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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D9 | E6 | F7 |
| Minimal | A· | B· | C1 |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Apr 30, 2026 | Fire safety | Fire Safety Standard | 1 | Potential harm | — | Open → |
| Apr 30, 2026 | Health | Health Standard | 4 | Actual harm | — | Open → |
| Dec 9, 2025 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Feb 26, 2025 | Fire safety | Fire Safety Standard | 3 | Potential harm | — | Open → |
| Feb 26, 2025 | Health | Health Standard | 2 | Potential harm | — | Open → |
| Sep 10, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jan 25, 2024 | Fire safety | Fire Safety Standard | 8 | Potential harm | — | Open → |
| Jan 25, 2024 | Health | Health Complaint, Health Standard | 3 | Potential harm | — | Open → |
| Nov 16, 2023 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Apr 30, 2026 | Civil money penalty (fine) | $8,492 | — | 455983|Fine|138902 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G1 | H· | I· |
| Potential harm | D9 | E6 | F7 |
| Minimal | A· | B· | C1 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Apr 30, 2026 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | G · Actual harm Isolated | Corrected May 25, 2026 | |
| Apr 30, 2026 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 6, 2026 | |
| Apr 30, 2026 | F-0550 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
12 facilities in 8 states. CMS chain ID 48.
Chain average overall rating (CMS): 2.9
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Ascension Health Senior Care | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Jul 1, 2014 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Ascension Health Senior Care | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Jul 1, 2014 |
| Amy Lefco | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Feb 17, 2025 |
| Darrell Pietsch | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 1, 2017 |
| Ryan Breedlove | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2024 |
| Lisa Musgrave |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Ridgecrest Retirement and Healthcare Community 1900 W. State Hwy 6, Waco, TX 76712 CCN 455670 | 1.6 km | 90 | Jun 15, 2025 | 341 IJ | $14k | |
| Woodway Rehabilitation and Healthcare Center 7801 Woodway Dr, Waco, TX 76712 CCN 675924 | 4.8 km | 144 | Aug 26, 2026 | 405 IJ1 harm | $31k | |
| Greenview Nursing and Rehabilitation 401 Owen Lane, Waco, TX 76710 CCN 455638 | 5.1 km | 128 | Jul 22, 2026 | 583 IJ6 harm | $65k | |
| Avir at Jeffrey Place 820 Jeffrey Dr, Waco, TX 76710 CCN 455489 | 5.6 km | 95 | Apr 9, 2026 | 452 IJ | $22k | |
| Wesley Woods Health & Rehabilitation 1700 Woodgate Drive, Waco, TX 76712 CCN 676211 | 6.2 km | 120 | Mar 19, 2026 | 371 IJ2 harm | $56k | |
| Avir at Waco 9101 Panther Way, Waco, TX 76712 CCN 676343 | 7.4 km | 120 | Apr 6, 2026 | 29 | — | |
| Ivy Creek Wellness & Rehabilitation 2501 Maple Ave, Waco, TX 76707 CCN 455478 | 7.7 km | 162 | Jul 1, 2026 | 454 IJ2 open | $149k | |
| Lakeshore Village Nursing and Rehabilitation 2320 Lake Shore Dr, Waco, TX 76708 CCN 675438 | 8.5 km | 151 | Aug 21, 2026 | 536 IJ1 harm | $107k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 455983 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 455983 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 455983 | county_fips County assigned by locating CMS coordinates in Census county boundaries (the CMS county name did not match the Census code list). | Inferred | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect |
| E · Potential harm Pattern |
| Corrected May 25, 2026 |
| Apr 30, 2026 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 25, 2026 |
| Apr 30, 2026 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected May 25, 2026 |
| Dec 9, 2025 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Dec 10, 2025 | Complaint |
| Feb 26, 2025 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 18, 2025 |
| Feb 26, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 18, 2025 |
| Feb 26, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 18, 2025 |
| Feb 26, 2025 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 18, 2025 |
| Feb 26, 2025 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Mar 18, 2025 |
| Sep 10, 2024 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 25, 2024 | Complaint |
| Jan 25, 2024 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Jan 25, 2024 |
| Jan 25, 2024 | K-0132 | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. Construction Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 8, 2024 |
| Jan 25, 2024 | K-0281 | Install proper backup exit lighting. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 8, 2024 |
| Jan 25, 2024 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 8, 2024 |
| Jan 25, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 29, 2024 |
| Jan 25, 2024 | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 25, 2024 |
| Jan 25, 2024 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 21, 2024 |
| Jan 25, 2024 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 16, 2024 |
| Jan 25, 2024 | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 16, 2024 |
| Jan 25, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Feb 16, 2024 | Complaint |
| Jan 25, 2024 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected Mar 8, 2024 |
| Nov 16, 2023 | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 6, 2023 | Complaint |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.43 (case-mix index 1.24).
| Individual |
| Corporate officer / director |
| CORPORATE DIRECTOR |
| not provided |
| Jan 1, 2024 |
| Kenneth Smoot | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Jan 1, 2024 |
| Erin Shadbolt | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Feb 28, 2023 |
| Ascension Health Senior Care | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jul 1, 2015 |
| Health Dimensions Consulting Inc | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Aug 2, 2019 |
| Medical Solutions LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Jun 14, 2017 |
| Ryan Breedlove | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jan 1, 2024 |
| Amy Lefco | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Feb 17, 2025 |
| Lisa Musgrave | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jan 1, 2024 |
| Darrell Pietsch | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Aug 1, 2017 |
| Erin Shadbolt | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jan 1, 2024 |
| Kenneth Smoot | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jan 1, 2024 |