Woodland Springs Nursing Center

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Springs Nursing Center

1010 Dallas St Waco, TX 76704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

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