Cycle 1
Health 2025-06-05 · Fire 2025-06-05
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Waco, TX
Woodway Rehabilitation And Healthcare Center
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
7801 Woodway Dr, Waco, TX
(254) 235-7801
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
144
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Momentum Skilled Services
Operator or chain grouping
Approved since
2002-08-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.27
Registered nurse staffing
LPN hours / resident day
0.85
Licensed practical nurse staffing
Aide hours / resident day
2.52
Nurse aide staffing
Weekend hours
3.32
Weekend nurse staffing
RN turnover
100%
Annual RN turnover
Total nurse turnover
100%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
97.1%
0.1 pts better
|
93.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
97.9%
0.8 pts worse
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.3%
0.1 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
2.7%
1.3 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.9% |
3.3%
0.4 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
18.9%
3.6 pts better
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 8.9% |
10.8%
1.9 pts better
|
16.7%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.6% |
15.4%
3.2 pts worse
|
16.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.5% |
16.1%
4.4 pts worse
|
14.9%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.3% |
15.0%
4.3 pts worse
|
19.8%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
4.2%
0.5 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
89.7%
4.2 pts better
|
81.7%
12.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
12.0%
0.7 pts worse
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 39.7% |
88.0%
48.3 pts worse
|
79.7%
40 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.4% |
25.9%
1.5 pts worse
|
23.9%
3.5 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-25 · Fire 2024-04-25
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-02-23 · Fire 2023-02-23
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-07-23
E · Potential for more than minimal harm
2025-06-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-20
F · Potential for more than minimal harm
2024-04-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-28
F · Potential for more than minimal harm
2024-04-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-28
F · Potential for more than minimal harm
2024-04-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-28
F · Potential for more than minimal harm
2024-04-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-28
E · Potential for more than minimal harm
2024-04-25
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-03-28
E · Potential for more than minimal harm
2024-04-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-03-28
E · Potential for more than minimal harm
2024-04-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-28
E · Potential for more than minimal harm
2024-04-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-28
E · Potential for more than minimal harm
2024-04-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-28
F · Potential for more than minimal harm
2023-02-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-12
F · Potential for more than minimal harm
2023-02-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-07
F · Potential for more than minimal harm
2023-02-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-05-27
F · Potential for more than minimal harm
2023-02-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-02-23
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-02-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-15
E · Potential for more than minimal harm
2023-02-23
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 2023-06-30
D · Potential for more than minimal harm
2023-02-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-27
D · Potential for more than minimal harm
2023-02-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-11-26
D · Potential for more than minimal harm
2025-11-20
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 2025-11-26
D · Potential for more than minimal harm
2025-06-05
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 2025-06-06
J · Immediate jeopardy
2025-03-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-15
J · Immediate jeopardy
2025-03-14
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-03-15
D · Potential for more than minimal harm
2025-03-14
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 2025-03-15
J · Immediate jeopardy
2025-01-23
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 2025-01-24
J · Immediate jeopardy
2025-01-23
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-01-24
J · Immediate jeopardy
2025-01-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-24
D · Potential for more than minimal harm
2025-01-23
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 2025-01-24
E · Potential for more than minimal harm
2024-12-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-07-17
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-04-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-09
D · Potential for more than minimal harm
2023-09-20
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 2023-10-17
D · Potential for more than minimal harm
2023-02-23
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 2023-03-10
Penalties and ownership
What sits behind the stars
$6,444
2025-03-14
Fine
Fine · fine $6,444
Fine
$8,509
2025-01-23
Fine
Fine · fine $8,509
Fine
Ownership
Coryell County Memorial Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Byrom, David
Corporate Officer · Individual
Fellbaum, Ernest
5% Or Greater Mortgage Interest · Individual
Fuze Ventures, LP
5% Or Greater Mortgage Interest · Organization
Healthcare Investments Rc, LLC
5% Or Greater Mortgage Interest · Organization
Ltc Houston Management LLC
Operational/Managerial Control · Organization
M Ventures 111, LLC
5% Or Greater Mortgage Interest · Organization
Martel, Michael
5% Or Greater Mortgage Interest · Individual
Mmt Realty-Waco, LLC
5% Or Greater Mortgage Interest · Organization
Studer, Stanley
5% Or Greater Mortgage Interest · Individual
Threadgill, Forrest
5% Or Greater Mortgage Interest · Individual
Threadgill, Morgan
5% Or Greater Mortgage Interest · Individual
Threadgill, Sharlyn
Operational/Managerial Control · Individual
Threadgill, Sharlyn
5% Or Greater Mortgage Interest · Individual
Threadgill, Wade
5% Or Greater Mortgage Interest · Individual
Wrhc Re, LLC
5% Or Greater Mortgage Interest · Organization
Wrhc,llc
Operational/Managerial Control · Organization
Nearby options
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#2
Wesley Woods Health & Rehabilitation
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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
#3
Avir at Jeffrey Place
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2-star overall rating with 2-star inspections with $29,666 in total fines with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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