Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Woodway Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility did not follow its abuse investigation policies after an incident where one resident was found holding another on the floor. Both residents had severe cognitive impairment and could not explain the event, and staff did not witness what happened. The only investigation conducted was a brief note, and the abuse coordinator did not complete a thorough review as required by facility policy.
Two residents with severe cognitive impairment were involved in a physical altercation, with one resident found holding another on the floor while staff responded to calls for help. Although the incident was reported internally, it was not reported to the state agency within the required 24-hour period, as facility leadership did not consider it abuse due to lack of witnesses and injuries. The facility's policy and regulatory requirements for timely reporting of alleged abuse or neglect were not followed.
Expired lab swabs and tubes were found in a medication storage room, despite facility policy requiring their removal and destruction. Staff interviews confirmed that nurses and managers were responsible for checking for expired items, but these supplies remained in stock past their expiration dates.
A resident with severe cognitive impairment and multiple health conditions was improperly fed health shakes through a syringe while unresponsive, against facility protocol. The CNA involved was instructed by a night nurse to use the syringe, despite not being trained for such procedures. The DON confirmed that syringe feeding was not standard practice and posed risks of aspiration. Interviews with the resident's family, medical director, and hospice nurse revealed no recommendation for syringe feeding, highlighting a failure to follow professional standards and the resident's care plan.
A resident with severe cognitive impairment and on hospice care was improperly fed health shakes via syringe by a CNA, despite being unresponsive. This action, contrary to facility protocol, was based on incorrect instructions from a night nurse. The facility failed to ensure nursing staff had the necessary competencies, leading to a risk of aspiration and choking.
A facility failed to update a comprehensive care plan for a resident receiving hospice services. The resident, with severe cognitive impairment and multiple diagnoses, did not have her care plan updated to include hospice services, despite a physician's order. Staff interviews revealed that the MDS Coordinator missed updating the care plan, which was necessary for communicating the resident's care needs. The facility's policy required care plan revisions upon status changes, but this was not adhered to, resulting in a deficiency.
A resident with severe cognitive impairment was involved in a physical altercation with a CNA, who retaliated after being slapped by the resident. The incident was captured on video, showing the CNA slapping the resident back and pulling her into a seated position. Despite the facility's policy requiring immediate suspension of staff accused of abuse, the CNA was allowed to finish her shift. The charge nurse was not informed until later, and the facility administrator delayed action, contributing to the deficiency.
A facility failed to implement its abuse prevention policies when a CNA slapped a resident in retaliation after being slapped first. The incident was captured on video, but the CNA was allowed to continue working her shift, violating the policy requiring suspension during investigations. The resident, with a history of cognitive impairments, was at risk of further harm due to the facility's inaction. The situation was identified as Immediate Jeopardy, indicating serious lapses in the facility's protocols.
A CNA in a memory care unit slapped a resident with severe cognitive impairment after being slapped by the resident. Despite the incident being reported, the CNA was not immediately suspended and continued working with other residents for several hours. The facility's administration delayed action, citing uncertainty about the nature of the abuse, which was against the facility's policy requiring immediate suspension of employees accused of abuse.
A facility failed to report an abuse incident within the required timeframe. A resident with severe cognitive impairment slapped a CNA, who retaliated by slapping the resident back and pulling her into a seated position. The incident, witnessed at 11:51 AM, was not reported to the Administrator until 2:17 PM, and the Administrator delayed reporting to HHSC until the next day, exceeding the mandated two-hour window. This delay placed residents at risk of harm.
The facility failed to ensure call lights were within reach for four residents, impacting their ability to request assistance. Observations showed call lights were inaccessible, and interviews with residents and staff confirmed this issue. The facility's policy on call light accessibility was not followed, leading to unmet resident needs.
A facility charged an inflated fee for a resident's medical records due to an outdated policy not reflecting updated Texas Health and Safety Code guidelines. The resident's representative was overcharged $116.28, as the facility's policy was not updated until months after the new guidelines took effect. The error was attributed to corporate oversight during a leadership change.
The facility failed to ensure that a resident with severe cognitive impairment had access to a call light within reach, as required by policy. Observations and interviews revealed that the call light was repeatedly found on the floor, out of the resident's reach, posing risks such as falls and delayed assessments.
Failure to Implement Abuse Investigation Procedures
Penalty
Summary
The facility failed to implement its written policies and procedures regarding the investigation of abuse for two residents reviewed for abuse and neglect. An incident occurred in which one resident was found holding another resident down on the floor after staff responded to calls for help. Both residents involved had severe cognitive impairments, and neither could provide a clear account of the incident. Staff did not witness the event, and no injuries were noted at the time. The incident was documented in nursing notes and incident/accident investigation worksheets, but the investigation summary indicated a lack of clarity about what caused the incident and no witnesses to the event. Despite the facility's policy requiring an immediate investigation upon any allegation or suspicion of abuse, the abuse coordinator did not conduct a thorough investigation following the incident. The only documentation of the investigation was a brief typed note provided by the DON and interim administrator, which lacked detail and did not meet the facility's policy standards. The DON stated that she did not consider the incident to be abuse due to the absence of witnesses and injuries, while the interim administrator acknowledged that any unprovoked physical contact between residents should warrant an investigation by the abuse coordinator. The facility's policy, last reviewed in May 2025, specifies that the administrator is responsible for determining necessary actions to protect residents and that an immediate investigation is warranted when abuse is suspected or reported. However, the investigation into the incident involving the two residents was insufficient, as it did not follow the required procedures or provide a comprehensive review of the circumstances, leading to a deficiency finding by surveyors.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse or neglect were reported to the administrator and the state agency within 24 hours, as required. Specifically, an incident occurred in which one resident was found holding another resident down on the floor, with the second resident attempting to release himself and calling for help. Staff responded to the incident, and both the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were notified immediately. However, the incident was not reported to the state agency within the required timeframe, as it was not considered abuse by the DON due to the lack of witnesses, inability of the residents to recount the event, and absence of injuries. The residents involved both had severe cognitive impairments and multiple medical diagnoses, including progressive neurological conditions, Alzheimer's disease, seizure disorder, anxiety, depression, and psychotic disorder for one resident, and heart failure, renal failure, diabetes, non-Alzheimer's dementia, anxiety, depression, insomnia, and malnutrition for the other. Both residents had care plans addressing behavioral issues, such as wandering and potential for physical aggression, with interventions in place to manage these risks. Despite these care plans, the incident of physical aggression occurred, and the facility's response did not meet regulatory requirements for timely reporting. Interviews with facility leadership revealed a lack of consensus and understanding regarding what constitutes reportable abuse, particularly in cases without witnesses or visible injuries. The interim administrator and DON provided differing interpretations of the reporting requirements, and the only documentation of the investigation was a brief typed note. The facility's own policy required immediate reporting of suspected abuse or neglect to the administrator and appropriate agencies, but this was not followed in this case.
Expired Lab Supplies Found in Medication Storage Room
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, as evidenced by the presence of expired lab testing supplies in one of two medication storage rooms. During an observation, multiple expired lab swabs and tubes were found in the medication storage room near the nurse's station, with expiration dates ranging from February 2023 to January 2025. The facility's policy required that all medication rooms be routinely inspected for discontinued or outdated medications and supplies, and that these items be destroyed. Interviews with staff, including an LVN, MA, DON, and the administrator, confirmed that the policy was to remove and dispose of expired medications and lab supplies, with responsibility for checking the medication rooms assigned to various nursing staff and managers. Despite these policies and assigned responsibilities, expired lab supplies remained in the medication storage room, indicating a failure to follow established procedures for the removal and destruction of outdated items.
Improper Feeding Practices for Unresponsive Resident
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for a resident with severe cognitive impairment and multiple health conditions, including Alzheimer's disease, dementia, hypertension, and bradycardia. The resident, who was receiving hospice services, was unresponsive and required substantial assistance with activities of daily living. Despite this, facility nurses administered health shakes through a 60ML syringe by mouth while the resident was unresponsive, which is against the facility's protocol and professional standards. The deficiency was identified when a CNA, who was working her first day at the facility through an agency, was observed preparing to administer a health shake to the unresponsive resident using a syringe. The CNA stated she was instructed by a night nurse to use the syringe to prevent dehydration, although this was not part of the facility's protocol. The CNA had not received formal training on feeding unresponsive residents or using a syringe for feeding. The Director of Nursing (DON) confirmed that syringe feeding was not a normal practice and posed a risk of aspiration pneumonia. Interviews with the resident's family member, the medical director, and the hospice nurse revealed that there was no recommendation or order to feed the resident using a syringe. The family member clarified that she only wanted the resident's mouth to be kept moist, not to be force-fed. The medical director and hospice nurse both emphasized the risks associated with syringe feeding, including aspiration and pneumonia. The facility's failure to adhere to professional standards and the resident's care plan placed the resident at risk for aspiration, choking, and death.
Improper Feeding Practices for Unresponsive Resident
Penalty
Summary
The facility failed to ensure that all nursing staff possessed the necessary competencies and skills to provide safe and appropriate care to residents, as evidenced by the improper administration of health shakes to a resident who was unresponsive. The resident, who had severe cognitive impairment and was receiving hospice services, was given health shakes through a 60 ml syringe by mouth on two occasions, despite being unresponsive. This action was contrary to the facility's protocol and posed a risk of aspiration, choking, and death. The resident in question was a female with a history of Alzheimer's disease, dementia, hypertension, and bradycardia. She required substantial assistance with activities of daily living and was on a fortified diet with health shakes ordered three times a day. Despite her unresponsive state, a CNA, who was working her first day at the facility through an agency, administered the health shakes via syringe based on instructions from a night nurse. The CNA was not aware that feeding a resident with a syringe was against facility protocol and had not received proper training on this matter. Interviews with the facility's DON, the resident's hospice nurse, and the medical director confirmed that feeding or giving fluids to an unresponsive resident with a syringe was not recommended and could lead to aspiration. The family member of the resident had expressed a desire for the resident's mouth to be kept moist, but did not request force-feeding. The facility's lack of formal training and communication regarding the proper care of unresponsive residents contributed to this deficiency.
Removal Plan
- As soon as the DON was made aware of the situation she immediately removed the syringe from the resident's room.
- CNA #1 was given a one-on-one education by ADON that a resident should never be syringe fed.
- DON started In-servicing facility & agency licensed nurses & CNAs that residents were never to be fed via a syringe.
- DON/ADON started In-servicing with agency staff to ensure they were educated on where to find the residents plan of care.
- DON/ADON started In-servicing with all CNAs both facility & agency on the importance of not attempting to feed a resident that is unresponsive.
- The agency binder was reviewed to ensure that agency staff know where to look to review the residents plan of care.
- Any new agency staff will be in-serviced by nurse management on how to find the residents plan of care prior to starting their shift.
- Shift Key will download the process of where to find the residents plan of care prior to accepting a shift.
- Nurse management will review the residents' care plan to ensure that it reflects the resident's needs.
- When a resident experiences a change of condition the care plan will be updated to reflect the resident's current needs.
- Nurse management will question random CNAs to ensure they understand Resident #1s plan of care.
- Staff will complete a questionnaire related to providing care that reflects the resident's needs.
- The DON/designee began a questionnaire to validate the effectiveness of the training.
- An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval.
Failure to Update Care Plan for Hospice Services
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who was receiving hospice services. The resident, an elderly female with severe cognitive impairment and multiple diagnoses including Alzheimer's disease, dementia, hypertension, and bradycardia, was admitted to the facility and later began receiving hospice services. However, the care plan for this resident did not include the necessary updates to reflect the hospice services being provided, despite a physician's order for hospice admission. Interviews with facility staff revealed that the MDS Coordinator was responsible for updating the care plan upon a significant change in the resident's status, such as the initiation of hospice care. The MDS Coordinator acknowledged missing the update, which was crucial for ensuring that staff were aware of the resident's changing care needs. The Unit Manager also confirmed that the care plan should have been updated to communicate the resident's care needs effectively. The facility's policy required care plan revisions upon status changes, but this was not followed, leading to a deficiency in the resident's care planning.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when a Certified Nursing Assistant (CNA) retaliated after being slapped by the resident. The incident occurred when the resident, who has severe cognitive impairment due to conditions such as traumatic brain dysfunction and dementia, slapped the CNA across the face. In response, the CNA slapped the resident back, causing the resident to turn about 45 degrees due to the force of the slap. This interaction was captured on video footage, which showed the CNA further pulling the resident back into a seated position after the slap. The resident involved in the incident is a female with a history of traumatic brain dysfunction, dementia, and age-related physical debility, with a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The resident's care plan included interventions for impaired cognitive function, such as cueing and reorienting as needed, and not correcting her if she becomes confused. Despite these interventions, the resident's actions led to a physical altercation with the CNA, which was not appropriately managed by the staff. The facility's policy on abuse, neglect, and exploitation requires that any employee accused of resident abuse be placed on leave with no resident contact until the investigation is complete. However, the CNA involved in the incident was allowed to finish her shift after the incident occurred. The charge nurse was not informed of the incident until later, and the facility administrator did not immediately suspend the CNA, citing uncertainty about whether the abuse was incidental or intentional. This delay in action and failure to follow the facility's policy contributed to the deficiency identified by the surveyors.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures regarding investigating abuse for one resident reviewed for abuse and neglect. The incident involved a certified nursing assistant (CNA) who slapped a resident in the memory care unit after the resident had initially slapped the CNA. This action was captured on video footage, which showed the CNA retaliating by slapping the resident back and subsequently pulling the resident into a seated position. Despite the incident, the CNA was allowed to continue working her shift, which was a violation of the facility's policy that requires any employee accused of resident abuse to be placed on leave with no resident contact until the investigation is complete. The resident involved was an elderly female with a history of traumatic brain dysfunction, dementia, and age-related physical debility. Her care plan indicated impaired cognitive function and thought processes, with interventions to cue, reorient, and supervise as needed. The incident was reported by another CNA who witnessed the event and informed the charge nurse and the administrator. However, the administrator did not immediately suspend the CNA, citing uncertainty about whether the abuse was incidental or intentional. The facility's failure to act promptly and in accordance with its policies placed residents at risk of further abuse, trauma, and psychosocial harm. The charge nurse was not informed of the incident until hours later, and the CNA was only terminated the following day. This delay in action and failure to protect the resident from potential harm was identified as an Immediate Jeopardy situation, highlighting significant lapses in the facility's abuse prevention and response protocols.
Removal Plan
- The facility IDON/ADON/Designee immediately initiated skin assessments to ensure no signs of physical injuries were present in all residents currently residing at the facility - no issues noted.
- The facility Adm/IDON/Designee initiated Life safety rounds with interviewable residents, Interviews revealed no new negative events.
- The VPO conducted a 1:1 in-service with the facility administrator on the company abuse and neglect policy focusing on immediately suspending employees pending allegations of abuse and neglect. This included returned verbalized understanding of the process. This was documented on a signed in-service sheet. Any reportable incidents will also be reported to the corporate VP of Operation and or VP of Clinical to ensure an appropriate investigation, interventions and follow-up takes place. Any issues identified with this process will be addressed through further education and or disciplinary action.
- The Adm initiated an in-service with the facility management staff on expectations to assure residents safety, abuse and neglect policy and reporting incidents immediately, this includes removing/suspending any staff members involved with any allegations or suspicion of abuse. Any staff member not present during initial in-servicing/training will not be allowed to assume their duties until in-service. Ongoing In-service will be completed by IDON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Comprehension was verified by successfully completing a questionnaire on the subject.
- The facility Adm/IDON/Designee initiated an in-service with the staff on the corporate compliance hot line to report unusual events. Comprehension was verified by successfully completing a questionnaire on the subject.
- The facility Adm/DON/Designee initiated in-service with the facility staff on Abuse and Neglect focusing on ensuring residents safety and immediately reporting suspected abuse or neglect to the abuse prevention coordinator and or the corporate compliance hot line. The Abuse prevention coordinator contact information is posted throughout the facility. The abuse prevention coordinator will suspend, investigate, rule out, or report any allegation of abuse and neglect within the allotted time frame. Comprehension was verified by successfully completing a questionnaire on the subject. Any staff member not present during initial in-servicing/training will not be allowed to assume their duties until in-service. Ongoing In-service will be completed by IDON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed.
- The facility IDT conduct residents Angel Rounds at least 5xweek to ensure residents do not have unknown safety concerns. Any concerns will be reported to the Adm/Designee immediately for proper follow up. VP of Ops and/or Regional Nurse will provide additional oversight to ensure steps are completed.
- The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire.
- An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval.
Failure to Suspend CNA After Alleged Abuse Incident
Penalty
Summary
The facility failed to adequately respond to an allegation of abuse involving a resident with severe cognitive impairment. The incident involved a certified nursing assistant (CNA A) who slapped a resident in the memory care unit after the resident had initially slapped her. Despite the incident being reported, CNA A was not immediately suspended or removed from resident care duties. Instead, she was moved to another wing and continued working with other residents for approximately 10 additional hours on the day of the incident. The resident involved in the incident was an elderly female with a history of traumatic brain dysfunction, dementia, and severe cognitive impairment, as indicated by a BIMS score of 00. The resident's care plan included interventions for impaired cognitive function and thought processes, such as cueing, reorienting, and supervising as needed. The incident was witnessed by another CNA, who reported it to the administration after consulting with coworkers. The facility's administration did not take immediate action to suspend CNA A, citing uncertainty about whether the abuse was incidental or intentional. This decision was made despite the facility's policy requiring employees accused of abuse to be placed on leave with no resident contact until the investigation is complete. The delay in removing CNA A from resident care duties placed residents at risk of further abuse, trauma, and psychosocial harm.
Removal Plan
- The facility IDON/ADON/Designee immediately initiated skin assessments to ensure no signs of physical injuries were present in all residents currently residing at the facility - no issues noted.
- The facility Adm/IDON/Designee initiated Life safety rounds with interviewable residents, Interviews revealed no new negative events.
- The VPO conducted a 1:1 in-service with the facility administrator on the company abuse and neglect policy focusing on immediately suspending employees pending allegations of abuse and neglect. This included returned verbalized understanding of the process. This was documented on a signed in-service sheet. Any reportable incidents will also be reported to the corporate VP of Operation and or VP of Clinical to ensure an appropriate investigation, interventions and follow-up takes place. Any issues identified with this process will be addressed through further education and or disciplinary action.
- The Adm initiated an in-service with the facility management staff on expectations to assure residents safety, abuse and neglect policy and reporting incidents immediately, this includes removing/suspending any staff members involved with any allegations or suspicion of abuse. Comprehension was verified by successfully completing a questionnaire on the subject.
- The facility Adm/IDON/Designee initiated an in-service with the staff on the corporate compliance hot line to report unusual events. Comprehension was verified by successfully completing a questionnaire on the subject.
- The facility Adm/DON/Designee initiated in-service with the facility staff on Abuse and Neglect focusing on ensuring residents safety and immediately reporting suspected abuse or neglect to the abuse prevention coordinator and or the corporate compliance hot line. The Abuse prevention coordinator contact information is posted throughout the facility. The abuse prevention coordinator will suspend, investigate, rule out, or report any allegation of abuse and neglect within the allotted time frame. Comprehension was verified by successfully completing a questionnaire on the subject.
- Any staff member not present during initial in-servicing/training will not be allowed to assume their duties until in-service. Ongoing In-service will be completed by IDON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed.
- The facility IDT conduct residents Angel Rounds at least 5xweek to ensure residents do not have unknown safety concerns. Any concerns will be reported to the Adm/Designee immediately for proper follow up. VP of Ops and/or Regional Nurse will provide additional oversight to ensure steps are completed.
- The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire.
- An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval.
Delayed Reporting of Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident within the required timeframe. On January 5, 2025, at 11:51 AM, CNA A witnessed an incident where a resident slapped her, and she retaliated by slapping the resident back and pulling the resident into a seated position. This incident was not reported to the Administrator until 2:17 PM, and the Administrator did not report it to the Health and Human Services Commission (HHSC) until January 6, 2025, at 8:43 PM, which is beyond the mandated two-hour reporting window for abuse allegations. The resident involved was an elderly female with severe cognitive impairment, as indicated by a BIMS score of 00, and had a history of traumatic brain dysfunction, dementia, and age-related physical debility. The facility's policy requires immediate reporting of abuse allegations, but the delay in reporting placed residents at risk of abuse, trauma, and/or psychosocial harm. The Administrator allowed CNA A to finish her shift, citing uncertainty about the intentionality of the incident, which further contributed to the delay in addressing the situation.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for four residents, which is a violation of resident rights. Observations on the specified date revealed that the call lights for Residents #1, #2, #3, and #4 were not accessible. Resident #1's call light was found on the floor, out of reach, preventing her from requesting assistance for personal needs. Similarly, Resident #2's call light was wrapped around the headboard and not within reach, and Resident #3's call light was also on the floor, out of reach. Resident #4's call light was behind her back, making it inaccessible. Interviews with the residents indicated that they were unable to call for assistance due to the inaccessibility of their call lights. Resident #1 expressed difficulty in getting help for a blanket and a drink, while Resident #3 mentioned needing assistance with a bedside urinal. Resident #4 was unable to reach her call light and did not know when staff last checked on her. These observations and interviews highlight the facility's failure to provide reasonable accommodations for the residents' needs, as the call lights were not positioned to allow residents to summon help when needed. Staff interviews confirmed the expectation that call lights should always be within reach of residents. A CNA stated that rounds should be made every two hours to ensure residents' needs are met, including checking the accessibility of call lights. The ADON and ADM both emphasized that it is the responsibility of all staff to ensure call lights are within reach, as this is crucial for meeting residents' needs. The facility's policy on call light accessibility and timely response was not adhered to, resulting in the deficiency noted in the report.
Facility Overcharges for Medical Records Due to Outdated Policy
Penalty
Summary
The facility failed to provide a reasonable cost-based fee for the provision of medical records for a resident, as required by the Texas Health and Safety Code. The resident's legal representative requested medical records, and the facility charged $274.28 for 216 pages, which was higher than the allowable cost under the updated Texas Health and Safety Code. The correct cost should have been $158.00, resulting in an inflated charge of $116.28. The discrepancy arose because the facility's Release of Medical Records Policy, dated January 2023, was not updated to reflect the new cost guidelines effective from May 27, 2023. The Chief Compliance Officer (CCO) acknowledged that the invoice was calculated using outdated guidelines, and the facility's policy was only updated on April 29, 2024. The corporate office was responsible for determining the costs, and the error was attributed to human oversight during a leadership change. Interviews with the medical records coordinator and the CCO revealed that the inflated charges were not communicated to the requestors who had been overcharged between the effective date of the new guidelines and the policy update. The facility's administration expressed dissatisfaction with being held accountable for a corporate-level error. The inflated cost posed a risk of financial hardship for the resident's representative.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that Resident #5 had access to a call light within reach, which is necessary for residents to call for staff assistance. Observations and interviews revealed that the call light button and cord were found on the floor, out of the resident's reach, on multiple occasions. Resident #5, who had severe cognitive impairment and was dependent on staff for various activities of daily living, was unable to use the call light to request assistance due to its improper placement. This failure was observed during room checks and rounds conducted by CNAs and administrative staff, who acknowledged the issue but did not consistently correct it. Resident #5's medical history included unspecified dementia, syncope, and dyspnea, and she was always incontinent and dependent on staff for mobility and personal care. Despite the facility's policy requiring call lights to be within easy reach of residents, staff interviews and observations indicated that this policy was not consistently followed. The Director of Nursing and the Administrator confirmed that the call light should always be within reach and that failure to do so posed risks such as falls, delayed assessments, and psychosocial harm.
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 74 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) |
|---|---|---|---|---|
| Greenview Nursing And Rehabilitation | 1.1 mi | ★★★★★ | 10 | 0 |
| Wesley Woods Health & Rehabilitation | 1.7 mi | ★★★★★ | 7 | 0 |
| Avir At Jeffrey Place | 2 mi | ★★★★★ | 4 | 0 |
| Ridgecrest Retirement And Healthcare Community | 2.1 mi | ★★★★★ | 0 | 0 |
| Avir At Waco | 2.1 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Woodway Rehabilitation And Healthcare Center.
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.