West Rest Haven
Inspection Findings
F-Tag F0658
F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
West Rest Haven
503 Meadow Drive West, TX 76691
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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.
Event ID:
Facility ID:
If continuation sheet
West Rest Haven in West, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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 West, 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 West Rest Haven or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.