Woodlands Place Rehabilitation Suites

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had a safe, clean, comfortable and homelike environment including clean bed linen in good condition for seven (Resident #55, Resident #11, and 5 confidential residents in group interview) of 16 residents and 4 of 4 bed linen closets reviewed for resident rights and homelike environment. 1. The facility failed to ensure Resident #55 and #11's and 5 confidential residents' in group interview fitted bed sheets were in good condition free of holes, tears and threadbare areas. 2. The facility failed to ensure 4 of 4 bed linen closets on resident halls did not have clean fitted bed sheets with holes, tears and threadbare areas. These failures place residents at risk of an unsanitary environment and a decline in quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 residents (Resident #47, Resident #66, Resident #84, and Resident #55) of 20 residents reviewed for ADLs. The facility failed to ensure Resident #s 47, 66, and 84 had their fingernails trimmed on 2/24/26. The facility failed to provide timely incontinent care for Resident #55 on 2/24/26. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and skin breakdown, and a decreased quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store food in accordance with professional standards for food safety for the facility's only kitchen in that:The facility failed to ensure food items in the walk-in refrigerator were covered and sealed on 2/24/2026. This failure could affect residents who received their meals from the facility's kitchen, by placing them at risk for food-borne illness, if consumed and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 for 4 of 10 residents (Resident #15, Resident #51, Resident #55 and Resident #86) observed for infection control. 1. The facility failed to ensure Agency RN H prevented cross contamination of the multi-resident use glucometer test strips and failed to maintain a clean and dirty side of diabetic caddy used for supplies to obtain fingerstick blood for Resident #15 on 02/24/26, when she placed the contaminated glucometer back in the clean side of the caddy next to the bottle of glucose test strips. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #7) of 5 residents reviewed for comprehensive care plans. The facility failed to ensure Resident #7 was care planned for limited range of motion related to his contracture. This failure could put Residents at risk of receiving unnecessary treatments, not receiving care or services and further decline of their physical health. Review of Resident #7's Face sheet dated 2/26/26 reflected a [AGE] year-old male with an initial admission date of 10/20/22 and readmission date of 9/9/25. The resident had the following active diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 (Resident #7) of 5 residents reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #7's contracture to his left hand upon discharge from therapy services on 9/3/25. This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Review of Resident #7's Face sheet dated 2/26/26 reflected a [AGE] year-old male with an initial admission date of 10/20/22 and readmission date of 9/9/25. The resident had the following active diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one of six residents (Resident #15) reviewed for pharmacy services. The facility failed to ensure Agency RN H followed the manufacturer's instructions to prime (means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly) the Humalog pen (Insulin Lispro) (Hormone) prior to dialing in required amount of Insulin to be administered to Resident #15. These failures placed residents at risk of not receiving full dosage of medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for the facility's one (hall 300 cart) of four medication carts reviewed for storage. The facility failed to ensure Resident # 15's Lispro Insulin (Hormone) Pen, that was used on [DATE], was dated when opened. These failures could affect residents resulting in diminished effectiveness and not receiving the therapeutic benefits of the medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident call system was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area from each resident's beside and toilet and bathing facilities for one (Resident #23) of six residents reviewed for physical environment. The facility failed to ensure Resident #23's toilet and shower call button were working in resident's bathroom. This failure placed residents at risk of a delay in resident getting assistance from staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's responsible party had the right to exercise the resident's rights for one (Resident #2) of 6 residents reviewed for resident rights. The facility failed to ensure Resident #2's representative was involved in the decision making before inserting a catheter. This failure could place residents at risk of not having their preferred responsible party represent them in care decisions. Findings Included:Record review of Resident #2's face sheet revealed Resident #2 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's face sheet identified his representatives were family members. Diagnosis included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents with indwelling urinary catheters receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #4) of three residents reviewed for Urinary Catheter or Urinary Tract Infection.-The facility failed to ensure that Resident #4 received care and services to avoid catheter-associated urinary tract infections to the extent possible as evidenced by not demonstrating sterile technique during indwelling urinary catheterization of Resident #4. This failure could place all residents requiring indwelling urinary catheters and catheter care at risk for catheter associated urinary tract infections or complications that could lead to serious harm. Record review of Resident #4's face sheet dated 12.23.2025 at 12:30 p.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate assistance devices to prevent accidents for 2 of 5 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure CNA A and the dietary staff checked the temperature and sealed Resident #1's cup of hot tea, which resulted in Resident #1 spilling tea in her lap on 10/13/25 acquiring a second-degree burn (partial thickness burn, damages the outer and middle layers of skin. Characterized by blistering-typically heal in 7 to 21 days) to her left upper thigh. The noncompliance was identified as PNC. The non-compliance began on 10/13/25 and ended on 10/14/25. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to store and label food in accordance with professional standards for food service safety for the facility's only kitchen in that: The facility failed to ensure food items in the facility refrigerator and freezer were dated or labeled. The facility failed to take the temperature of the soup after re-heating the soup in the microwave. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination. Findings Include: *At 8:45am revealed an opened box of slice smoked ham had two plastic 3-pound bags of sliced smoked ham without a date received or date used by. *At 8:49am revealed an unopened loaf of white sliced bread in non-labeled clear bag without a date used by or label of contents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 for 3 of 12 residents (Resident #21, Resident #63, and Resident #45) observed for infection control. 1. The facility failed to ensure RN B prepared Resident 21's medication without cross contaminating her medications on 12/04/24 2. The facility failed to ensure that CNA D performed hand hygiene after providing dressing assistance and transfer of Resident # 63 and before leaving the resident's room on 12/04/24. 3. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for one of six residents (Residents #8) reviewed for pharmacy services. The facility failed to ensure LVN C followed the Physician orders and facility procedures for checking residual before administering Resident #8's medication through his g-tube on 12/04/24. This failure placed the residents at risk of aspiration, vomiting or incomplete administration of medication if tube was blocked or obstructed.

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority the resident representative when there was a a significant change in the resident's physical status for one of six residents (Resident #1) reviewed for change of condition. ADON A failed to read Resident #1's x-ray results received at the facility on 01/18/24 and failed to notify/consult the Physician about the resident's femur (thigh bone) fracture and change of condition using the facility's approved notification methods leaving Resident #1 with an undiagnosed/untreated fracture for 29 days (01/18/24 to 02/13/24). Resident #1 fell on [DATE] at 03:15 a.m. with no apparent injury, but when attempting to get up, the resident's legs kept giving way. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the resident has the right to be free from neglect for one of six residents(Resident #1) reviewed for neglect. 1. ADON A failed to follow the facility's process for documentation, transcription and notifications when she failed to transcribe the physician's order on 01/18/24 for an X-ray request for Resident #1's left femur (thigh bone), failed to document an assessment of Resident #1's pain to determine the location, duration, and scale of Resident #1's pain, failed to place the X-ray request for 01/18/24 on the 24-hour report for follow-up, and failed to notify the responsible party of the X-ray request and results. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to promptly notify the ordering physician, results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner for one of six residents (Resident #1) reviewed for diagnostic services in that. 1. ADON A failed to read Resident #1's x-ray results received at the facility on 01/18/24 and failed to notify/consult the Physician about the resident's femur (thigh bone) fracture and change of condition using the facility's approved notification methods leaving Resident #1 with an undiagnosed/untreated fracture for 29 days (01/18/24 to 02/13/24). 2. The facility failed to have a system in place to ensure verbal notification was promptly received from the contracted Radiology company. Resident #1 fell on [DATE] at 03:15 a.m. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to 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 for three of six residents (Resident #39, Resident # 33, Resident # 385 and Resident # 336) and eight of 13 rooms (Rooms #201, #202, #203, #204, #205, #207, #208 and #209) reviewed for infection control. 1. LVN C failed to perform hand hygiene after completion of insulin injection on Resident # 39. 2. LVN D failed to clean Resident #33's administration site with an alcohol wipe prior to giving her an insulin injection. 3. CNA J failed to use hand hygiene while passing lunch trays on the 200 hall, Rooms #201, #202, #203, #204, #205, #207, #208 and #209. 4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 18 residents (Resident #79) reviewed for accommodation of needs. The facility failed to ensure Resident #79's call light was placed within his reach. This failure could place residents at risk of injuries and unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one (Residents #15) of two resident reviewed for feeding tubes. 1. LVN E failed to check for residual of Resident #15's G-tube prior to medication administration. 2. The facility failed to ensure Resident #15's G-tube was flushed with 35 cc's water prior to and after medication administration per physician orders. 3. The facility failed to ensure Resident #15's G-tube was flushed with water between each medication administration. 4. The facility failed to ensure medication was dissolved completely prior to Resident #15's medication administration. These failures could place residents at risk of not receiving full dosage of medication, abdominal discomfort, medication incompatibility, tube obstruction, nausea, and risk of aspiration.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #285) reviewed for respiratory care. The facility failed to ensure the supplemental O2 was provided at the physician ordered liter amount for Resident #285. This failure could place residents at risk of receiving an incorrect amount of oxygen and the risk of oxygen toxicity.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for two of eight residents (Resident #2 and Resident # 51) reviewed for medication storage. The facility failed to ensure Resident #2, and Resident #51 did not have unsecured medication in their rooms on 11/14/23. This deficient practice could place residents at risk of not being monitored for their medications, adverse reactions, and drug diversion.

Inspectors wroteBased on observation, interview and record review the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for one of 24 residents (Residents #26) reviewed for dental services. The facility failed to assist in providing dental services for Resident #26. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life.