Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ivy Creek Wellness & Rehabilitation during CMS and state inspections, most recent first.
Two residents experienced misappropriation of their prescribed hydrocodone-acetaminophen when pharmacy manifests showed higher quantities delivered than were documented on facility narcotic count sheets, resulting in 60 missing tablets for one resident on scheduled PEG-tube hydrocodone and 30 missing tablets for another resident receiving PRN hydrocodone. In both cases, records indicated that an LVN was involved in receiving or handling the medications, with altered quantities and missing signatures on the narcotic logs and no witnesses to the changes. Facility leadership and the MD confirmed that these discrepancies were discovered during review of narcotic records and that the missing medications constituted misappropriation of resident property under the facility’s abuse, neglect, and exploitation policy.
Misappropriation of Controlled Pain Medications for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of property, specifically controlled pain medications, for two residents reviewed. For the first resident, an older female with hemiplegia, vascular dementia, chronic pain syndrome, and severe cognitive impairment, the physician had ordered hydrocodone-acetaminophen 7.5/325 mg via PEG tube three times daily for pain. Pharmacy records showed that 124 tablets of this medication were delivered and received by LVN A, but the facility’s narcotic count sheet documented only 64 tablets, with the quantity changed from 124 to 64. This discrepancy was discovered when a nurse attempted to reorder the narcotic and the pharmacy reported it was too soon, leading to the identification of 60 missing tablets for this resident. For the second resident, an older male with paraplegia, Type 2 diabetes, heart disease, muscle wasting, and major depressive disorder, the physician had ordered hydrocodone-acetaminophen 10/325 mg every six hours as needed for pain. The narcotic count sheet for this resident showed that 60 tablets were received on a specific date, but the signature of the receiving staff member was missing, and only a date and amount were recorded. Pharmacy records, however, reflected that 90 tablets were delivered for this resident and received by LVN B, who reported handing the medication off to LVN A. Review of the narcotic count sheets revealed that 30 tablets of hydrocodone-acetaminophen 10/325 mg were missing for this resident. Interviews with facility leadership and the physician confirmed that the discrepancies in narcotic counts for both residents were identified during internal review of narcotic records. The DON stated that LVN A had received the hydrocodone-acetaminophen for the first resident and that the quantity on the narcotic count sheet had been altered, with no witnesses to the change. For the second resident, the DON noted that the handwriting on the narcotic count sheet entry for receipt resembled that of LVN A, again without witnesses and without a staff signature. The administrator and physician both described expectations that narcotics be managed without errors, diversion, or missing medications, and the facility’s abuse, neglect, and exploitation policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent. Attempts to contact LVN A for an interview were unsuccessful, and the second resident reported awareness of the missing medications but stated he was not personally affected and had no concerns with his pain management.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Waco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Catherine Center | 1.3 mi | — | 1 | 0 |
| Woodland Springs Nursing Center | 2.2 mi | — | 3 | 1 |
| The Atrium Of Bellmead | 2.4 mi | — | 2 | 0 |
| Avir At Jeffrey Place | 2.4 mi | — | 4 | 0 |
| Crestview Healthcare Residence | 2.6 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.