Woodway Rehabilitation and Healthcare Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices reviewed for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility nurses failed to hold Resident #1s health shakes and administered them through a 60ML syringe by mouth while she was not responsive on 3/10/25 at 10:20pm and 3/11/25 at 12:10pm. These failures resulted in an identification of an Immediate Jeopardy (IJ) On 3/12/2025 at 4:35 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being for 1 (Resident #1) of 5 residents reviewed. The facility nurses failed to hold Resident #1's health shakes and administered them through a 60 ML syringe by mouth while she was not responsive on 3/10/25 at 10:20pm and 3/11/25 at 12:10pm. These failures resulted in an identification of an Immediate Jeopardy (IJ) On 3/12/2025 at 4:35 p.m. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from abuse for one (Resident #1) of five residents reviewed for abuse. The facility failed to protect Resident #1 from physical abuse when CNA A was slapped by Resident #1 across the face and CNA A slapped Resident #1 back across their face on 1/5/2025. An Immediate Jeopardy (IJ) was identified on 01/22/2025. The IJ template was provided to the facility on [DATE] at 5:43 PM. While the IJ was removed on 01/23/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on abuse/neglect. This failure placed residents at risk of abuse, trauma, and/or psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to implement their written policies and procedures regarding investigating abuse for one (Resident #1) of five residents reviewed for abuse and neglect. The facility failed to ensure CNA A was suspended/terminated or removed from working with all residents after she slapped a resident in the memory care unit, potentially causing additional abuse and/or emotional distress. An Immediate Jeopardy (IJ) was identified on 01/22/2025. The IJ template was provided to the facility on [DATE] at 5:43 PM. While the IJ was removed on 01/23/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on abuse/neglect. [...]

Inspectors wroteBased on interview and record review, the facility failed to, in response to allegations of abuse, prevent further potential abuse for one (Resident #1) of five residents reviewed for abuse and neglect while the investigation of alleged abuse was in progress. The facility failed to ensure CNA A was suspended/terminated or removed from working with all residents while the investigation of alleged abuse was ongoing. CNA A was moved to another wing to continue the remainder of her shift working with other residents for approximately 10 additional hours on the day she slapped a resident in the memory care unit. An Immediate Jeopardy (IJ) was identified on 01/22/2025. The IJ template was provided to the facility on [DATE] at 5:43 PM. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.