West Rest Haven
West Rest Haven in West, TX — inspection on September 16, 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.
Inspection Findings
medication.
Her RP was notified of the incident as well as her DR who was also the medical director of the facility.
The DR gave an order to monitor Resident #1 for 24 hours and report any negative findings to him.
The DON stated RN A was immediately suspended and then was terminated the facility on 08/14/25.
The DON then educated all nursing staff on scope of practice and falsifying order on 08/14/25.
She then reported RN A to the State Board of Nursing on 08/14/25.
The DON stated Resident #1 did not have any negative outcomes related to the incident. In an interview on 9/16/25 12:30 RN A stated she had given Resident #1 the Antibiotic injections without calling the DR.
She stated she would normally call the dr and obtain an order for any medication, but she was trying to be respectful since the Urinalysis came in the middle of the night. RN A stated the resident was not feeling well, Resident #1 had been treated with Ceftriaxone in the past and she had assumed it would have been ok. RN A stated negative effects for treating residents with unnecessary medications could include reactions to the medication or creation of a superbug in the urine by using the wrong type of antibiotics. In an interview on 9/16/25 at 12:45pm The facility Medical Director stated he expects all nurses to call him for an order prior to administration. He stated he was shocked that a nurse took it upon herself to administer medications without an order.
The Medical Director stated there were no ill effects related to the administration of the antibiotic to Resident #1.
He stated Resident #1 has had frequent urinary tract infections. He stated the nurse was terminated almost immediately and the staff were educated on calling him or any DR for orders prior to administering any medications.
Record review of undated facility policy titled PHARMACY POLICY AND PROCEDURE'S reflected The purpose of this Pharmacy Policy and Procedure Manual is to: Ensure that drugs are prescribed, administered, and handled in this facility in a manner that protects the safety and welfare of the patient. No Medication shall be administered to a patient without a written order by the patients attending physician and if unnecessary.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/16/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
West Rest Haven
503 Meadow Drive West, TX 76691
SUMMARY STATEMENT OF DEFICIENCIES
feeling well, Resident #1 had been treated with Ceftriaxone in the past and she had assumed it would have been ok. RN A stated negative effects for treating residents with unnecessary medications could include reactions to the medication or creation of a superbug in the urine by using the wrong type of antibiotics. In an interview on 9/16/25 at 12:45pm The facility Medical Director stated he expects all nurses to call him for an order prior to administration. He stated he was shocked that a nurse took it upon herself to administer medications without an order.
The Medical Director stated there were no ill effects related to the administration of the antibiotic to Resident #1. He stated Resident #1 has had frequent urinary tract infections. He stated the nurse was terminated almost immediately and the staff were educated on calling him or any DR for orders prior to administering any medications.
Record review of undated facility policy titled PHARMACY POLICY AND PROCEDURE'S reflected The purpose of this Pharmacy Policy and Procedure Manual is to: Ensure that drugs are prescribed, administered, and handled in this facility in a manner that protects the safety and welfare of the patient. No Medication shall be administered to a patient without a written order by the patients attending physician and if unnecessary.
Facility ID:
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.