Health inspection·November 20, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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 implement their written policies and procedures regarding investigating abuse for two (Resident #1 and Resident #2) of five residents reviewed for abuse and neglect. The facility failed to ensure a thorough investigation was completed by the abuse coordinator after an allegation of abuse was made on 10/11/2025 by Resident #2. This failure could place residents at risk of abuse, trauma, and psychosocial harm. Findings included:Review of Resident #1's comprehensive MDS assessment, dated 09/10/2025, reflected a [AGE] year-old male, admitted [DATE]. His diagnoses included progressive neurological conditions (gradual decline in neurological function), diabetes mellitus (chronic condition that affects how your body processes blood sugar), Alzheimer's disease (memory impairment), seizure disorder (abnormal electrical activity in the brain), anxiety (feelings of worry, fear, or unease), depression (persistent feeling of sadness), and psychotic disorder (severe mental health conditions). His BIMS score was a 3, indicating severe cognitive impairment. Review of Resident #1's care plan, dated 9/28/25, revealed he was care planned for having a behavior problem of wandering with interventions of, Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.Review of a nursing incident/accident investigation worksheet, dated 10/10/25 by agency LVN A, revealed that on 10/10/25 at 2:15 p.m. physical aggression was initiated by Resident #1 and there was resident to resident contact. Under the investigation summary section, it was indicated that the resident did not say what happened, the staff did not know what caused the incident, and there were no witnesses. The statement also reflected, When staff arrived at D/R this resident [Resident #1] had the other resident [Resident #2] on the floor-holding him down. The other resident [Resident #2] was noted lying on the floor with his shoulders up-trying to release himself from the resident.Review of Resident #1's progress note, dated 10/10/25, documented by agency LVN A revealed, Nurse and medication aide heard resident calling out for Help When we arrived at the d/r this resident had the other resident on the floor holding him down. The other resident was noted lying on the floor with his shoulders up-trying to release himself from the resident. No apparent injuries noted to RESIDENTS. NP was informed via phone with orders for U/A. Psych NP here with new orders: Depakote and Hydroxyzine-See Orders.Review of Resident #1's progress note, dated 10/23/25, revealed he was admitted to a behavioral health inpatient facility.Review of Resident #2's quarterly MDS assessment, dated 09/01/25, reflected a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included: heart failure, renal failure (medical condition in which the kidneys can no longer filter waste products from the blood), diabetes mellitus (chronic condition that affects how your body processes blood sugar), non-Alzheimer's dementia, anxiety (feelings of worry, fear, or unease), depression (persistent feeling of sadness), insomnia (inability to sleep), and malnutrition. His BIMS score was a 4, indicating severe cognitive impairment. Review of Resident #2's care plan, dated 9/12/25, revealed he Residents Affected - Few Page 1 of 4 675924 675924 11/20/2025 Woodway Rehabilitation and Healthcare Center 7801 Woodway Dr Waco, TX 76712

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was care planned for the potential to be physically aggressive when he pushed another resident on 1/25/25. His interventions included monitoring for agitation, redirection, give the resident choices, and to intervene before agitation escalates. Review of the facility's incident/accident reports from the last three months revealed an incident occurred on 10/10/25 where physical aggression was received by Resident #2, and physical aggression was initiated by Resident #1.Review of a nursing incident/accident investigation worksheet, dated 10/10/25 by agency LVN A, revealed that on 10/10/25 at 2:15PM Physical Aggression was received by Resident #2 and there was resident to resident contact. Under the investigation summary section, it was indicated that the resident said, I don't know why he just walked up and hit me., and the staff did not know what caused the incident, and there were no witnesses. It indicated the resident was not injured. It also revealed a staff statement, Staff heard residents calling for HELP When staff arrived at D/R resident was on the floor-and the other resident was noted holding him down. Resident was noted lying on the floor with his shoulders up-trying to release himself from the residentReview of a typed document on a piece of paper provided to the surveyor by the DON and VPHR revealed: [Resident #2] and [Resident #1]Completed by [previous ADM], 10.10.25Staff heard a cry for help and went to dining room. Found [Resident #2] on the floor with [Resident #1] holding his shoulders. No staff on duty witnessed the incident. Staff escorted [Resident #2] back to room. Nursing staff immediately notified DON and ADONof incident. DON, came to notify me of incident. [Resident 1] unable to retell events of what occurred. He was witnessed walkingdown hall and appears to be calm at this time. [Resident 2] stated I don't know why he just walked up and hit me.Psych NP notified 10.10.25 of incident, came to facility, spoke with [Resident 1] and wrote new orders. Staff will continue to monitor for any adverse affects.An interview was attempted with the previous ADM on 11/20/2025 at 10:55 a.m. but the surveyor did not receive a return call after leaving a voicemail. In an interview on 11/20/2025 at 11:10 a.m. with the DON she stated that it was not Resident #1's normal behavior to act in the way he did with Resident #2. She stated that she did not consider the incident to be abuse because no one saw the incident happen and neither resident could tell them what happened, and that neither resident received injuries. She stated that resident to resident abuse would be if one resident was seeking out another resident, like intentionally following them around, trying to push the other resident, and that Resident #1 had not been exhibiting those behaviors. An observation and interview was attempted on 11/20/2025 at 12:20 p.m. of Resident #1 and Resident #2 but both were pleasantly confused and unable to participate in interviews due to severe cognitive impairments. They both appeared well groomed and dressed appropriately. In an interview on 11/20/2025 at 1:03 p.m. with the VPHR who was serving the facility as the interim ADM, she stated that resident to resident abuse would be any unprovoked physical contact between residents. She stated that the incident on 10/10 was an instance that would warrant an investigation by the AC. She stated the DON investigated the incident from 10/10/25, which resulted in the facility unable to determine if resident abuse occurred due to no witnesses of the incident and no new injuries, but the only investigation she could locate that the AC conducted was what she provided the surveyor typed on a blank sheet of paper. She stated the AC was responsible for investigating abuse allegations. She stated that on 10/10 the previous ADM was the AC.Review of the facility's Abuse, Neglect and Exploitation policy dated last reviewed 05/2025 reflected: 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property orinjury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. 675924 Page 2 of 4 675924 11/20/2025 Woodway Rehabilitation and Healthcare Center 7801 Woodway Dr Waco, TX 76712

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported no later than 24 hours after the allegation is made to the administrator of the facility and to HHSC, if the events that cause the allegation do not involve abuse, and do not result in serious bodily injury for 2 (Resident #1 and Resident #2) of five residents reviewed for reporting abuse and neglect. The facility failed to report an allegation of abuse made by Resident #2 on 10/10/25 that did not result in bodily injury within 24 hours to the state agency. This failure could place residents at risk of abuse, trauma, and/or psychosocial harm. Findings included:Review of Resident #1's comprehensive MDS assessment, dated 09/10/25, reflected a [AGE] year-old male who was on 09/10/2021. His diagnoses included: progressive neurological conditions (gradual decline in neurological function), diabetes mellitus (chronic condition that affects how your body processes blood sugar), Alzheimer's disease (memory impairment), seizure disorder (abnormal electrical activity in the brain), anxiety (feelings of worry, fear, or unease), depression (persistent feeling of sadness), psychotic disorder (severe mental health conditions). His BIMS score was a 3, indicating severe cognitive impairment. Review of Resident #1's care plan, dated 9/28/25, revealed he was care planned for having a behavior problem of wandering with interventions of, Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.Review of a nursing incident/accident investigation worksheet, dated 10/10/25 by agency LVN A, revealed that on 10/10/25 at 2:15 p.m. physical aggression was initiated by Resident #1 and there was resident to resident contact. Under the investigation summary section, it was indicated the Resident #2 did not say what happened, the staff did not know what caused the incident, and there were no witnesses. The statement also reflected, When staff arrived at D/R this resident [Resident #1] had the other resident [Resident #2] on the floor-holding him down. The other resident [Resident #2] was noted lying on the floor with his shoulders up-trying to release himself from the resident.Review of Resident #1's progress note, dated 10/10/25 documented by agency LVN A, revealed, Nurse and medication aide heard resident calling out for help. When we arrived at D/R this resident had the other resident on the floor holding him down. The other resident was noted lying on the floor with his shoulders up-trying to release himself from the resident. No apparent injuries noted to residents. The NP was informed via phone with orders for U/A. Psychiatric NP here with new orders: Depakote and Hydroxyzine-See Orders.Review of Resident #1's progress note, dated 10/23/25, revealed he was admitted to a behavioral health inpatient facility.Review of Resident #2's quarterly MDS assessment, dated 09/01/25, reflected a [AGE] year-old male who admitted on [DATE]. His diagnoses included: heart failure, renal failure (medical condition in which the kidneys can no longer filter waste products from the blood), diabetes mellitus (chronic condition that affects how your body processes blood sugar), non-Alzheimer's dementia, anxiety (feelings of worry, fear, or unease), depression (persistent feeling of sadness), insomnia (inability to sleep), and malnutrition. His BIMS score was a 4, indicating severe cognitive impairment. Review of Resident #2's care plan, dated 9/12/25, revealed he was care planned for the potential to be physically aggressive when he pushed another resident on 1/25/25. His interventions included monitoring for agitation, redirection, give the resident choices, and to intervene before agitation escalates. Review of the facility's incident/accident reports from the last 3 months revealed that an incident occurred on 10/10/25 where physical aggression was received by Resident #2, and physical aggression was initiated by Resident #1.Review of a typed document on a piece of paper provided to the surveyor on 11/20/2025 at 1:05 675924 Page 3 of 4 675924 11/20/2025 Woodway Rehabilitation and Healthcare Center 7801 Woodway Dr Waco, TX 76712

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few p.m. by the DON and VPHR revealed: [Resident #2] and [Resident #1]Completed by [previous ADM], 10.10.25Staff heard a cry for help and went to dining room. Found [Resident #2] on the floor with [Resident #1] holding his shoulders. No staff on duty witnessed the incident. Staff escorted [Resident #2] back to room. Nursing staff immediately notified DON and ADONof incident. DON, came to notify me of incident. [Resident 1] unable to retell events of what occurred. He was witnessed walkingdown hall and appears to be calm at this time. [Resident 2] stated I don't know why he just walked up and hit me. Psych NP notified 10.10.25 of incident, came to facility, spoke with [Resident 1] and wrote new orders. Staff will continue to monitor for any adverse affects.An interview was attempted with the previous ADM on 11/20/2025 at 10:55 a.m. but the surveyor did not receive a return call after leaving a voicemail. In an interview on 11/20/2025 at 11:10 a.m. with the DON she stated it was not Resident #1's normal behavior to act in the way he did with Resident #2. She stated that she did not consider the incident to be abuse because no one saw the incident happen and neither resident could tell them what happened, nor did either resident receive injuries. She stated that a resident-to-resident altercation would be if one resident was seeking out another resident, intentionally following them around, trying to push the other resident, and that Resident #1 had not been exhibiting those behaviors. In an interview on 11/20/2025 at 1:03 p.m. with the VPHR who was serving the facility as the interim ADM, stated that resident to resident abuse would be unprovoked physical contact between residents. She stated that the incident on 10/10/25 was an instance that would warrant an investigation by the AC. When asked if it warranted a report to the state agency, she stated that would be determined after the investigation by the AC. She stated the DON investigated the incident from 10/10/25, which resulted in the facility unable to determine if resident abuse occurred due to no witnesses of the incident and no new injuries, but the only investigation she could locate that the AC conducted was what she provided the surveyor typed on a blank sheet of paper. She stated the AC was responsible for investigating abuse allegations and reporting it to the necessary entities. She stated that on 10/10/25 the previous ADM was the AC.Review of the facility's Abuse, Neglect and Exploitation policy, dated 05/2025, reflected: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a. The state licensing/certification agency responsible for surveying/licensing the facility. 675924 Page 4 of 4