Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ivy Creek Wellness & Rehabilitation during CMS and state inspections, most recent first.
Two residents experienced misappropriation of their prescribed hydrocodone-acetaminophen when pharmacy manifests showed higher quantities delivered than were documented on facility narcotic count sheets, resulting in 60 missing tablets for one resident on scheduled PEG-tube hydrocodone and 30 missing tablets for another resident receiving PRN hydrocodone. In both cases, records indicated that an LVN was involved in receiving or handling the medications, with altered quantities and missing signatures on the narcotic logs and no witnesses to the changes. Facility leadership and the MD confirmed that these discrepancies were discovered during review of narcotic records and that the missing medications constituted misappropriation of resident property under the facility’s abuse, neglect, and exploitation policy.
Kitchen Food Handling and Sanitation Lapses: A dietary employee prepared food without a beard net, later wore the beard net below the lip, and handled multiple food prep tasks with the same gloves after touching other surfaces. Another dietary employee prepared trays on the serving line without gloves. The same food processor was washed but not sanitized between pureed items, and a dirty towel with food particles was used to wipe the equipment and prep area. Interviews confirmed staff were trained to wear gloves, use hair/beard restraints, and sanitize equipment between uses.
A facility failed to maintain infection control when laundry staff transported resident linens on a cart that was only covered on top and left open on the sides, with resident clothing visible during hallway transport. The facility also failed when an MA used the same reusable BP cuff on four residents without cleaning it between uses, then placed the cuff on the med cart near medication preparation. Staff interviews and the facility policy stated linens were to be fully covered during transport and reusable equipment was to be sanitized between residents.
A resident with stroke, hemiplegia, severe cognitive impairment, and dependent mobility needs was evaluated by OT for decreased bed mobility, activity tolerance, and ROM, with MD-certified goals for strengthening, PROM, and improved bed mobility. Although the resident received initial therapy visits, the facility stopped services while he remained Medicaid pending, citing corporate approval limits and staffing issues. Interviews and observation showed the resident was not receiving ongoing OT despite continued need for contracture management and mobility support.
Incomplete Narcotic Count Documentation on Medication Carts: The facility failed to ensure controlled substance counts were fully documented on the East Cart and 1 [NAME] Back Cart. Observation found missing and blank entries on the narcotic logs, including absent nurse signatures and incomplete shift counts. Interviews with the DON, ADM, nurses, and medication aides confirmed counts were expected at each shift change by 2 nurses and documented before keys were passed.
Smoking Policy and Smoking Area Cleanliness: A resident with CAD, DM, HLD, and mild cognitive impairment was observed asking another resident for a cigar during a smoke break after not being informed of the facility’s smoking rules. The AD stated the resident had borrowed cigars from other residents before and that staff providing smoke breaks were responsible for explaining the rules. The smoking area was also observed with cigarette butts, cigar wrappers, and butts in plant pots near an exit door, and the AD acknowledged the area was dirty and could pose a fire hazard.
Misappropriation of Controlled Pain Medications for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of property, specifically controlled pain medications, for two residents reviewed. For the first resident, an older female with hemiplegia, vascular dementia, chronic pain syndrome, and severe cognitive impairment, the physician had ordered hydrocodone-acetaminophen 7.5/325 mg via PEG tube three times daily for pain. Pharmacy records showed that 124 tablets of this medication were delivered and received by LVN A, but the facility’s narcotic count sheet documented only 64 tablets, with the quantity changed from 124 to 64. This discrepancy was discovered when a nurse attempted to reorder the narcotic and the pharmacy reported it was too soon, leading to the identification of 60 missing tablets for this resident. For the second resident, an older male with paraplegia, Type 2 diabetes, heart disease, muscle wasting, and major depressive disorder, the physician had ordered hydrocodone-acetaminophen 10/325 mg every six hours as needed for pain. The narcotic count sheet for this resident showed that 60 tablets were received on a specific date, but the signature of the receiving staff member was missing, and only a date and amount were recorded. Pharmacy records, however, reflected that 90 tablets were delivered for this resident and received by LVN B, who reported handing the medication off to LVN A. Review of the narcotic count sheets revealed that 30 tablets of hydrocodone-acetaminophen 10/325 mg were missing for this resident. Interviews with facility leadership and the physician confirmed that the discrepancies in narcotic counts for both residents were identified during internal review of narcotic records. The DON stated that LVN A had received the hydrocodone-acetaminophen for the first resident and that the quantity on the narcotic count sheet had been altered, with no witnesses to the change. For the second resident, the DON noted that the handwriting on the narcotic count sheet entry for receipt resembled that of LVN A, again without witnesses and without a staff signature. The administrator and physician both described expectations that narcotics be managed without errors, diversion, or missing medications, and the facility’s abuse, neglect, and exploitation policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent. Attempts to contact LVN A for an interview were unsuccessful, and the second resident reported awareness of the missing medications but stated he was not personally affected and had no concerns with his pain management.
Kitchen Food Handling and Sanitation Lapses
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observation, dietary CK 1 was preparing food without a beard net, and later had the beard net pulled below the bottom lip while working near the food preparation area and stove. CK 2 was observed on the serving line without gloves while preparing trays. In interviews, both CK 1 and CK 2 acknowledged they were trained on proper hand hygiene, glove use, and hair/beard restraints, and both stated staff were required to wear gloves and hair or beard nets while preparing food. During pureeing tasks, CK 1 handled pureed chicken, broccoli, and garlic bread while wearing the same gloves throughout multiple tasks and after touching other surfaces in the kitchen, including the food processor, sink handles, and sink. CK 1 did not wash his hands or change gloves between tasks. CK 1 also washed the food processor in the three-compartment sink and rinsed it with running water, but did not sanitize it before using it again for additional food items. He then used a dirty towel with food particles and brown spots from a dirty cart to wipe down the food processor base and food preparation area. The dietary manager stated staff were to always wear gloves and hair or beard nets when preparing food, change gloves and wash hands between tasks and after touching contaminated surfaces, and clean and sanitize the food processor between uses. CK 2 stated staff should wash and sanitize the blender between pureed items and that anyone entering the kitchen was supposed to wear the appropriate hair and beard net. Record review showed the facility’s food processor cleaning policy required disassembly, washing, sanitizing, and proper handling between food item changes, and the FDA Food Code required food employees to wear effective hair restraints, including beard restraints.
Infection Control Lapses With Laundry Transport and Shared BP Cuff Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 4 residents and 1 laundry cart reviewed. The deficiency involved laundry staff handling and transporting linens in a manner that did not keep them fully covered during transport, and medication staff not sanitizing a reusable blood pressure cuff between residents. The report states these failures were identified during observation, interview, and record review. Resident #15 was a female with diagnoses including hypothyroidism, ocular hypertension, hypertension, and schizophrenia. Resident #25 was a female with diagnoses including congestive heart failure, kidney transplant, hypertension, and chronic obstructive pulmonary disease. Resident #34 was a male with diagnoses including hemiplegia, bipolar disorder, hypertension, and cerebral infarct, and his BIMS score was 08, indicating moderately impaired cognition. Resident #70 was a male with diagnoses including multiple sclerosis, elevated white blood cell count, hypertension, and elevated liver enzyme levels, and his MDS assessment had not yet been completed due to his recent admission. On 07/21/2025, LS-A was observed pushing a laundry cart down the hall on the [NAME] Nursing Unit. The top of the cart was covered with a cloth, but the sides were open to the air, and multiple residents' hanging clothes were visible in the exposed area while residents and visitors were moving in the hall. On 07/22/2025, MA-A was observed using the same blood pressure cuff for Residents #34, #70, #25, and #15 without cleaning it between residents. After each blood pressure check, the cuff was placed on the medication cart near where medications were being prepared, and MA-A then administered medications and performed hand hygiene without cleaning the cuff. During interview, MA-A stated she forgot to clean the cuff between residents and acknowledged the policy was to clean it to prevent spreading infections. Staff interviews and the facility policy stated linens were to be delivered covered and reusable equipment was to be cleaned between residents.
Failure to Continue OT Services for Resident With Limited ROM and Mobility
Penalty
Summary
The facility failed to ensure a resident with limited ROM and limited mobility continued to receive OT services that had been signed off on by the MD on the resident’s initial OT evaluation. Resident #22 was admitted with diagnoses including stroke, HTN, DM, and hemiplegia/hemiparesis. His MDS reflected severe cognitive impairment with a BIMS score of 00, and in Section GG he was coded as dependent for sit to lying, lying to sitting, sit to stand, and chair/bed-to-chair transfers, with substantial/maximal assistance needed for rolling left and right. The resident’s care plan identified an ADL self-care performance deficit with a goal to improve bed mobility, transfers, eating, dressing, toilet use, and personal hygiene, and included an intervention to notify the DOR of the need for ST/PT/OT evaluation and treatment as per MD orders. His physician orders included PT, OT, and ST evaluations and treatment on admission. The OT evaluation dated 4/18/2025 documented decreased bed mobility, activity tolerance, and ROM of the left upper extremity, and stated the resident would benefit from OT to address these deficits and maximize quality of life. The plan of treatment included therapeutic exercises, neuromuscular reeducation, therapeutic activities, self-care management training, and goals related to strengthening, PROM, bed mobility, and caregiver safety strategies. The MD certified the need for these medically necessary services from 4/18/2025 through 5/17/2025. During observation, the resident was seen using only his left hand to indicate responses and was not verbally responding to surveyors. A confidential interview stated staff reported the resident refused therapy, that he was often found lying in the same position in bed, and that the facility would not do anything until Medicaid was approved. The DOR stated the resident had been Medicaid pending since admission, that corporate procedures limited therapy visits, and that he was not receiving services at the time. She also stated he had rehabilitation potential for contracture management and to prevent more contractures, but therapy had stopped after the initial visits. Additional interviews confirmed the resident still needed therapy to work toward bed mobility and repositioning goals, and that he was not receiving therapy because of the facility’s approval process, staffing limitations, and limited approved therapy visits.
Incomplete Narcotic Count Documentation on Medication Carts
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring accurate acquiring, receiving, dispensing, and administering of controlled substances on 2 of 3 medication carts reviewed, including the East Cart and 1 [NAME] Back Cart. Observation of the East Medication Cart Narcotic Log on 7/22/25 showed 2 shifts with no narcotic counts recorded and 2 additional shifts with incomplete entries. The 7/19/25 6 PM line was missing a time and the off-going nurse’s signature, the 7/20/25 6 AM and 6 PM shifts were blank, and the 7/21/25 8 AM line had only the oncoming medication aide’s signature and was missing a nurse’s signature. Observation of the 1 [NAME] Back Medication Cart Narcotic Log showed the 7/20/25 6:05 PM line had a blank box where the oncoming nurse should have signed. Interviews with the DON, MA-B, MA-C, RN-A, the ADM, MA-A, and LVN-A confirmed that narcotic counts were expected to be completed by 2 nurses at shift change and documented on the narcotic log before keys were passed. Staff stated the counts were important to verify the narcotic count, prevent diversion, and ensure medications were available for residents. The facility policy titled Controlled Substance Administration & Accountability dated 2025 stated that all controlled substances obtained from a non-automated medication cart are recorded on the designated usage form, documentation must be clearly legible with all applicable information provided, and two licensed nurses account for all controlled substances and access keys at the end of each shift.
Smoking Policy and Smoking Area Cleanliness
Penalty
Summary
The facility failed to implement its established smoking policy for Resident #49, a [AGE]-year-old female admitted with diagnoses including amputation, anemia, coronary artery disease, diabetes, high cholesterol, hyperlipidemia, mild cognitive impairment, and limitation of activities due to disability. Her MDS reflected a BIMS score of 11 and indicated current tobacco use. Her care plan, last revised 7/7/2025, included an intervention to encourage her to refrain from smoking due to coronary artery disease related to hypercholesterolemia, but there was no indication that she had been informed of the facility’s smoking policy before 7/21/2025. During an observed smoking break on 7/21/2025, Resident #49 had a pouch for her smoking materials and was seen asking a male resident for a cigar, which the AD stopped. The smoking area was observed to be littered with cigarette butts and cigar wrappers, and cigarette butts were also seen in plant pots by one of the facility’s exit doors. In interviews, the AD stated she provided smoke breaks twice daily when working, believed housekeeping or maintenance should clean the cigarette butts, and acknowledged the area looked bad because of the trash and cigarette butts. Resident #49 later stated she had never been informed of the smoking rules or that she could not share tobacco products until the AD told her during the observed smoke break. The AD later confirmed that Resident #49 had borrowed cigars from other residents in the past and stated that staff providing smoke breaks were responsible for informing smokers of the rules. The facility’s smoking policy prohibited residents from sharing or loaning tobacco products, and the resident rights policy stated residents have the right to be informed of rules and to a safe, clean environment.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 75 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Waco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Catherine Center | 1.3 mi | ★★★★★ | 6 | 0 |
| Woodland Springs Nursing Center | 2.2 mi | ★★★★★ | 4 | 1 |
| The Atrium Of Bellmead | 2.4 mi | ★★★★★ | 2 | 0 |
| Avir At Jeffrey Place | 2.4 mi | ★★★★★ | 4 | 0 |
| Crestview Healthcare Residence | 2.6 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ivy Creek Wellness & Rehabilitation.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.