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: