Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed treat each resident with respect and dignity and
care for each resident in a manner and in an environment that promotes maintenance or enhancement of
his or her quality of life for one (Resident #1) of six residents reviewed for resident rights.
The facility failed to ensure CNA C treated Resident #1 with dignity while in his room prior to providing care
on 09/25/24 as she was observed talking about non-sensical information.
This failure could place residents at risk of intimidation, psychosocial harm, and a decreased quality of life.
Findings included:
Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the
facility on [DATE] with diagnoses including Alzheimer's Disease (a brain disorder that slowly destroys
memory), cognitive communication deficit disorder (a brain injury that affects a person's ability to
communicate effectively), and ADL self-care performance deficit.
Review of Resident #1's undated care plan reflected a focus revised on 11/20/19 of impaired
cognition/thought process as evidenced by long/short memory deficits and needs supervision assistance
with decisions and a goal revised on 07/16/24 of Resident #1 will be able to communicate basic needs on a
daily basis with interventions revised on 11/20/19 of face the resident when speaking and make eye contact
and introduce self to resident and explain care/procedure to be performed prior to beginning.
Review of Resident #1's quarterly MDS assessment, dated 9/24/2024, a BIMS was not conducted due to
him rarely/never being understood. Section GG (Functional Abilities and Goals) reflected he was dependent
for ADLs.
Review of Resident #1's quarterly care plan, dated 7/16/2024, reflected he had an ADL Self Care
Performance Deficit and required extensive, total assistance with all ADL areas.
Observation of video footage provided by Resident #1's RP D, dated 9/25/2024 at 7:48 PM, revealed CNA
C in Resident #1's room, grabbing a brief from a cabinet and other various items while Resident #1 was in
bed. CNA C was heard saying (directed to no one in particular), 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.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
676211
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676211
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wesley Woods Health & Rehabilitation
1700 Woodgate Drive
Waco, TX 76712
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 03/04/2025 at 3:05 PM, Resident #1's RP D revealed the same details viewed in the
video. She stated, The staff act like they simply do not care about the residents, and some should not have
jobs working directly with human beings.
A telephone interview was attempted on 3/4/2025 at 4:10 PM with CNA C. A returned call was not received
prior to exit.
During an interview on 03/04/2025 at 5:45 PM, the ADM stated she was shown the video of CNA C in
Resident #1's room by RP D. She stated it was inappropriate for her to be talking about other things while in
a resident's room. She stated staff should be focused solely on the resident and making them feel
comfortable.
Review of the facility's undated Resident Rights Policy reflected the following:
The resident has the right:
- To a dignified existence, self-determination .
- To be treated with respect and dignity.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676211
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676211
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wesley Woods Health & Rehabilitation
1700 Woodgate Drive
Waco, TX 76712
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure the residents environment remained
as free of accident hazards as is possible and ensure each resident received adequate supervision for one
(Resident #1) of six residents reviewed for accidents and hazards.
The facility failed to ensure CNA B and CNA C appropriately utilized the mechanical lift on 9/25/24 while
transferring Resident #1 to his bed causing him to hit his head on the wall.
This failure could place residents at risk of harm, injury, and hospitalization.
Findings included:
Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the
facility on [DATE] with diagnoses including Alzheimer's Disease (a brain disorder that slowly destroys
memory), cognitive communication deficit disorder (a brain injury that affects a person's ability to
communicate effectively), and ADL self-care performance deficit.
Review of Resident #1's quarterly MDS assessment, dated 9/24/2024, a BIMS was not conducted due to
him rarely/never being understood. Section GG (Functional Abilities and Goals) reflected he required a
mechanical lift for transferring.
Review of Resident #1's care plan, undated, reflected a focus, undated, of ADL self-care performance in
bed mobility and transfers and a goal revised on 07/16/24 for Resident #1 to maintain current level of
function in bed, mobility, and transfers with an intervention dated 10/10/23 that reflected Resident #1
required mechanical lift for transfers and provide 2 person for transfer, provide reassurance as needed,
observe extremities and devices during transfer and position for comfort, encourage and remind resident to
use handles as able during transfers.
Observation of video footage provided by Resident #1's RP D, dated 09/25/2024 at 7:44 PM, revealed CNA
B and CNA C, who were moving the resident from Geri-chair back to his bed using a mechanical lift.
Resident #1's bed was against the wall. CNAs B and C moved the lift quickly and did not line up the sling to
his bed or lock the lift. Resident #1's head hit the wall and he immediately grabbed his head with his left
hand in pain and shock.
During an interview on 03/04/2025 at 2:51 PM, CNA A stated she recalled placing Resident #1 in the
Geri-chair, but did not recall any injuries on Resident #1, and if she had, she would have reported it to the
charge nurse. She stated, I knew the family have video cameras in the resident's room, but I was never
shown the video. She said she was trained on abuse and neglect and mechanical lifts.
During an interview on 03/04/2025 at 3:05 PM, Resident #1's RP D revealed the same details viewed in the
video. She stated, The staff act like they simply do not care about the residents, and some should not have
jobs working directly with human beings.
A telephone interview was attempted on 3/4/2025 at 4:10 PM with CNA C. A returned call was not received
prior to exit.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676211
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676211
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wesley Woods Health & Rehabilitation
1700 Woodgate Drive
Waco, TX 76712
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 3/4/2025 at 5:20 PM, CNA B stated she did not recall the incident with Resident #1.
She recited the necessary steps to safely transfer a resident in and out of bed. She said the mechanical lift
should have been parallel with the bed. She said effective communication with the other CNA's was what
ensured a safe transfer; making sure all staff were coordinated. She provided examples of abuse and
neglect and to whom suspected abuse should be reported. She stated she was unaware of facility staff who
were rough or disrespectful with residents.
During an interview on 3/4/2025 at 5:45 PM the ADM stated CNA B immediately told a nurse about
Resident #1 hitting his head during the transfer on 09/25/24. She stated CNA C retired and CNA B was
counseled, retrained on mechanical lift procedures, and remained employed by the facility.
Review of the CNA B's personnel file, on 03/04/24, reflected she was re-trained on proper mechanical lift
techniques and received a written warning on 10/02/24. A performance evaluation dated 10/31/2024
reflected CNA B had consistently performed above acceptable levels of performance. Comments on the
performance evaluation stated, Employee works well with others and provides excellent care to residents.
She is very interactive with the residents, on top of her CNA duties. Employee is ambitious and has a lot of
drive to further her nursing career.
Review of the facility's undated Resident Abuse and Neglect Policy, reflected the following:
.
D. Neglect Allegation - Neglect is defined as failure to provide goods and services necessary to avoid
physical harm, mental anguish or mental illness .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676211
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676211
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wesley Woods Health & Rehabilitation
1700 Woodgate Drive
Waco, TX 76712
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review the facility failed to store, prepare, and distribute food in
accordance with professional standards for food service safety in one of one kitchen reviewed for kitchen
and food sanitation.
The facility failed to ensure DA A wore a beard restraint while preparing food for residents.
These failures could have placed residents at risk for food contamination and foodborne illness.
Findings included:
Observation on 3/4/2025 at 12:30 PM of the kitchen revealed DA A was near the serving table and was not
wearing a beard guard when near the food. DA A had a visible sideburns, mustache, and beard no more
than one half inch in length.
Observation on 3/4/2025 at 4:20 PM of the kitchen revealed DA A was in the kitchen and moving about the
serving, drink and dessert tables with the beard net pulled down underneath their chin.
In an interview on 3/4/2025 at 4:25 PM, DA A stated they were supposed to wear hair and beard nets when
in the kitchen. They said it was important to wear hair and beard nets to prevent resident illness.
In an interview on 3/4/2025 at 4:35 PM, the DM stated all dietary staff were aware of the policy that
required them to wear beard nets when in the kitchen. They cited negative outcomes were food
contamination and risk of illness for residents.
During an interview on 2/24/2024 at 5:27 PM, the DON stated her expectation was anyone who entered the
kitchen should have worn the appropriate hair/beard nets to prevent hair from falling into the food.
During an interview on 2/24/2025 at 5:45 PM the ADM stated anyone who was in the kitchen should have
been wearing the required hair/beard nets to prevent food contamination.
Review of the facility's undated policy titled Section 9 - Dietary and Food Service reflected the following:
Policy: Hair Nets
Procedure:
It is MANDATORY that all Dietary Staff wear hairnets while on duty in any food preparation area this facility.
Any person with a beard must wear a beard net.
Bald persons are excluded from wearing hair nets and clean-shaven persons are excluded from wearing
beard nets.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676211
If continuation sheet
Page 5 of 5
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the March 19, 2025 survey of Wesley Woods Health & Rehabilitation?
This was a inspection survey of Wesley Woods Health & Rehabilitation on March 19, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Wesley Woods Health & Rehabilitation on March 19, 2025?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.