Cycle 1
Health 2023-08-02 · Fire 2023-08-02
13 health deficiencies
Top issue: Resident Rights (5 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Waco, TX
Wesley Woods Health & Rehabilitation
2-star overall rating with 2-star inspections with $17,550 in total fines with 13 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1700 Woodgate Drive, Waco, TX
(254) 666-5454
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2009-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.33
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.58
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.23
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
4.05
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,391
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9931
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.64
Baseline 19.18% · Performance 20.21% · Measure score 2.64 · Achievement 2.64 · Improvement 0
Healthcare-associated infections
5.85
Baseline 8.90% · Performance 6.42% · Measure score 5.85 · Achievement 4.73 · Improvement 5.85
Total nurse turnover
2.84
Baseline 72.66% · Performance 56.72% · Measure score 2.84 · Achievement 1.70 · Improvement 2.84
Adjusted total nurse staffing
4.74
Baseline 4.25 hours · Performance 4.43 hours · Measure score 4.74 · Achievement 4.74 · Improvement 0.63
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.59% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 8.75% · Lower 95% interval 7.15% |
| Discharge to community | 49.17% |
50.57%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 46.55% · Lower 95% interval 40.94% |
| Medicare spending per beneficiary | 1.29 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 87.88% |
95.27%
7.4 pts worse
|
Numerator 29 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | 59.09% |
53.69%
5.4 pts better
|
Numerator 13 · Denominator 22 |
| Discharge mobility score | 40.91% |
50.94%
10 pts worse
|
Numerator 9 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 3.03% |
2.29%
0.7 pts worse
|
Numerator 1 · Denominator 33 · Adjusted rate 3.42% |
| Healthcare-associated infections requiring hospitalization | 6.42% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 3.64% · Lower 95% interval 3.65% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 149 |
| Staff flu vaccination coverage | 33.08% |
42%
8.9 pts worse
|
Numerator 44 · Denominator 133 |
| Discharge function score | 45.45% |
56.45%
11 pts worse
|
Numerator 10 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.6 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.3 |
2.1
1.2 pts worse
|
1.8
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.6% |
97.9%
5.3 pts worse
|
95.5%
2.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.3%
0.9 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.0% · Q3 2.9% · Q4 3.8% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
2.7%
2.4 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 8.7% |
3.3%
5.4 pts worse
|
5.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 11.9% · Q3 9.8% · Q4 4.7% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.0% |
18.9%
8.1 pts worse
|
19.6%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 27.4% · Q3 23.0% · Q4 27.3% · 4Q avg 27.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.5% |
10.8%
13.7 pts worse
|
16.7%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 23.6% · Q3 27.4% · Q4 24.7% · 4Q avg 24.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.5% |
15.4%
3.1 pts worse
|
16.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 10.6% · Q3 22.2% · Q4 18.4% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.9% |
16.1%
0.8 pts worse
|
14.9%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 12.8% · Q3 20.3% · Q4 11.0% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.5%
0.1 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
0.8%
0.6 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.1% |
15.0%
6.1 pts worse
|
19.8%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 12.2% · Q3 25.4% · Q4 17.7% · 4Q avg 21.1% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
4.2%
0.1 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.4% · Q3 8.5% · Q4 2.3% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
89.7%
9.6 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.6% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 29.9% |
12.0%
17.9 pts worse
|
12.0%
17.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.9% · Observed 29.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.5% |
88.0%
7.5 pts worse
|
79.7%
0.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.3% |
25.9%
2.4 pts worse
|
23.9%
4.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.3% · Observed 27.0% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-23 · Fire 2022-06-23
7 health deficiencies
Top issue: Environmental (1 deficiency)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2021-09-23 · Fire 2021-09-23
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-08-02
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-25
F · Potential for more than minimal harm
2023-08-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-25
F · Potential for more than minimal harm
2023-08-02
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2024-05-17
F · Potential for more than minimal harm
2023-08-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-17
F · Potential for more than minimal harm
2023-08-02
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-04-25
E · Potential for more than minimal harm
2023-08-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-26
D · Potential for more than minimal harm
2023-08-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-25
F · Potential for more than minimal harm
2022-06-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-18
F · Potential for more than minimal harm
2022-06-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-04-26
F · Potential for more than minimal harm
2022-06-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-04
F · Potential for more than minimal harm
2022-06-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-26
F · Potential for more than minimal harm
2022-06-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-26
F · Potential for more than minimal harm
2022-06-23
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2023-05-01
E · Potential for more than minimal harm
2022-06-23
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-05-19
D · Potential for more than minimal harm
2022-06-23
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-05-19
F · Potential for more than minimal harm
2021-09-23
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2021-11-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-15
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-08-17
E · Potential for more than minimal harm
2025-06-24
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-06-24
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-11
E · Potential for more than minimal harm
2025-05-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-10
K · Immediate jeopardy
2025-04-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-03-28
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-03-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-03-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-12
G · Actual harm
2024-06-13
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-06-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-14
F · Potential for more than minimal harm
2024-05-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-12
E · Potential for more than minimal harm
2024-05-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-12
E · Potential for more than minimal harm
2024-01-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-02-06
G · Actual harm
2023-08-02
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-08-03
F · Potential for more than minimal harm
2023-08-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-11
E · Potential for more than minimal harm
2023-08-02
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-03
E · Potential for more than minimal harm
2023-08-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-03
D · Potential for more than minimal harm
2023-06-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-28
J · Immediate jeopardy
2023-06-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-05-06
D · Potential for more than minimal harm
2023-05-19
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-05-20
F · Potential for more than minimal harm
2022-06-23
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2022-07-08
D · Potential for more than minimal harm
2022-06-23
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-06-24
D · Potential for more than minimal harm
2022-06-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-24
F · Potential for more than minimal harm
2021-09-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-10-25
E · Potential for more than minimal harm
2021-09-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-25
D · Potential for more than minimal harm
2021-09-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-10-25
D · Potential for more than minimal harm
2021-09-23
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-10-25
Penalties and ownership
What sits behind the stars
$6,095
2023-05-19
Fine
Fine · fine $6,095
Fine
$11,455
2023-05-19
Fine
Fine · fine $11,455
Fine
Ownership
Byrom, David
Corporate Director · Individual
Cook, Catherine
Operational/Managerial Control · Individual
Cook, Jack
Operational/Managerial Control · Individual
Coryell County Memorial Hospital Authority
Operational/Managerial Control · Organization
Flowers, Adam
Operational/Managerial Control · Individual
Thomasson, Debra
Operational/Managerial Control · Individual
Woodgate Senior Care LLC
Operational/Managerial Control · Organization
Nearby options
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4-star overall rating with 4-star inspections with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Woodway Rehabilitation And Healthcare Center
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2-star overall rating with 2-star inspections with $14,953 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Hewitt Nursing And Rehabilitation
Hewitt, TX
1-star overall rating with 2-star inspections with $33,539 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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