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Complaint Investigation

The Brazos Of Waco

August 28, 2025 · Waco, TX · 2430 Market Place Drive
Citations 2
CMS Rating 1/5
Beds 123
Provider ID 676409
Healthcare Facility
The Brazos Of Waco
Waco, TX  ·  View full profile →
Inspection Summary

The Brazos of Waco in Waco, TX — inspection on August 28, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0580
Resident Rights Deficiencies
Potential for More Than Minimal Harm

Inservice with LVN D regarding reporting incident/change of condition to the DON/Designee.

Documentation of the Personnel action was present and reflected the signature of LVN D.

Record Review of in-service dated 08/11/2025 reflected 20 staff had been in-serviced on notification of resident change.

Our ability to ensure trust is paramount in what we do daily, and by keeping lines of communication open and involving the resident and their responsible party/emergency contact in the care we are providing; we build that foundation. It is REQUIRED to notify residents, responsible parties, or an emergency contact of any changes that occur with our residents.

Responsible Party (RP) or an emergency contact if resident is their own RP will be notified of any changes at the time of occurrence and be DOCUMENTED in the progress notes.Record Review of in-service dated 08/11/2025 reflected 14 staff had been in-serviced on notification to the director of nursing but there was no mention of notification of the physician.

Communication is crucial for proper management of nursing facilities and notification of the Director of nursing is imperative.

You are required to notify the Director of Nursing and or designee for the following immediately: Incidents and Accidents with C/O Pain or Observed Injury BurnsSafety Hazards / Equipment Malfunction Record Review of in-service dated 08/12/2025 reflected 22 staff had been in-serviced on burns.

Burns are a major incident in nursing homes and can cause serious negative out comes.

Any burn injuries are required to have the provider assigned, DON, RP, and administrator notified immediately no matter the severity of the burn.

Record Review of facility wound care policies and procedures revision date 06/01/2015 reflected all burns and scalds will be seen by a physician or a nurse as soon as possible for appropriate treatment.

The purpose is to provide immediate first aid when injury occurs in the facility.

Record review of the policy entitled: Care of a Burn Injury dated 06/01/2025 states Notify the physician and supervisor as soon as possible.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Brazos of Waco

2430 Market Place Drive Waco, TX 76711

SUMMARY STATEMENT OF DEFICIENCIES

Review of evaluations completed for all residents.

Their criteria were all the same for the evaluations.

Residents were screened for cognition, mobility, dexterity, and behaviors to see if they were safe with hot beverages.

Record Review of facility daily monitor log for appropriate hot beverage cup/lids reflected 08/11/25 through 08/15/25 no concerns. On 08/28/25 at 3:00 PM conducted Interview the DON stated she had worked at the facility for four months.She stated she had been trained on abuse, neglect, resident rights, and hot beverages.

She stated the electric urn was discontinued immediately.

She stated coffee is being served from an urn.

She stated the dietary manager, DON, and Administrator were reeducated on coffee service for the r[TRUNCATED]

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Waco, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Brazos of Waco or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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