Ivy Creek Wellness & Rehabilitation
2501 Maple Ave, Waco, TX 76707 · Mc Lennan County · 162 certified beds · avg 65 residents/day · certified since May 18, 1983
Part of chain: OPCO SKILLED MANAGEMENT (66 facilities, chain avg rating 2.3★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Dec 29, 2023 · F-0610 · triggered by a complaint
The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Why it matters: When allegations aren't investigated, harm to residents can continue unchecked.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 17, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Dec 29, 2023 · F-0656 · triggered by a complaint
The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 17, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Dec 29, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 17, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (18)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 1, 2026 | E · Potential for harm, repeated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jul 1, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jul 1, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 6, 2026 | E · Potential for harm, repeated | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Jul 23, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 23, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not have policies on smoking. |
| Jun 13, 2024 | E · Potential for harm, repeated | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. |
| Jun 13, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 13, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 13, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jun 13, 2024 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Dec 29, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Dec 29, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Dec 29, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 10, 2023 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (5 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 4 | 3 | J ▲ |
| 2024 | 5 | 0 | E |
| 2025 | 5 | 0 | E |
| 2026 | 4 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $149,039.
| Date | Type | Amount / length |
|---|---|---|
| Apr 16, 2025 | Fine | $140,085 |
| Dec 29, 2023 | Fine | $8,954 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.45 | 3.46 | 3.95 | top 39% in Texas; bottom 34% in the U.S. |
| Registered Nurse hours | 0.39 | 0.44 | 0.69 | top 49% in Texas; bottom 21% in the U.S. |
| Weekend total nurse staffing | 3.08 | 3.04 | 3.50 | top 36% in Texas; bottom 35% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.22 | 0.34 | 0.48 | bottom 30% in Texas; bottom 17% in the U.S. |
| Total nursing staff turnover (%) | 64.7 | 55.3 | 45.8 | bottom 25% in Texas; bottom 10% in the U.S. |
| RN turnover (%) | 85.7 | 54.6 | 42.9 | bottom 14% in Texas; bottom 3% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.21, RN 0.37, weekend 2.86. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Coryell County Memorial Hospital Authority | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/02/2024 |
| 2501 Maple Ave TX LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/01/2026 |
| Beasley, Carolyn | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/15/2024 |
| Beasley, Carolyn | Individual | ADP of the SNF | NOT APPLICABLE | 01/15/2024 |
| Byrom, David | Individual | Corporate Director | NOT APPLICABLE | 09/01/2014 |
| Davidovich, Niv | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 02/02/2026 |
| Esdov Investments LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/01/2026 |
| First Sweetzer Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/01/2026 |
| Garetz, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/01/2026 |
| Hagins, Elizabeth | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 02/02/2026 |
| Ivy Creek Wellness & Rehabilitation LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/01/2026 |
| Jian, Peter | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/02/2024 |
| Jian, Peter | Individual | ADP of the SNF | NOT APPLICABLE | 01/02/2024 |
| Kaplan, Esther | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 02/02/2026 |
| Linz Trust | Organization | ADP of the SNF | NOT APPLICABLE | 02/01/2026 |
| Mindle, Adam | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 02/02/2026 |
| Pimento Property Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/01/2026 |
| Red Stone Advisors LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/01/2026 |
| Rojo Re Trust | Organization | ADP of the SNF | NOT APPLICABLE | 02/01/2026 |
| Sternshein, Jennifer | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 02/02/2026 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "What safeguards do you have to protect residents' money and belongings, and what happens when something goes missing?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Woodland Springs Nursing Center | 2.2 mi | Waco, TX | ★☆☆☆☆ | 1/5 | abuse |
| The Atrium of Bellmead | 2.4 mi | Bellmead, TX | ★☆☆☆☆ | 2/5 | |
| Avir at Jeffrey Place | 2.4 mi | Waco, TX | ★★★☆☆ | 3/5 | |
| Crestview Healthcare Residence | 2.6 mi | Waco, TX | ★★★★☆ | 4/5 | |
| Lakeshore Village Nursing and Rehabilitation | 2.7 mi | Waco, TX | ★☆☆☆☆ | 1/5 | |
| Greenview Nursing and Rehabilitation | 3.2 mi | Waco, TX | ★☆☆☆☆ | 1/5 | |
| The Chateau Waco | 4.0 mi | Waco, TX | ★☆☆☆☆ | 1/5 | |
| Ridgecrest Retirement and Healthcare Community | 4.2 mi | Waco, TX | ★☆☆☆☆ | 2/5 | |
| Woodway Rehabilitation and Healthcare Center | 4.3 mi | Waco, TX | ★★☆☆☆ | 2/5 | |
| St. Catherine Center | 4.8 mi | Waco, TX | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 455478.