Waco, TX

Woodland Springs Nursing Center

1-star overall rating with 1-star inspections with abuse icon flag with $79,787 in total fines with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

1010 Dallas St, Waco, TX

(254) 752-9774

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

132

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Charleston Healthcare Group

Operator or chain grouping

Approved since

1994-06-27

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

5 facilities

Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars

Changed ownership

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

0.31

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.69

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.17

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.17

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.00

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.81

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.20

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.32

CMS adjusted RN staffing hours

Adjusted total hours

3.28

CMS adjusted total nurse staffing hours

Case-mix index

1.32

Higher values indicate more complex resident acuity

RN turnover

63%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

49%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,935

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

18.58

Composite VBP score used to determine payment impact.

Payment multiplier

0.9820

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

2.51

Baseline 48.53% · Performance 53.42% · Measure score 2.51 · Achievement 2.51 · Improvement 0

Adjusted total nurse staffing

1.21

Baseline 3.90 hours · Performance 3.42 hours · Measure score 1.21 · Achievement 1.21 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.23%	10.72% 0.5 pts worse	No Different than the National Rate · Eligible stays 26 · Observed rate 15.38% · Lower 95% interval 6.71%
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	2.01	1.02 1 pts worse
Drug regimen review with follow-up	96.3%	95.27% 1 pts better	Numerator 26 · Denominator 27
Falls with major injury	3.7%	0.77% 2.9 pts worse	Numerator 1 · Denominator 27
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 27 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 84
Staff flu vaccination coverage	17.24%	42% 24.8 pts worse	Numerator 20 · Denominator 116
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 16 · 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	1.8	2.1 0.3 pts better	1.9 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.5 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.0	2.1 0.9 pts worse	1.8 1.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 3.2 · Expected 1.8 · 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	100.0%	97.9% 2.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	2.0%	3.3% 1.3 pts better	3.3% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.3% · Q3 2.2% · Q4 2.3% · 4Q avg 2.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.6%	2.7% 2.1 pts better	11.4% 10.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6%
Percentage of long-stay residents who lose too much weight	3.5%	3.3% 0.2 pts worse	5.4% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.6% · Q3 2.6% · Q4 4.0% · 4Q avg 3.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.7%	18.9% 0.8 pts worse	19.6% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 21.7% · Q3 19.2% · Q4 17.7% · 4Q avg 19.7%
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 25.0% · Q2 16.2% · Q3 17.1% · Q4 14.8% · 4Q avg 18.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	21.1%	16.1% 5 pts worse	14.9% 6.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 13.9% · Q3 32.9% · Q4 10.7% · 4Q avg 21.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.1%	0.5% 0.6 pts worse	1.0% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 0.0% · Q4 2.2% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.3%	0.8% 0.5 pts better	1.7% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	20.8%	15.0% 5.8 pts worse	19.8% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 26.8% · Q3 15.4% · Q4 21.2% · 4Q avg 20.8%
Percentage of long-stay residents with pressure ulcers	5.5%	4.2% 1.3 pts worse	5.1% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 3.3% · Q3 4.1% · Q4 8.4% · 4Q avg 5.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	89.7% 10.3 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	15.0%	12.0% 3 pts worse	12.0% 3 pts worse	Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 19.2% · Expected 14.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	7.1%	1.5% 5.6 pts worse	1.6% 5.5 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 7.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	88.0% 12 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	26.4%	25.9% 0.5 pts worse	23.9% 2.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 26.4% · Observed 26.9% · Expected 24.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-08-31 · Fire 2024-08-31

15 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)

4 fire-safety deficiencies

Top issue: Services (2 deficiencies)

Cycle 2 Health 2023-06-29 · Fire 2023-06-29

4 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

1 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 3 Health 2022-05-12 · Fire 2022-05-12

9 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

4 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-08-31

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-09-23

E · Potential for more than minimal harm 2024-08-31

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-09-23

D · Potential for more than minimal harm 2024-08-31

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-09-23

C · Minimal harm 2024-08-31

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

C · Minimal harm 2023-06-29

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Not marked corrected

F · Potential for more than minimal harm 2022-05-12

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-05-14

E · Potential for more than minimal harm 2022-05-12

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2023-04-05

D · Potential for more than minimal harm 2022-05-12

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-05-14

C · Minimal harm 2022-05-12

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-03-31

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-12-30

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 2025-12-31

E · Potential for more than minimal harm 2025-12-30

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-12-31

D · Potential for more than minimal harm 2025-08-29

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2025-09-20

E · Potential for more than minimal harm 2025-07-15

F680 · Quality of Life and Care Deficiencies

Health

Ensure the activities program is directed by a qualified professional.

Corrected 2025-08-07

D · Potential for more than minimal harm 2025-07-15

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-08-07

D · Potential for more than minimal harm 2025-06-25

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2025-07-24

J · Immediate jeopardy 2025-06-11

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 2025-07-03

E · Potential for more than minimal harm 2025-06-11

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-07-03

D · Potential for more than minimal harm 2025-05-17

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-07-07

J · Immediate jeopardy 2025-01-15

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 2025-02-04

H · Actual harm 2024-08-31

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 2024-09-23

H · Actual harm 2024-08-31

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-09-23

H · Actual harm 2024-08-31

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-09-23

E · Potential for more than minimal harm 2024-08-31

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 2024-09-23

D · Potential for more than minimal harm 2024-08-31

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-09-23

D · Potential for more than minimal harm 2024-08-31

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-23

G · Actual harm 2024-01-16

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-02-02

G · Actual harm 2024-01-16

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-02-02

D · Potential for more than minimal harm 2023-10-19

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 2023-09-27

E · Potential for more than minimal harm 2023-06-29

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2023-07-30

D · Potential for more than minimal harm 2023-06-29

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2023-07-30

D · Potential for more than minimal harm 2023-06-29

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2023-07-30

G · Actual harm 2022-05-12

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 2022-05-20

E · Potential for more than minimal harm 2022-05-12

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2022-06-10

E · Potential for more than minimal harm 2022-05-12

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2022-06-10

E · Potential for more than minimal harm 2022-05-12

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 2022-06-10

E · Potential for more than minimal harm 2022-05-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-07-05

D · Potential for more than minimal harm 2022-05-12

F808 · Nutrition and Dietary Deficiencies

Health

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Corrected 2022-06-10

Penalties and ownership

What sits behind the stars

$29,858 2025-05-17

Fine

Fine · fine $29,858

Fine

$0 2025-05-17

Payment Denial

Payment Denial · denial start 2025-07-10 · 14 days

14 day denial

$12,428 2025-01-15

Fine

Fine · fine $12,428

Fine

$28,677 2024-08-31

Fine

Fine · fine $28,677

Fine

$8,824 2024-01-16

Fine

Fine · fine $8,824

Fine

Ownership

Broussard, Kendall

Operational/Managerial Control · Individual

0% 9 facilities 2015-01-23

Broussard, Kendall