Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Wesley Woods Health & Rehabilitation during CMS and state inspections, most recent first.
Surveyors identified a deficiency in which the facility failed to follow professional standards and facility policy for labeling and storing opened food items in the kitchen. During observation, multiple opened items in the pantry, refrigerator, and freezer—including dry goods, cooked eggs and breakfast meat, lettuce mix, ground turkey, frozen potatoes, frozen chicken, and other products—were found unsealed, unlabeled, and undated. Dietary staff and the ADM acknowledged that food should be placed in sealed containers or bags and labeled and dated, and reported that they had seen food improperly stored despite training. Facility policies required open dry foods to be kept in closed, labeled containers with tight covers and required refrigerated foods returned to storage after cooking or prep to be covered and labeled with contents and date, but these requirements were not followed for the items observed, affecting all residents who receive meals from the kitchen.
Food Service Failed to Provide Palatable, Properly Cooked Meals at Appropriate Temperatures: Residents reported late meal service, cold and unappetizing food, missing beverage and food preferences, and lack of snacks and fresh fruit. During a resident council meeting, staff and residents reported raw chicken, raw ground meat, and undercooked potatoes being served. The ADM acknowledged food complaints, staffing shortages in dietary, and confirmed a chicken preparation error that left the outside burnt and the inside raw.
Improper Food Storage, Temperature Control, and Sanitation: A kitchen deficiency was identified when multiple food items were found uncovered, unlabeled, undated, or out of date, including items with moldlike substance and a personal beverage stored with resident food. Staff also failed to sanitize the thermometer and puree blender between items, wore the same gloves throughout food prep, and served a meat loaf at 126.1 degrees F without recording the temp or bringing it to the required 140 degrees F.
Improper storage of expired medications and opened sterile supplies was found in the Hall 300 med storage room. Surveyors observed opened sterile wound dressings still in stock and a bottle of zinc 50 mg tablets that had expired, while CNA A, an LVN, the DON, and the ADM all stated that expired or opened items were to be discarded per facility policy.
Clean resident gowns were observed stored uncovered on the dirty side of the laundry room, even though they were folded and appeared ready for use. LA C and the ESD confirmed the gowns were clean laundry, but the ESD stated they would need rewashing before use because they were stored on the dirty side. Staff and leadership interviews and facility policy all reflected that clean and dirty laundry should be kept separate to prevent cross-contamination.
An LVN left a computer unlocked and unattended at the nurse's station, displaying residents' medical information in an area accessible to others. The LVN stated she was trained to leave the computer this way, while facility leadership confirmed staff are responsible for securing resident information on computers.
The facility did not submit a Provider Investigation Report (Form 3613-A) to HHSC after an allegation of misappropriation of property involving a resident, despite facility policy and state regulations requiring this report within five working days. The Administrator believed the initial online report was sufficient and did not complete the required form, resulting in noncompliance with reporting requirements.
The facility did not consistently serve meals at scheduled times, resulting in residents, including those with chronic medical conditions, experiencing late breakfasts, lunches, and dinners on multiple occasions. Staff and residents reported that meal delays were due to kitchen disorganization and staffing issues, with some meals served several hours late, causing residents to feel hungry and neglected.
A staff member failed to treat a resident with severe cognitive impairment and a history of anxiety and aggression with respect and dignity during personal care. The staff member admitted to making unprofessional statements out of frustration, and the resident's family reported rough handling and inappropriate comments. Facility policy requires respectful treatment, but the staff member's actions did not meet these standards, as confirmed by investigation and video evidence.
The facility failed to ensure proper pharmaceutical services by allowing medication blister cards with unapproved tape corrections from the pharmacy to be accepted and used without staff training or policy guidance, and by permitting inaccurate documentation of narcotic counts, including marking medications as wasted when they were not. Multiple residents with complex medical needs were affected, and staff interviews revealed a lack of awareness and training regarding these practices.
Three residents with complex medical histories received double doses of narcotic pain medications after a medication aide failed to document administration in the EMR, leading a nurse to administer a second dose. The incident was not documented in progress notes, residents were not monitored for adverse effects, and responsible parties were not notified, in violation of facility policy.
A resident with multiple complex medical conditions had an out-of-range lithium lab result that was not communicated to the responsible party. Nursing staff reviewed and filed the result for practitioner review but did not notify the responsible party due to unclear processes and communication lapses among staff. Facility leadership confirmed that the responsible party should have been informed, in accordance with resident rights policies.
A CNA failed to treat a resident with respect and dignity by speaking about unrelated and inappropriate topics while preparing to provide care to a dependent resident with Alzheimer's and cognitive deficits. The resident's care plan required staff to communicate clearly and respectfully, but the CNA's actions did not align with these expectations, as confirmed by video evidence and the facility's administrator.
A resident with Alzheimer's Disease and significant communication and self-care deficits was injured when two CNAs failed to properly use a mechanical lift during a transfer, causing the resident's head to strike the wall. The transfer was performed without aligning the sling or locking the lift, contrary to the resident's care plan, resulting in immediate pain and distress for the resident.
A dietary aide was observed preparing and serving food without properly wearing a beard net, despite having visible facial hair. Interviews with the aide and facility leadership confirmed awareness of the policy requiring beard restraints in the kitchen, but the policy was not consistently enforced.
A resident with severe cognitive impairment and aggressive behavior was pushed by a CNA, resulting in a fall. The incident was captured on video, contradicting staff reports. The resident was left unassessed for 30 minutes, leading to a deficiency finding.
A resident with severe cognitive impairment and aggressive behaviors fell after being pushed by a CNA. The resident was not immediately assessed for injuries, contrary to facility policy. The incident was captured on video, and the family member reported the lack of assessment to the facility, leading to a care plan meeting where the deficiency was confirmed.
The facility failed to store and label food items properly in the kitchen's walk-in refrigerator and freezer, with several items lacking labels and dates. Dietary aides were unsure of food handling policies and had not received training. The dietary manager was unavailable for guidance, and no in-service training had been conducted on food handling since January 2024.
The facility failed to document medication administration for three residents, leading to potential medication errors. An LVN did not record doses of Lorazepam, Tramadol, and Ativan in the MAR, despite being logged in the controlled drug log. The DON confirmed the requirement for immediate documentation in the MAR, highlighting a lapse in adherence to facility policy and nursing standards.
Improper Labeling and Storage of Opened Food Items in Kitchen
Penalty
Summary
The deficiency involves the facility’s failure to store, prepare, distribute, and serve food in accordance with professional standards and its own policies for dry storage and refrigerated food. During a kitchen observation, surveyors found multiple opened food items in the pantry, refrigerator, and freezer that were not properly sealed, labeled, or dated. These included an opened bag of cocoa with the top rolled down, an opened bag of cake mix in an unlabeled and undated zip bag, an unsealed and undated bag of lettuce mix, an unlabeled and undated plastic container of a jello and fruit-like substance, metal containers of cooked eggs and cooked breakfast meat that were not labeled or dated, and an open zip bag of ground turkey without a label or date. In the freezer, surveyors observed an opened, unlabeled, undated bag of hashbrowns, an open box with an open bag of frozen egg products, and opened, unlabeled, undated bags of frozen potatoes and frozen chicken breasts. During interviews, the dietary manager acknowledged that all the opened, unlabeled food items identified by surveyors were not stored properly and stated that staff knew they should label and date open items and store them in appropriate sealed containers. Dietary staff members reported they had received training on proper food storage and described expectations that opened food be covered or placed in sealed containers or bags, then labeled and dated, but also reported having seen food improperly stored and noted that some shifts were better than others about following these practices. The administrator stated her expectation that food be sealed, labeled, and dated, and expressed concern that improper storage could lead to expired food and exposure to bacteria, creating an infection control issue. Facility policy for dry storage required open packages of food to be stored in closed containers with tight covers and dated as to when opened, and the refrigeration policy required food returned to storage after cooking or preparation to be covered and all containers labeled with contents and date placed in storage. All 113 residents were reported to receive food from the kitchen.
Food Service Failed to Provide Palatable, Properly Cooked Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at a safe and appetizing temperature for 5 of 13 residents reviewed for dietary services, including Residents #13, #37, #53, #58, and #79. Record review showed these residents had diagnoses and care plans identifying nutritional risk, therapeutic diets, food preferences, and the need for food and fluids as ordered. Resident #13 had a history of enterocolitis from C. difficile, moderate protein-calorie malnutrition, and depression with psychotic symptoms, with a care plan noting a preference for hamburgers and eggs. Resident #37 had diagnoses including hypothyroidism, spinal fusion, bone density disorder, hyperlipidemia, and hypertension, with a care plan requiring diet and fluids as ordered and offering food preferences. Resident #53 had dementia with anxiety, hypertensive chronic kidney disease, and iron deficiency anemia, with a care plan for therapeutic diet and fluids. Resident #58 had atrial fibrillation, morbid obesity, hyperlipidemia, and hypertension, with a care plan addressing therapeutic diet, dietary likes and dislikes, and nutritional risk. Resident #79 had mild dementia, type 2 diabetes, severe obesity, and GERD, with a care plan requiring diet and fluids as ordered, including food preferences and alternatives within dietary restrictions. During lunch observation, meal service was delayed and varied by unit, with meals transported to dining rooms at consecutive times rather than being served consistently at the posted times. Facility grievance forms for December 2025 showed resident complaints about late meal service and dietary preferences. In interviews, Resident #79 stated the food was horrible, did not taste as expected, was often served cold because of slow service, and that a diet soda listed on meal tickets was sometimes not provided. The resident also stated fresh fruit was not served despite requests. Resident #53 stated the taste and temperature of the food were not good and that coffee was often unavailable when requested with meals. At a resident council meeting, residents reported that they were unaware snacks were available, that food taste and appearance were consistently unappetizing, that substitutions were rarely provided as requested, that meals were served late, and that fresh fruit was never served or was rarely served. Residents also reported that kitchen staff failed to read food preference requests. The same meeting included reports that Residents #37, #57, and #79 were served raw chicken and ground meat, and that residents were served raw potatoes cut in half. The ADM stated she was aware of some food complaints, that the DM had been hired 2 months earlier, that the former dietary manager had been fired due to food complaints, and that the kitchen was short 2 dietary aides. She also stated she had received a complaint about raw chicken being served and confirmed that the chicken had been cooked too fast, burnt on the outside but raw on the inside. The facility policy required nourishing, palatable, well-balanced food served in adequate amounts, at the proper temperature, on schedule, and prepared in accordance with professional food preparation practices.
Improper Food Storage, Temperature Control, and Sanitation
Penalty
Summary
Food was not stored, prepared, and served in accordance with professional foodservice standards in the kitchen. During observation of the walk-in cooler, multiple items were found improperly stored or out of date, including heavy cream past its expiration date, uncovered buckets of pickled eggs and pickles, celery with no expiration date, an open bag of greens, squash with a moldlike substance, strawberries with a mold-like substance, and an open personal-sized bottle of coffee. In the kitchen, cereal and powdered sugar were left open and exposed, sugar was not labeled with an expiration date, several loaves of bread were not dated, and the juice dispenser and coffee maker had old residue under the machines. Food handling practices during meal preparation and temperature monitoring were also not followed. While temperatures were being taken on the warming table, staff used a paper towel or the glove on their hand to wipe the thermometer before checking another item. During puree preparation, the blender was not sanitized between food items, and the same gloves were worn throughout the process while touching multiple kitchen surfaces and items, including the oven handle and a container of thickening powder. Staff interviews confirmed that the thermometer should be sanitized between items, the blender should be sanitized between each food item, and personal food items were not supposed to be stored in the kitchen cooler. A meat loaf on the warming table was taken at 126.1 degrees Fahrenheit, but the temperature was not recorded and the meat loaf was served to residents without being brought to the required 140 degrees Fahrenheit internal temperature. Interviews with kitchen and administrative staff confirmed that food items should be labeled, dated, sealed, and discarded when out of date, that temperatures should be recorded, and that sanitation should occur between food items. The facility’s food storage and cleaning policies were reviewed and reflected requirements for temperature control and cleaning of food contact surfaces and utensils.
Improper Storage of Expired Medications and Opened Sterile Supplies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored properly in 1 of 2 medication storage rooms reviewed, specifically the Hall 300 medication storage room. Observation of the room revealed 2 packages of 4x4 sterile wound dressings that were opened but still in stock for use, 1 package of 4x4 sterile silver wound dressing that was opened but still in stock for use, and 1 bottle of zinc 50 mg tablets that had expired on 11/30/2025. During interviews, CNA A, LVN B, the DON, and the ADM each stated that expired medications and opened or expired medical supplies were to be discarded, with nursing responsible for removing expired items. The facility's undated Storage of Medications policy stated that no discontinued, outdated, or deteriorated medications are to be available for use and that all such medications are destroyed, and that medications are to be stored in a safe, secure, and orderly manner.
Clean Linen Stored on Dirty Side of Laundry Room
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for the laundry room. On 12/30/2025 at 3:35 pm, surveyors observed one shelf of clean linen, specifically resident gowns, stored on the dirty side of the laundry room. The gowns were folded, stacked neatly, and appeared ready for use, but they were not covered or protected while on the dirty side. There was also no signage giving directions on the use of the gowns. During interviews, the LA C stated the gowns on the shelf were clean laundry but did not know why they were stored on the dirty side or why they were uncovered. The ESD stated the laundry on that shelf was clean laundry, but anything on the shelf would need rewashing before use because it was stored on the dirty side. CNA A, LVN B, the DON, and the ADM all stated that clean and dirty laundry should not be mixed and should be kept separate, with the DON and ADM noting that separation was important to prevent cross-contamination. Record review showed the facility's policies stated soiled laundry must be kept separate from clean laundry and that contaminated laundry and all other laundry shall be kept separated.
Unattended Computer with Resident Information Visible at Nurse's Station
Penalty
Summary
A deficiency occurred when an LVN left a facility computer open and unattended at the nurse's station, with residents' personal medical information visible to anyone passing by. The observation took place while the LVN was approximately 35 feet away, passing medication, leaving the computer screen displaying sensitive information in an open area accessible to residents, visitors, and guests. During interviews, the LVN stated she believed it was acceptable to leave the computer unlocked with resident information displayed, as that was how she was trained, though she could not recall who provided this instruction. Further interviews with the ADON, DON, and ADM confirmed that the responsibility for securing resident information on computers lies with the staff member using the device. Each acknowledged that leaving a computer unattended with resident information visible could result in unauthorized access. Review of the facility's HIPAA Privacy Notice Acknowledgment indicated that employees are required to protect personal health information and that violations could result in termination and reporting to the Employee Misconduct Registry.
Failure to Submit Required Investigation Report for Misappropriation Allegation
Penalty
Summary
The facility failed to report the findings of an investigation into an allegation of misappropriation of property involving a resident, as required by state law. Although the initial incident was reported to the Texas Health and Human Services Commission (HHSC) on the date of occurrence, a Provider Investigation Report (Form 3613-A) was not submitted through the TULIP system. Record review confirmed the absence of the required report, and the Administrator stated during interview that she believed submitting the initial report online fulfilled the reporting requirement, and therefore did not complete the 3613-A form. Facility policy requires the Administrator and Director of Nursing to investigate and report all alleged violations, including misappropriation of resident property, and to submit findings in accordance with state regulations. State guidance specifies that a Provider Investigation Report must be submitted within five working days of the incident, including all investigation findings and any additional information obtained. The failure to submit the required investigation report for the incident involving misappropriation of property resulted in noncompliance with state reporting requirements.
Failure to Provide Timely Meal Service to Residents
Penalty
Summary
The facility failed to provide residents with meals at regular, scheduled times in accordance with their needs, preferences, and requests, as well as the facility's own designated meal service schedules. Multiple residents reported and staff confirmed that meals, including breakfast, lunch, and dinner, were often served late, sometimes by several hours. For example, lunch was served as late as 2:00 PM when it was scheduled for 11:30 AM-12:30 PM, and dinner was once served at 8:00 PM. These delays occurred on multiple occasions over the course of at least two months. Residents affected by these late meals included individuals with significant medical histories, such as chronic kidney disease, hypertension, and neuropathy, all of whom were cognitively intact and able to report their experiences. Residents described feeling hungry, unpleased, and forgotten due to the late meal service. Staff interviews corroborated these accounts, with explanations including disorganization in the kitchen and a specific incident where the head cook left unexpectedly, resulting in a significant delay in meal preparation and service. Staff, including the dietary manager, LVN, DON, and administrator, acknowledged that late meals had occurred multiple times and recognized the potential negative impact on residents, such as hunger and possible interference with medication administration. The facility's own documentation indicated that meals were to be served at regular hours, but this standard was not consistently met, as evidenced by both resident and staff testimony and direct observation.
Failure to Ensure Resident Dignity and Respect During Personal Care
Penalty
Summary
A deficiency occurred when a staff member failed to treat a resident with respect and dignity during the provision of personal care. The resident, an elderly woman with Alzheimer's disease, depression, and anxiety disorder, was admitted to the facility with a history of resisting or refusing care and exhibiting physical and verbal aggression. The resident also had severe cognitive impairment, as indicated by a BIMS score of 00, and difficulty communicating her needs. The incident was identified through observation, interviews, and record reviews. The staff member involved admitted to being frustrated with the resident due to a demanding workload and acknowledged making unprofessional statements to the resident. The resident's family reported that the staff member told the resident not to touch them and that there was no one available to help. Additionally, a family member reported that the night aide was rough with the resident, although a subsequent skin assessment revealed no marks or bruises. Facility policy requires that residents be treated with respect and dignity and be free from abuse and neglect. Despite this, the staff member's actions during personal care did not meet these standards, as confirmed by the staff member's own admission and by video evidence reviewed during the facility's investigation. The deficiency was substantiated by the facility's investigation and interviews with administrative staff.
Failure to Ensure Proper Pharmaceutical Services and Medication Handling
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of residents, as evidenced by improper handling and documentation of medications, and lack of staff training regarding pharmacy procedures. Observations revealed that two medication blister cards, one for each of two residents, had white tape on the reverse side, which staff interpreted as potential tampering. Multiple staff members, including LVNs and medication aides, reported they had not received training on the acceptance of medication cards with tape or patches from the pharmacy, and were unaware of any facility policy allowing such cards to be accepted. The pharmacy later confirmed that tape was used to correct errors, but there was no written agreement or policy in place to guide staff on this practice. A facility audit identified an additional thirteen blister cards with similar tape, and the facility lacked a policy addressing the use of tape patches by the pharmacy or the acceptance of such cards by nursing staff. Additionally, a narcotic count sheet reconciliation error was discovered during a shift change. An LVN marked a medication as wasted on the count sheet when it had not been wasted, following the direction of the DON, who later acknowledged that this was not the correct procedure. The LVN and DON both signed the correction, despite knowing the information was inaccurate. The nurse involved later realized the error and expressed concern about the potential consequences of falsifying narcotic count sheets. The DON admitted to instructing the LVN to mark the medication as wasted, even though it had actually been administered to another resident, and acknowledged that this was not the appropriate action. The residents involved had significant medical histories, including dementia, chronic pain, and other comorbidities, and were receiving narcotic pain medications as part of their care. Documentation review showed that medication errors and discrepancies were not always recorded in the residents' progress notes, and staff interviews confirmed a lack of training and clear procedures regarding the handling of medication cards with tape or patches. Facility policies on receiving medications and shift change procedures required immediate notification of discrepancies, but did not address the specific issue of pharmacy-applied tape or patches, contributing to confusion and improper medication handling.
Failure to Prevent and Document Double Dosing of Narcotic Medications
Penalty
Summary
A deficiency occurred when three residents received double doses of their scheduled narcotic pain medications due to failures in medication administration and documentation. Specifically, a medication aide administered narcotic pain medications to three residents but did not sign off the administration in the electronic medical record (EMR), only on the narcotic count sheet. The aide wrote the medication administration on a piece of paper and gave it to the nurse on the next shift, who subsequently forgot about the note and, seeing the medications still due in the EMR, administered a second dose to each resident. Both staff members acknowledged they had been trained that the person administering the medication is responsible for signing off in both the EMR and the narcotic count sheet. The residents involved had complex medical histories, including dementia, chronic pain, and other significant diagnoses. The double dosing of narcotic medications was not documented in the residents' progress notes, and there was no follow-up monitoring of the residents for adverse effects after the error. Additionally, responsible parties for the residents were not notified of the medication errors, and the errors were not included in the 24-hour report to inform subsequent shifts. The facility's policy required prompt reporting of medication errors, detailed documentation, and close monitoring of affected residents, none of which were followed in this incident. Interviews with facility staff, including the DON, administrator, and medical director, confirmed that the required documentation, monitoring, and notifications were not completed. The medical director expressed concern about the lack of follow-up monitoring, stating that vital signs and respiratory status should have been checked due to the risk of narcotic overdose. The failure to adhere to established medication administration and error reporting protocols led to the identification of an Immediate Jeopardy situation by surveyors.
Removal Plan
- Responsible parties for Residents #1, #2, and #3 were contacted and made aware of the med errors.
- The Medical Director was made aware of past med error.
- Missed Medication Report was pulled to ensure no other residents were administered narcotics twice.
- Review of all Narcotic sheets was completed to ensure that there were no double doses of narcotics based on the sign out sheets and comparing to nurse notes and EMARs.
- ADONs are reviewing count sheets daily to ensure no double doses have been administered.
- The Chief Operating Officer and Director of Clinical Operations educated the DON and Administrator with a posttest to show understanding.
- The Director of Nurses provided training to the nurses and medication aides on duty with a post test to show understanding.
- Training for nurses and med aides on duty was provided with a post test to show understanding.
- Training was concluded for all staff on-site.
- Training will be concluded for those not present; they will be educated and required to pass a post test before they take their next assignment.
- New hires will receive training from the DON or designee during new hire orientation.
- The person who made the error(s) received an in-service and a disciplinary action.
- Residents with med errors were assessed and all notifications were made and documented by the ADON and CHARGE NURSE.
- Ad-Hoc QAPI meeting was held to discuss medication errors and failure to document; in-services over administering medications, medication errors, and notifications and reviewed post test for administering medications.
- Missed Medications report will be run during daily stand-up meeting to review medications that were missed.
- Any medication errors, the staff member will be contacted and an in-service and disciplinary action (where necessary) will be initiated.
- All nursing staff who administer medications will be given reminder education over the policy and procedures by the DON or Nurse Managers that will be initiated immediately following the med error until all staff who administer medications has received re-education.
- The ADONs are reviewing count sheets to ensure no one has been double dosed or that a dose has been missed and not documented in the EMAR. This is part of their morning routines.
- Missed Medication Report will be run prior to daily stand-up meeting by the DON. This will be an ongoing process.
Failure to Notify Responsible Party of Out-of-Range Lab Result
Penalty
Summary
The facility failed to ensure that a resident and their responsible party were fully informed of the resident's health status and treatment, specifically regarding an out-of-range lithium lab result. The resident, a male with a history of traumatic subarachnoid hemorrhage, type 2 diabetes, bipolar disorder, depression, hypertension, kidney disorder, and stroke, was admitted with moderate cognitive impairment. A lab order for a lithium level was placed, and the result returned as high, outside the reference range. Upon receipt of the lab result, nursing staff reviewed and filed the result in the practitioner folder for physician review, but did not notify the resident's responsible party. Interviews with staff revealed confusion and inconsistency in the process for communicating abnormal lab results. The charge nurse on duty was unaware the result had been received and did not notify the responsible party, as the result was not handed directly to her. The ADON who received the result placed it in the folder, following what she described as normal practice, but did not ensure the charge nurse was aware or that the responsible party was notified. Further interviews with facility leadership, including the DON and administrator, confirmed that the expectation was for the charge nurse to notify the responsible party of out-of-range lab results. However, due to recent changes in workflow and lack of clear communication, this did not occur. The facility's policy states that residents have the right to be fully informed of their health status and care, but this was not followed in this instance.
Failure to Treat Resident with Dignity During Care
Penalty
Summary
A certified nursing assistant (CNA) failed to treat a resident with respect and dignity while providing care. The incident involved a male resident with Alzheimer's Disease, cognitive communication deficit disorder, and an ADL self-care performance deficit, who was dependent for activities of daily living and had impaired cognition. The resident's care plan required staff to face him, make eye contact, introduce themselves, and explain care procedures prior to beginning care. However, video footage showed the CNA in the resident's room talking about unrelated, non-sensical matters, including statements such as, "You aren't going to be doing anything to me. Trust me, I ain't scared. The way I found this one, I'll find another. Doesn't scare me one little bit. I can guarantee you that," while preparing to provide care. The resident's representative confirmed the details observed in the video and expressed concern about staff attitudes toward residents. The facility's administrator acknowledged that the CNA's behavior was inappropriate and that staff should focus on the resident and their comfort during care. The facility's policy states that residents have the right to a dignified existence and to be treated with respect and dignity. The CNA's actions did not align with these requirements, resulting in a failure to promote or maintain the resident's quality of life.
Improper Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision during a transfer involving a male resident with Alzheimer's Disease, cognitive communication deficit, and ADL self-care performance deficit. The resident required a mechanical lift and two-person assistance for transfers, as documented in his care plan. On the date of the incident, two CNAs used a mechanical lift to transfer the resident from a Geri-chair to his bed. The bed was positioned against the wall, and the CNAs moved the lift quickly without properly aligning the sling or locking the lift. As a result, the resident's head struck the wall, and he immediately showed signs of pain and shock. Video footage confirmed the improper transfer technique, and interviews with staff revealed a lack of recall of the incident by the involved CNAs. The resident's care plan specified the need for careful positioning and supervision during transfers, which was not followed. The incident was observed by the resident's representative, who reported concerns about staff attitudes and care. Documentation and interviews confirmed that the required safety procedures for mechanical lift transfers were not adhered to, directly leading to the resident's injury.
Failure to Enforce Beard Restraint Policy in Food Service Area
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed in accordance with professional standards for food service safety. Specifically, a dietary aide (DA A) was observed in the kitchen near serving tables without wearing a beard restraint, despite having visible facial hair including sideburns, a mustache, and a beard. On another occasion, DA A was seen in the kitchen with the beard net pulled down underneath their chin while moving about the serving, drink, and dessert tables. Interviews with DA A, the dietary manager (DM), the director of nursing (DON), and the administrator (ADM) confirmed that all dietary staff were aware of the policy requiring hair and beard nets in the kitchen to prevent food contamination. The facility's policy mandates that all dietary staff wear hairnets in food preparation areas and that anyone with a beard must wear a beard net. These observations and interviews demonstrate that the facility did not consistently enforce its own policy regarding beard restraints for staff involved in food preparation and distribution.
Failure to Protect Resident from Abuse Leading to Fall
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in a fall incident involving a CNA and RN. The resident, who had severe cognitive impairment and a history of aggressive behavior, was being assisted to his room when he became combative. During this interaction, the CNA was observed on video pushing the resident, causing him to fall and hit his bed before landing on the floor. The staff then assisted the resident to his feet and left the room without conducting an immediate assessment or checking his vital signs. The resident's family member reviewed the video footage and observed the push, which contradicted the staff's initial reports that the resident had fallen on his own. The family member was upset by the incident and reported that the resident was left alone for approximately 30 minutes before being assessed by the facility's PA. The resident sustained a scratch and an abrasion, which were not immediately documented or addressed by the staff present at the time of the fall. Interviews with facility staff, including the AD and DON, revealed discrepancies in the accounts of the incident and the actions taken afterward. The CNA involved was suspended, and the RN received additional training. The facility's failure to immediately assess the resident after the fall and the lack of communication with the resident about his condition were significant factors in the deficiency identified by the surveyors.
Failure to Assess Resident After Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice following a fall incident. The resident, who had severe cognitive impairment and a history of aggressive and combative behaviors, fell on 5/27/2024 while being assisted to his room by a nurse and a CNA. The fall occurred after the resident exhibited combative behavior, and the CNA was observed on video pushing the resident, causing him to lose balance and fall. Despite the fall, the resident was not immediately assessed for injuries by the attending nurse, RN B, who left the room with the CNA after the resident continued to exhibit aggressive behavior. The resident's family member (FM) was informed of the fall and arrived at the facility approximately 30 minutes later. Upon reviewing video footage of the incident, the FM observed that the resident was pushed by the CNA and left alone in the room without being assessed for injuries. The FM reported their concerns to the facility, leading to a care plan meeting the following day. During this meeting, the FM showed the video footage to the Assistant Director (AD) and the Director of Nursing (DON), who confirmed the lack of immediate assessment and the inappropriate actions of the CNA. The facility's policy on post-fall management requires immediate assessment of residents for injuries, including pain and neurological assessments. However, the resident was not assessed until the facility's Physician Assistant (PA) arrived approximately 30 minutes after the fall. The delay in assessment and the failure to follow the facility's policy on post-fall procedures contributed to the deficiency, as the resident's injuries, including a scratch and an abrasion, were not identified until the following day.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen's walk-in refrigerator and freezer. Several food items were found improperly stored, lacking labels, and missing dates indicating when they were opened or prepared. Specific items included a plastic container with a pink substance identified as ham, a container with chopped mixed vegetables, a steel tray with sandwiches, and a cardboard box with packets of ham, all without proper labeling. Additionally, there were containers with substances like peach, coleslaw, and baked chicken, some with outdated stickers, and others without any date or identification. Food items were also improperly stored on the floor in both the refrigerator and freezer. Interviews with dietary aides (DA B and DA C) revealed a lack of training and understanding of the facility's food handling policies. DA B, who had recently started working at the facility, was unsure about the policy regarding the storage duration of prepared or opened food items, initially suggesting a 3-day limit, then reconsidering to 5 days. DA C also expressed uncertainty about the shelf life of prepared foods and confirmed the absence of training on food handling. The facility administrator (ADM) acknowledged that the dietary manager (DM) was unavailable during weekends and could not be reached for guidance. A review of in-service records showed no training sessions on food preparation, labeling, and storage between January and May 2024, despite the facility's policy requiring all containers to be labeled with contents and storage dates, and previously cooked foods to be discarded after seven days.
Medication Documentation Deficiency
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of three residents, as evidenced by the lack of proper documentation of medication administration in the Medication Administration Record (MAR). Licensed Vocational Nurse (LVN) A did not document the administration of medications for three residents, which could lead to medication administration errors and potential overdosing. The Director of Nursing (DON) confirmed that any medication administered should be recorded in the MAR immediately, and if a scheduled medication was not given, the reason should be documented. Resident #1, a female with multiple diagnoses including Alzheimer's disease and anxiety disorder, had several doses of Lorazepam recorded in the controlled drug log but not in the MAR. Resident #2, with conditions such as hemiplegia and chronic kidney disease, had a dose of Tramadol recorded in the controlled drug log but not in the MAR. Resident #3, with diagnoses including type 2 diabetes mellitus and dementia, had several doses of Ativan recorded in the controlled drug log but not in the MAR. These documentation errors were attributed to LVN A, who was new to the facility and worked the night shift. The facility's policy mandates that all medication administrations be documented in the MAR, and the Texas Board of Nursing requires accurate and complete documentation of medication administration. The DON acknowledged the lack of auditing for medication documentation errors and the absence of in-service training on medication administration documentation. The facility's policy and the Texas Board of Nursing standards emphasize the importance of accurate documentation to ensure safe medication practices.
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 69 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) |
|---|---|---|---|---|
| Avir At Waco | 0.8 mi | ★★★★★ | 7 | 0 |
| Woodway Rehabilitation And Healthcare Center | 1.7 mi | ★★★★★ | 2 | 0 |
| Hewitt Nursing And Rehabilitation | 1.9 mi | ★★★★★ | 2 | 0 |
| St. Anthony's Care Center | 2.3 mi | ★★★★★ | 4 | 0 |
| Greenview Nursing And Rehabilitation | 2.7 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Wesley Woods Health & 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.