Woodway Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 resident of 20 residents (Res#1) reviewed for quality of care. The facility failed to answer Res#1's call light after Res#1 pressed the call light button for 34 minutes. This failure could place residents at risk of not trusting the facility, physical harm, and mental anguish.Findings included: Record review of Res#1's admission's record dated 06/30/26 indicated she was a [AGE] year-old female admitted to the facility 09/29/25. Her diagnoses included other specified diabetes mellitus (group of diseases that affect how the body uses blood sugar) with diabetic neuropathy (common complication of diabetes, characterized by nerve damage that can lead to pain, numbness, and other disfunctions in the body) chronic obstructive pulmonary disease (a progressive lung disease that restricted air flow), unspecified, metabolic encephalopathy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement their written policies and procedures regarding investigating abuse for two (Resident #1 and Resident #2) of five residents reviewed for abuse and neglect. The facility failed to ensure a thorough investigation was completed by the abuse coordinator after an allegation of abuse was made on 10/11/2025 by Resident #2. This failure could place residents at risk of abuse, trauma, and psychosocial harm. Findings included:Review of Resident #1's comprehensive MDS assessment, dated 09/10/2025, reflected a [AGE] year-old male, admitted [DATE]. His diagnoses included progressive neurological conditions (gradual decline in neurological function), diabetes mellitus (chronic condition that affects how your body processes blood sugar), Alzheimer's disease (memory impairment), seizure disorder (abnormal electrical activity in the brain), anxiety (feelings of worry, fear, or unease), depression (persistent feeling of sadness), and psychotic disorder (severe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported no later than 24 hours after the allegation is made to the administrator of the facility and to HHSC, if the events that cause the allegation do not involve abuse, and do not result in serious bodily injury for 2 (Resident #1 and Resident #2) of five residents reviewed for reporting abuse and neglect. The facility failed to report an allegation of abuse made by Resident #2 on 10/10/25 that did not result in bodily injury within 24 hours to the state agency. This failure could place residents at risk of abuse, trauma, and/or psychosocial harm. Findings included:Review of Resident #1's comprehensive MDS assessment, dated 09/10/25, reflected a [AGE] year-old male who was on 09/10/2021. His diagnoses included: progressive neurological conditions (gradual decline in neurological function), diabetes mellitus (chronic condition that affects how your body processes blood sugar), Alzheimer's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1of 2 medication storage rooms (Nurse's Station Room). The facility failed on 6/4/25 to ensure that expired lab testing supplies were removed from 1 of 2 medication storage rooms (Nurse's Station Room). This failure could place residents at risk for misdiagnosis from expired and possibly ineffective lab testing supplies. Use of these expired supplies would not meet acceptable standards of medical practice and could cause a resident to receive an incorrect treatment, which would allow their medical condition to worsen. Findings included: Observation on 6/4/25 at 3:55 PM of the Medication Storage Room located by the nurse's station revealed the following: 3 Lab swabs expired 2/9/2023. 4 Gray lab tubes expired 4/30/2023. 1 Gold lab tube expired 12/31/2023. 5 Lab swabs expired 7/1/2024. 3 Red tubes expired 9/19/2024.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement a comprehensive care plan to meet the medical and nursing needs and the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being of 1 (Resident #1) of 5 residents reviewed for care plans. The facility failed to complete an accurate comprehensive care plan for Resident #1, by not care planning her Hospice services received on 1/20/25. This failure could place residents at risk of not having their care and treatment needs met to ensure necessary care and services were provided for specific to Hospice specialized services. Findings included: Record review of Resident #1's undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of Alzheimer Disease (A brain disorder that slowly destroys a person's memory), Dementia (the loss of cognitive function, remembering, thinking, and reasoning), Hypertension (elevated blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported immediately, but not later than 2 hours after the allegation was made for one (Resident #1) of five residents reviewed for abuse and neglect. The facility failed to report alleged violations related to abuse within prescribed timeframes when CNA A witnessed abuse at 11:51 AM on 1/5/2025, did not report it to the ADM until 2:17 PM on 1/5/2025, and the ADM did not report to HHSC until 1/6/2025 at 8:43 PM. This failure placed residents at risk of abuse, trauma, and/or psychosocial harm. Findings included: Review of Resident #1's Quarterly MDS dated [DATE] revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including traumatic bran dysfunction (an injury to the brain caused by external mechanical force), dementia (a group of symptoms affecting memory, thinking, and social abilities), senile degeneration of brain (progressive deterioration of brain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 4 of 5 residents (Residents #1, #2, #3, & #4) reviewed for resident rights. The facility failed to ensure Residents #1, #2, #3, and #4's call light was within reach on 12/28/24. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #1's admission record dated 12/28/24 documented a [AGE] year-old female admitted on [DATE]. Resident #1 had diagnoses which included: need for assistance with personal care, major depressive disorder (loss of interest in activities), and essential primary hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause). Record review of Resident #1's Quarterly MDS assessment, dated 10/18/24, revealed the resident had a BIMS score of 03 indicating the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a reasonable cost-based fee for the provision of medical records for 1 of 2 residents (Resident #1) who were reviewed for access to medical records. The facility failed to charge the RP, for Resident #1, reasonable prices for medical records cost determined in the Texas Health and Safety Code, Title 4. Health Facilities; Subtitle B. Licensing of Health Facilities; Chapter 241. Hospitals; Subchapter A. General Provisions; Section 241.154 (THSC 241.154.) This failure placed residents, or their RP, at risk for complications with continuity of care and financial hardship. Findings included: Record review of Resident #1's Discharge MDS, dated [DATE], reflected the Resident was a [AGE] year-old female who admitted to the facility on [DATE]. She was diagnosed with peripheral vascular disease (which was slow and progressive circulation disorder caused by narrowing of the blood vessels.) Section C., Cognitive Patterns: Indicated Resident #1's short-term…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area for 1 of 12 residents (Residents #5) reviewed for call lights. The facility failed to place Resident #5's call light within reach to call staff for assistance. This failure placed residents at risk for having their needs go unmet. Findings included: Record review of Resident #5's undated face sheet revealed an [AGE] year-old woman who admitted to the facility on [DATE]. She was diagnosed with Unspecified Dementia (which was a disease that affected memory, thought, and interfered with daily life;) Syncope and Collapse (which was also known as fainting;) and, Dyspnea (which was a condition that causes shortness of breath.) Record review of Resident #5's Quarterly MDS, dated [DATE], reflected Section C., Cognitive Patterns; Resident #5 had a BIMS Score of 00. A BIMS Score of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure residents were free from abuse for 1 of 7 residents (Res #1) reviewed for abuse. The facility failed to ensure CNA A did not verbally and physically abuse Resident #1 during ADL care. This failure placed residents at risk of abuse, decreased feelings of dignity, self-worth, and humiliation. Findings include: Record review on 9-20-2023 of the facility's face sheet reflected Res # 1 was born on [DATE] and was admitted to the facility on [DATE]. Res # 1 was diagnosed with dementia and cognitive communication deficit. Record review on 9-20-2023 of a ring doorbell video clip, date stamped 6-22-2023 at 7:32:06 AM, reflected two CNAs, CNA A and CNA B, in Res # 1's room having performed ADL care. The video showed CNA A having stood over Res # 1 and having spoken to Res # 1 in an aggressive manner in response to Res # 1 attempted touching of CNA B's body. CNA A was viewed having restricted both of Res # 1's forearms and having aggressively told Res # 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the need of 1 (Resident#336) of 4 residents reviewed for pharmacy services. 1.MA (A) administered Ketorolac Sol 0.5% 1 drop to both right and left eye, instead of following order which stated to give 1 drop to right eye only. These failure placed residents at risk for inadequate therapeutic outcomes, ineffective disease management and a decline in health. The findings included: Review of Resident #336's face sheet, dated 2/23/2023 revealed an [AGE] year-old male admitted to the facility on [DATE] with the following diagnosis: Unspecified atrial fibrillation (Irregular Heart Rhythm), Type 2 diabetes mellitus with unspecified complications, Nonexudative age-related macular degeneration ( an eye diseases affecting a specific part of inner eyewall ) , Atherosclerosis (buildup…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.