaction that could happen with Resident #1 the antibiotics is he could go septic shock. During an interview on 12/30/2025 at 6:15 p.m., Charge Nurse A revealed it was everybody's responsibility to make sure orders were correctly put into the electronic system. Charge Nurse A stated the marketing person would bring the discharge paperwork to the nurses then the nurses will add the necessary documentation into the computer. The DON and ADON are supposed to go behind the nurse to make sure it is done. Sometimes the ADON or the DON would put the orders in. Charge Nurse A stated he does not know why the medications were missed. He stated Resident #1 returned to the facility about 9:20 p.m. after being gone for 72 hours and readmitted as a new admit. He stated he gave Resident #1 the initial medication for one of the medications and he had to call the pharmacy for the Linezolid medication. He stated the paperwork reflected what happened during resident hospital stay and not the medication. He stated the next morning, the paperwork that came reflected the doctors' medication orders. He stated he was advised by another nurse he had two medications on his discharge paperwork, and she went to see if they had it in their e-kit and the Cipro was the only one and he reached out to the pharmacy to get the medication sent in the Charge Nurse stated that it was the resident's right to get his medication. Charge Nurse A stated the adverse reaction that could happen with Resident #1 not receiving the antibiotics is he could die. During an interview on 12/30/2025 at 7:05 p.m., The DON stated The Charge Nurse A did not put the orders in and when DON asked the charge nurse why they were not put in he stated he did not see them on the discharge medication list. DON stated once they realized the error, they notified the NP and did a medication error report. Resident #1 was given an order to restart the medication on 12/26/25. The DON stated Linezolid medication was on back order due to the holidays, and they did not have any in their ekit. The DON stated they tried to go through other pharmacies but did not have a contract with any other company. They have gone in the past to pick up the medications when it happens but the pharmacy they use is the company pharmacy. The DON stated they were waiting for the medication, no date was provided, and it showed a status out for delivery. The DON stated an adverse reaction that could happen to Resident #1 not receiving his prescribed medication was the condition could worsen or delay the healing. Review of facility undated medication reconciliation policy reflected the facility reconciled medication frequently throughout a resident's stay to ensure that the resident was free of any significant medication errors, and that the facility's medication error rate was less than 5 percent. Policy and Explanation and Compliance Guidelines: 3. Pre-admission Processes:a. Obtain current medication list from referral sources (i.e. hospital, home health, hospice, or primary care provider). b. Obtain current medication/admission orders. c. Verify resident identifiers. d. Forward to nursing unit accepting the resident. 4. admission Process: b. Compare orders to hospital records, etc. Obtain clarification orders as needed. e. Order medications from pharmacy in accordance with facility procedures for ordering medications. f. Verify medication received match the medication orders. 675360 Page 4 of 4