The Woodlands Nursing and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to ensure that pain management was provided to a resident who required such services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 15 residents (Resident #1) reviewed for pain management. The facility failed to administer Resident #1's scheduled pain medications on o5/29/2026 at 4:oopm Resident #1 did not receive Baclofen 5 mg, one tablet by mouth three times daily; Tramadol 50 mg, two tablets by mouth three times daily; and Zanaflex 6 mg, one capsule by mouth three times daily, as scheduled. This failure could place the resident at risk for increased pain, delayed treatment and pain management interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and support for daily living safely for 1 (Resident #1) of 10 residents and 1 facility reviewed for sanitary conditions. Debris, dirt, and black sticky spots of dried hand sanitizer were observed along hall A. Resident #1 had a brownish red ring inside of his toilet bowl, toothpaste splatters on the mirror, and had a strong smell of urine left behind in the toilet bowl. Room A had a dark brown ring inside the toilet bowl and brown fecal splashed inside of the toilet bowl. These failures could place residents at risk of diminished quality of life and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one of eight residents (Resident #5) reviewed for resident rights. The facility failed to provide care in a manner that promoted maintenance of a resident's quality of life on 1/27/26 when Resident #5 was left in the shower alone, cold, and unclothed for approximately 5 minutes and was unable to call for help. This deficient practice could place residents at risk of fearfulness, helplessness and loss of dignity.

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the physician when resident arrived to the facility for 1 of 14 residents (CR#1) reviewed for resident rights.1. The facility failed to contact the physician when CR#1 had an unwitnessed fall on 1/17/2026 that resulted in a head injury.2. The facility failed to notify physician of CR#1 unwitnessed fall with head injury3. The facility failed to call 911 emergency services when initially requested by family4. CR #1 was hospitalized from [DATE] to 01/25/26 with the admitting diagnosis being fall, initial encounter. These failures could place residents at risk of decline in health status, increase level of pain, and could lead to more serious injuries. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that residents received treatment and necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with professional standards of practice and resident choices, for 1 to 14 (CR#1) residents reviewed for Quality of care. The facility failed to ensure that appropriate preventative measures, monitoring, and interventions were consistently implemented to reduce the risk of falls and ensure CR#1's safety in accordance with accepted standards of nursing practice. The facility failed to respond timely to CR#1 who was in distress after a fall on 1/17/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 7 emergency exits (dining room exit doors #1 and #2) reviewed for physical environment.- The facility failed to ensure the area beyond dining room exit door #2 were unobstructed. On 3/31/26 and 4/13/26, there was a large pallet of medical supply boxes on the sidewalk that obstructed the only ramp accessible to the dining room exit door #2. - The facility failed to ensure the area beyond dining room exit door #1 was free of clutter. On 3/31/26, the sidewalk area outside of the door was cluttered with crates, wood furniture, a grill, ice cooler, and trash bin. This deficient practice could place residents at risk of falls, injuries, and confusion during evacuations.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, was provided such care, consistent with professional standards of practice for 3 (Residents #185, #55 and #49) of 5 reviewed for respiratory care. 1. Resident #185's Bi-pap (bilevel positive airway pressure) mask was not covered in a plastic bag when it was not used on 12/16/2025.2. The facility failed to ensure empty portable oxygen tank in Resident #55's room was secure and in a base.3. The facility failed to ensure Resident #49's received 2 liters of oxygen as ordered. This failure could affect residents with oxygen therapy and bilevel positive airway pressure and could lead them to lack of care including possible infection by not following infection control.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in lockedcompartments for 3 of 6 medication carts (med aide cart in hall 200, med aide cart in 300 hall, and med aide cart for secured hall) observed for medication storage. One unidentified small round white pill was observed in the bottom drawer of the medication cart on 200 hall. Medication aide cart on 200 hall was left unlocked and unattended in an out cove across from the nurses station. Two unidentified small round white pills were observed in the top drawer of the medication cart on 300 hall. One unidentified small round white pill was observed in the bottom drawer of the medication cart for the secured hall. This failure could place residents at risk of missing or misuse of drugs by unauthorized personnel.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.1. The facility failed to ensure leftovers to be used later with a temperature in the danger zone were discarded. 2. The facility failed to ensure food was stored 6 inches off the floor. These failures could place residents who ate food from the kitchen at risk of food- borne illness and disease. Observation of the facility kitchen on 12/16/25 at 8:45 AM revealed the following. 1. A pan of white gravy 45.7 degrees Fahrenheit with a temperature in the danger zone.2. A Plastic container of Scrambled eggs 55 degrees Fahrenheit.3. A Pan of hot dogs 50 degrees Fahrenheit with a temperature in the danger zone. 4. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 (Resident #187, #97, and #138) of 33 residents reviewed for infection control practices. 1. MA-F measured Resident #187's blood pressure without cleaning the blood pressure cuff on 12/17/2025. 2. When CNA-A and CNA-G were providing indwelling urinary catheter care to Resident #97, they did not wear gowns. Resident #97 had enhanced barrier precautions, and the sign attached on the door said, Staff must wear gloves and gown for the following high-contact resident care activities such as urinary catheter care. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 17 residents (Resident #151 and #140) reviewed for resident rights. CNA-A and LVN-B were standing over Residents #151 and #140 while assisting them to eat, rather than sitting next to the residents, on 12/16/2025 at the dining area of the memory care unit. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 33 residents (Resident #166) reviewed for assessments: Resident #166's quarterly MDS, dated [DATE], identified the resident was receiving hospice care. However, Resident #166's Prognosis of Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? was coded to No, instead of Yes in Section J (health Conditions). This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #49) reviewed for care plans. The facility failed to ensure Resident #49's care plan included her need for oxygen as needed. This deficient practice placed residents at risk of not receiving proper care and services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #22) reviewed for incontinence care. When CNA-D was providing perineal care to Resident #22 on 12/18/2025, CNA-D did not clean the resident's right and left buttock area. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #86) out of 8 residents reviewed for medical records. Resident #86's electronic medication administration record was inaccurate as evidence by indicating Rosuvastatin Calcium Tablet 20 milligram, give 1 tablet via gastrostomy tube one time a day for lipid control, but the physician order said Rosuvastatin Calcium Tablet 40 milligram. This failure placed residents at risk for missed treatment and medications which could result in decline in health and well-being.

Inspectors wroteThe facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 12 (Resident #1) reviewed for abuse. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 1 of 14 residents reviewed for ADL care (Residents #1). Facility staff failed to provide personal hygiene care to Resident #1 on 10/31/24. This failure could place residents at risk of not receiving necessary care and assistance when needed.

Inspectors wroteBased on interviews and records reviewed, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (CR #1) of 3 residents reviewed for quality of care. - The facility failed to ensure treatment and care was provided to CR #1 consistent with professional standards of practice. CR #1's left stump was found with maggots and roaches on 06/07/25. The wound was also found with roaches in addition to the maggots per the findings. CR #1 was transported to the hospital where she later had an above the knee amputation. An Immediate Jeopardy (IJ) was identified on 06/13/25. The IJ template was provided to the facility on [DATE] at 10:51 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections including hand hygiene procedures to be followed by staff involved in direct resident contact for 2 (Resident #1 and Resident #2) of 6 residents reviewed for infection control. 1.-The facility failed to ensure proper hand hygiene and infection control procedures, when LVN A applied clean dressing without washing/sanitizing her hands or changing her gloves during Resident #1's catheter care on 06/05/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 10 residents (Resident #1) reviewed for pharmaceutical services. RN A failed to request a refill of Resident #1's prescribed Testosterone medication (administered every two weeks) timely and resulted in a missed dose on 03/25/2025 until one week later (04/01/2025). This failure placed residents at risk of experiencing worsening symptoms/conditions, pain, and possible infection from missed doses of prescribed medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility did not store, prepare, or distribute food in a safe and sanitary manner: Dry storage contained undated food/drink items; Refrigerator contained undated drink items; Freezer contained opened/not sealed food items. These failures could place residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #4, #14 and #10) reviewed for infection control. MA S failed to perform hand hygiene between Resident #4, #14 and #10 during medication pass. This failure could place residents at risk for cross contamination, infection and decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services, which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 29 residents (Residents #2) reviewed for pharmacy services. The facility failed to ensure Midodrine (a blood pressure (BP) medication given to elevate hypotension (low blood pressure) was administered to Resident #2 as ordered by the physician. This failure could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were stored securely for one (400 Hall Nurse Medication Cart) of four medication carts reviewed for storage of medications. The Nurse Medication Cart for 400 Hall had torn protective seals on the back of Resident #103's Tramadol HCL 50mg (a narcotic used to treat moderately severe pain) medication blister pill card (a type of medication packaging, with multiple small, sealed compartments that hold individual doses of medication) found in the locked narcotic drawer during review of medication carts. This failure could place all residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, infection, and drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 25 residents (Residents #86) reviewed for pharmacy services. The facility failed to ensure Midodrine (a blood pressure (BP) medication given to elevate hypotension (low blood pressure) was administered to Resident #86 as ordered by the physician. This failure could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 23% based on 8 errors out of 34 opportunities, which involved 4 of 11 (Residents #120, #1, #4 and #72) residents reviewed for medication errors. 1. MA A administered the wrong dose of Hydralazine and Losartan (two blood pressure medications used to lower blood pressure) to Resident #120. She also administered Sennosides instead of Sennosides with Docusate (a medication used to treat constipation), Ferrous sulfate instead of Ferrous Gluconate (an iron supplement) and did not administer Finasteride to Resident #120 (a medication used to shrink an enlarged prostate) as ordered by the Physician. 2. MA B administered the wrong dose of Miralax to Resident #1. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that: Food items were found in the kitchen with expired and beyond the use by date. Potentially hazardous /time control for safety food on the work counter With temperature of 66.5 degrees Fahrenheit. These failures could affect residents who ate food from the facility kitchen and place them at risk of food borne illness and disease.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents (Residents #113) reviewed for care plans. -Resident #113 did not have a care plan addressing his use of smokeless tobacco. This failure could affect the resident by placing him at risk of not receiving individualized care and services to meet his specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 1 of 11 residents (Resident #120) was free from significant medication errors. MA A administered the wrong dose of Hydralazine and Losartan (two blood pressure medications used to lower blood pressure) to Resident #120. She also administered Sennosides instead of Sennosides with Docusate, Ferrous sulfate instead of Ferrous Gluconate, and did not administer Finasteride to Resident #120 as ordered by the Physician.