Health inspection·January 23, 2026

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) for complete and accurate records. The facility failed to ensure Resident #1's wound treatment for sacrum(base of spine that forms the posterior wall of the pelvis), coccyx(tailbone), left hip, left distial(further from the center of the body) medial(closer to the midline of the body) foot ,and left lateral(away from midline of the body) foot was documented in Matrix on January 10th and January 12th. This failure could place residents at risk for the possibility of not verifying the needed care and services to meet their needs.Findings include:A record review of Resident #1's face sheet, dated 01/23/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's had diagnoses which included essential (primary) hypertension (high blood pressure), dysphagia (difficult swallowing), and edema (swelling of body tissue caused by trapped, excess fluid, commonly affecting the feet, ankles, legs, hands, or abdomen)A record review of Resident #1's Quarterly MDS assessment, dated 01/07/2026, reflected Resident #1 had BIMS score of 3, indicated severe cognitive impairment with pressure ulcers.A record review of Resident #1's care plan, dated 01/23/2026, reflected Resident #1 had an actual pressure ulcer(skin and tissue damage cause by prolonged pressure) on the left distal medial foot, left lateral foot, right hip, left hip, coccyx(tail bone), sacrum(triangular shaped bone located at the base of the spine) related to reduced mobility.A record review of Resident #1's physician's order dated 01/07/2026 reflected wound treatment coccyx (tail bone) (unstageable) apply zinc oxide (skin protectant) to wound three times every shift start date 01/07/2026.A record review of Resident #1's MAR dated 01/10/2026 reflected wound treatment coccyx (tail bone) (unstageable) apply zinc oxide (skin protectant) to wound three times every shift was not signed off by RN A at 7:00 PM and 11:00 PM.A record review of Resident #1's MAR dated 01/12/2026 reflected wound treatment coccyx (tail bone) (unstageable) apply zinc oxide (skin protectant) to wound three times every shift was not signed off by RN B at 7:00 PM.A record review of Resident #1's physician's order dated 01/07/2026 reflected wound treatment sacrum (triangular shaped bone located at the base of the spine) (stage 3) apply zinc oxide (skin protectant) three times every shift.A record review of Resident #1's MAR dated 01/10/2026 reflected wound treatment sacrum (triangular shaped bone located at the base of the spine) (stage 3) apply zinc oxide (skin protectant) three times every shift was not signed off by RN A at 7:00 PM and 11:00 PM.A record review of Resident #1's MAR dated 01/12/2026 reflected wound treatment sacrum (triangular shaped bone located at the base of the spine) (stage 3) apply zinc oxide (skin protectant) three times every shift was not signed off by RN B at 7:00 PM.A record review of Resident #1's physician's order dated 12/26/2025 reflected wound treatment left, distal medial foot cleanse wound with Dakins, blot dry, apply gauze sponge sterile moisten with Dakins to wound, Page 1 of 3 676409 676409 01/23/2026 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cover with a dry dressing, and wrap with Kerlix/Secure with tape daily.A record review of Resident #1's MAR dated 01/10/2026 reflected wound treatment left, distal medial foot cleanse wound with Dakins(antiseptic wound cleanser), blot dry, apply gauze sponge sterile moisten with Dakins (antiseptic wound cleanser), to wound, cover with a dry dressing, and wrap with Kerlix(sterile gauze)Secure with tape daily was not signed off by RN A between 7:00 AM-7:00 PM.A record review of Resident #1's physician's order dated 12/26/2025 reflected wound treatment left lateral foot, cleanse wound with Dakins (antiseptic wound cleanser), blot dry, apply gauze sponge sterile moisten with Dakins (antiseptic wound cleanser), to wound, cover with a dry dressing, and wrap with Kerlix (sterile gauze) Secure with tape daily.A record review of Resident #1's MAR dated 01/10/2026 reflected wound treatment left lateral foot, cleanse wound with Dakins(antiseptic wound cleanser), blot dry, apply gauze sponge sterile moisten with Dakins(antiseptic wound cleanser), to wound, cover with a dry dressing, and wrap with Kerlix(sterile gauze)Secure with tape daily was not signed off by RN A between 7:00 AM-7:00 PM.A record review of Resident #1's physician's order dated 01/07/2026 reflected wound treatment left hip (stage 3) cleanse with normal saline (sterile solution), blot dry, cover with Alginate Calcium (non-adhesive gel) size to fit, cover with dry dressing, and apply house barrier cream to surrounding area daily.A record review of Resident #1's MAR dated 01/10/2026 reflected wound treatment left hip(stage 3) cleanse with normal saline, blot dry, cover with Alginate Calcium (size to fit), cover with dry dressing , and apply house barrier cream (protectant)to surrounding area daily was not signed off on by RN A between 7:00 AM-7:00 PM.Unable to interview Resident # 1 on 01/23/2026, he was sent out to the hospital on [DATE] for change of condition.During an interview with Resident #1's RP on 01/23/2026 at 11:04 AM stated that Resident # 1 was very sick and have been in and out of the hospital for some time now. Resident #1's RP stated Resident # 1 was sent out to the hospital on [DATE] for a change in condition. Resident # 1's RP stated Resident #1 was very sick and she cannot blame anyone on Resident #1's health decline.During an interview with the WCD on 01/23/2026 at 3:00 PM, the WCD stated he come to the facility weekly to see Resident # 1. The WCD stated he debrided Resident # 1 foot on 01/17/2026 and Resident#1's bone was exposed. The WCD had Resident #1 sent out to the hospital for higher level of care as the facility was not going to be able to handle. The WCD stated Resident # 1 had daily wound care treatments and if there were treatments that were not signed off on would not make things any worse for Resident #1. The WCD stated that 01/10/2026 and 01/12/2026 wound treatment not documented would not have any effects of the wounds getting worse if the treatment was not completed or signed off on. The WCD stated wound care in some cases would not have to change out dressings every day and he was not aware of any missed wound care treatments for Resident#1.During an interview with RN A on 01/23/2026 at 3:45 PM stated on 01/10/2026 he provided all wound treatments to Resident #1. RN A stated he did not sign off being completed as he was assisting with other nursing duties after. RN A stated it was expected for him to sign off on treatments when they were completed. RN A stated if the treatments was not signed off on would indicate the treatments was not completed.During an interview with the DON on 01/23/2026 at 3:54 PM, the DON stated it was expected for RN A and RN B to have signed off on the MAR on 01/10/2026 and 01/12/2026. The DON stated it was expected for RN A and RN B to have clear accurate documentation and signed off in Matrix once treatment was completed. The DON stated when the MAR was not signed off would indicate the treatment was not completed.During an interview with the ADM on 01/23/2026 at 4:11 PM, the ADM stated it was expected for RN A and RN B to have signed off on Resident # 1's MAR in Matrix on 01/10/2026 and 01/12/2026 to ensure documentation was completed. The ADM stated if the MAR was not signed off on would have indicated that it was not completed.During an interview with RN B on 01/23/2026 at 5:50 PM stated on 676409 Page 2 of 3 676409 01/23/2026 The Brazos of Waco 2430 Market Place Drive Waco, TX 76711

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 01/12/2026 she provided all the wound care treatments for Resident #1 but just did not sign off on being completed. RN B stated she was busy with other job duties and failed to complete documents. RN B stated it was expected to sign off when the treatment was completed. RN B stated when the treatment was not signed off on would show that the wound treatment was not completed.Record review of the facility's, dated 2023, policy titled Nursing Policies and Procedures Documentation reflected Documentation pretraining to the patient/resident will be recorded in accordance with regulatory requirements. The nursing staff will be responsible for recording care and treatment, observations and assessments and other appropriate entries in the patient/resident clinical record.4. Medications and Treatments The quailed nursing staff notes the time, date and dosage of all medications and treatments at the time they are administered and initials the note on the medication and/or treatment record. The nurse's full name and title must be written at least once on each page of the Medication/Treatment Record or on an individual resident specific signature sheet. 676409 Page 3 of 3