Woodlands Rehabilitation and Healthcare Center

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to implement physician ordered treatments for one (1) of eight (8) residents sampled residents. Resident #2.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide appropriate perineal care by thoroughly cleansing the perineal area following an incontinent episode for one (1) of three (3) residents observed receiving incontinent care. Resident #6.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure residents were treated with respect and dignity during the provision of care for two (2) of three (3) sampled residents. Resident #2 and Resident #3. Findings Included:Record review of the facility policy, Nursing Facility Resident Rights dated 3/06/26 revealed, The following rights are guaranteed to residents. To be treated with dignity, courtesy and respect. To privacy during personal care, visits, and phone calls .Record review of the facility document titled, Skills Checklist: Feeding a Resident (undated) revealed Procedure Step 11. Stated, Sits facing resident. Sits at resident's eye level. Sits on the stronger side if resident has one-sided weakness. [...]

Inspectors wroteBased on observation, interview, record review, and skills checklist review the facility failed to ensure a call light was maintained within reach for one (1) of three (3) residents. Resident #2. Findings Included:Record review of the facility policy document titled, Skills Checklist: Feeding a Resident (undated) revealed Procedure Step 21 Leaves call light within resident's reach . The facility was unable to provide a call light policy. On 4/28/26 at 2:15 PM, observation and interview revealed Resident #2 was awake and resting in bed with his lunch tray on the over the bed table in front of him. The resident's call light was lying on the floor under the head of his bed. He stated that he could use his call light but did not know where it was. On 4/29/26 at 12:00 PM, observation revealed that Resident #2 was resting in bed with his lunch tray on the over the bed table in front of him. [...]

Inspectors wroteBased on observation, record review, facility policy review, and interviews the facility failed to provide treatment and care in accordance with professional standards of practice to prevent urinary tract infections for one (1) of three (3) sampled residents who required incontinent care. Resident #2Findings Included:Record review of the facility policy/procedure titled, Peri Care-Incontinent Care with revision Date 1-2023 (January 2023) revealed the procedure stated, FOR MALE RESIDENTS: For a male resident: a. Wet washcloth/cleaning wipes and apply soap or skin cleansing agent. b. Wash perineal area starting with urethra and working outward.c. Retract foreskin of the uncircumcised male. d. Wash and rinse urethral area using a circular motion. e. Continue to wash the perineal area including the penis, scrotum, and inner thighs. F. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to maintain a medication error rate below five (5) percent (%), for two (2) of 31 medication opportunities observed, resulting in a 6.45 % medication error rate. Included was Resident #3, who was not instructed to rinse with water following administration of a steroid inhaler, and Resident #141, for whom the nurse prepared an incorrect dosage of Thiamine.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to maintain an infection prevention and control program to help prevent the possible development and transmission of communicable diseases and infections for three (3) of 26 sampled residents, as evidenced by failing to conduct hand hygiene between glove changes (Resident #5 and Resident #115) and failing to adhere to Enhanced Barrier Precautions (EBP) during care (Resident #32). Findings Include: Review of the facility’s policy, “Infection Prevention and Control Program” with a revision date of 6/30/25 revealed “Policy Statement: [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure that a resident was informed of their right to formulate an advance directive (AD) and was provided assistance to do so for one (1) of (26) sampled residents (Resident #22). Findings Include:A review of the facility's policy, Resident Rights, undated, revealed, .Facility must protect and promote the rights of each resident, including each of the following rights . 5. Advance Directives .a. Facility will inform and provide written information to Resident concerning the right to accept or refuse medical or surgical treatment and, at the Resident's option, formulate an advance directive. A record review of Resident #22's clinical record revealed there was no documentation indicating whether the resident had been informed of ADs or was offered assistance by the facility in formulating one. [...]

Inspectors wroteBased on observation, record review, facility policy review, and interview, the facility failed to implement care plan interventions related to Enhanced Barrier Precautions for one (1) of 26 sampled residents (Resident #115).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident #140) received supervision and assistance during activities of daily living (ADL) bathing to prevent accidents or injury. The facility failed to ensure staff followed the resident's functional status, used appropriate transfer assistance, and sought help when the resident displayed signs of weakness during a shower transfer.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one (1) of (26) sampled residents (Resident #46) receiving dialysis treatment was transported in a timely manner to receive the full duration of the prescribed treatment. This resulted in multiple shortened dialysis sessions over the previous month and placed the resident at risk for adverse health outcomes, including hyperkalemia, gastrointestinal distress, and other dialysis-related complications.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure medications were securely stored and monitored to maintain safety and integrity for one (1) of five (5) residents reviewed for medication administration and storage, Resident #62.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to maintain a complete and accurate medical record by not documenting whether a resident had an advance directive (AD) in place, declined to complete one, or was offered assistance to formulate one for one (1) of (26) sampled residents (Resident #22). Findings Include:A record review of Resident #22's clinical record revealed there was no documentation indicating whether the resident had an AD in place, declined to complete one, or had been offered assistance by the facility in formulating one. During an interview and concurrent observation of the electronic health record (EHR), on 8/12/25 at 8:00 AM, Licensed Practical Nurse (LPN) #1 in Medical Records confirmed that Resident #22 had no documentation indicating the resident did or did not have an AD. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to maintain a medication error rate below 5 percent (%) during an annual recertification survey on 4/11/24 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of nine (9) deficiencies cited. (F759)Findings Include: Review of the facility's policy Quality Assurance Performance Improvement (QAPI) Program, reviewed 6/25, revealed, .The purpose of Quality Assurance Performance Improvement committee is to create a system for improving the care for our residents. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent Resident #1, a vulnerable resident, from leaving the facility premises unsupervised for one (1) of six (6) residents reviewed. Resident #1. On 3/22/25 at 8:17 AM, Resident #1, who has a Brief Interview for Mental Status (BIMS) score of 7, left the facility unsupervised. The facility's transportation aide let the resident out of the front door to sit on the porch. Licensed Practical Nurse (LPN) #1 encountered Resident #1 in the facility parking lot and attempted to redirect the resident back to the facility. She left the resident unsupervised to get help from additional staff. When staff returned, the resident had moved further off-site, and was across the street in a daycare parking lot, approximately one-fourth (1/4) of a mile from the facility. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to protect the residents' right to be free from physical abuse from a staff member for one (1) of five (5) sampled residents. Resident #1 Resident #1 was physically and emotionally abused on 12/25/24 when Certified Nursing Aide (CNA) #1 handled him roughly, sprayed cold water on his face, and turned out the lights in the shower room, while laughing. The facility's failure to protect resulted in Resident #1 reporting he felt sad, taken advantage of, and a little afraid. Additionally, the facility's failure to immediately remove CNA #1 from the facility placed this resident and other residents in a situation that was likely to result in ongoing serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to report an allegation of abuse within the required two (2) hour timeframe for one (1) of five (5) sampled residents. Resident #1 Licensed Practical Nurse (LPN) #1 witnessed physical and emotional abuse of Resident #1 on 12/25/24, however, the facility did not report it to the State Agency (SA) until 12/30/24, delaying the facility's ability to protect the resident from further harm. The facility's failure to ensure immediate reporting increased the risk of further harm which left Resident #1 and other residents in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). [...]

Inspectors wroteBased on observations, interviews, facility policy review, and record review, the facility failed to ensure a clean, homelike environment for three (3) of five (5) sampled residents, Residents #2, #3, and #4. Findings Include: A review of the facility's policy titled Homelike Environment, revised February 2021, revealed Residents are provided with a safe, clean, comfortable, and homelike environment .1. Staff provides person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include: a. clean, sanitary, and orderly environment .f. pleasant, neutral scents . [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure the Comprehensive Care Plan interventions were implemented for two (2) of five (5) sampled residents. Residents #2, and #3 Findings Include: A review of the facility policy titled Care Plans Comprehensive Person-Centered, reviewed January 2023, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that timely incontinent care was provided two (2) of five (5) sampled residents. Residents #2 and #3 Findings Include: Resident #2 On 09/23/24 at 1:25 PM, during an observation and interview, Resident #2 was found kneeling on a bedside mat with his upper torso resting on the mattress. He was wearing a saturated incontinence brief that had sagged down to his lower thighs. On 09/23/24 at 2:05 PM, during an interview, Certified Nursing Assistant (CNA) #1 stated that she last checked Resident #2 for incontinence care before 11:00 AM on 09/23/24. CNA #1 confirmed that Resident #2's care instructions included incontinence care every two (2) hours and as needed. CNA #1 returned from lunch at 1:29 PM and found the resident on the floor but had not provided care between 11:00 AM and 1:29 PM. [...]

Inspectors wroteBased on observation, policy review, record review, and staff interviews, the facility failed to ensure mechanical patient care equipment was maintained in a safe operational condition for one (1) of six (6) mechanical lifts. Findings Include: A review of the facility policy titled Safe Patient Handling and Moving Protocol, with a review date of 06/10/24, revealed, The QA (Quality Assurance) Committee will ensure implementation of this policy to identify, assess, and develop strategies to control risk of injury to residents and nursing staff associated with the lifting, transferring, repositioning or movement of a resident . Mechanical or Electric Lift . All staff shall adhere to each lift's specific manufacturer guidelines for safe handling and operation .The facility should develop and assign routine maintenance schedules to ensure equipment is in good working order . [...]

Inspectors wroteBased on record review, resident and staff interview, and facility policy review the facility failed to notify the physician of a resident's severe pain rated initially at a ten (10) on a pain scale of (0-10) with 10 being the most severe for one (1) of four (4) sampled residents. Resident #2.

Inspectors wroteBased on staff and resident interview, record review and facility policy review, the facility failed to respond and administer pain medication timely for a resident's complaint of severe pain rated initially at a ten (10) on a pain scale of (0-10) with 10 being the most severe for one (1) of four (4) sampled residents. Resident #2. Findings Include: Record review of the facility policy titled, Pain Management Program Policy, revised 10/22, revealed, The facility will ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management . Monitoring . 5. If a resident is experiencing pain during that shift, then pain medication and or alternative therapies should be administered as ordered . Additional Guidance . [...]

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to accurately code a Minimum Data Set (MDS) for one (1) of 26 sampled residents.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) Level II was obtained for a resident diagnosed with a serious mental disorder for one (1) of 26 sampled residents. (Resident #31)

Inspectors wroteBased on observations, interviews, record reviews, and the facility policy review, the facility failed to revise the Care Plans for two (2) of 26 sampled residents. (Residents #80 and #105)

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to maintain less than a 5% medication error administration rate for two (2) errors of 25 medication administration opportunities. This observation resulted in an 8% medication error rate. Findings Include: Review of the facility's, Instillation of Eye Drops, revised January 2014, revealed, . General Guidelines . 4. When administering two or more different eye drops allow three to five minutes between each application . During a medication administration observation on 04/10/24 at 9:00 AM, Registered Nurse (RN) # 1 instilled one (1) drop of Prednisolone Acetate Ophthalmic Suspension 1 % in the left eye of Resident #81. The nurse immediately instilled one (1) drop of Ofloxacin Ophthalmic Solution 0.3 % 1 into the resident's left eye. [...]

Inspectors wroteBased on observations, interviews, record review, and the facility policy review, the facility failed to transport dirty linen in a manner to prevent the possible spread of infection, for one (1) of three (3) days of observations.

Inspectors wroteBased on observation, interviews, record review, facility policy review, the facility failed to follow physician orders and dialysis aftercare communication related to AV (Arteriovenous) shunt for one (1) of two (2) dialysis residents reviewed.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to accurately code the discharge Minimum Data Set (MDS) assessment for one (1) of three (3) sampled closed records. Resident #127. Findings Include: A record review of the facility's MDS Coding Policy with a reviewed date of March 25, 2022, and (Proper Name of Corporation) affiliated facilities utilize the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately . A record review of Resident #127's admission Record revealed the facility admitted Resident #127 on 03/23/2022 with diagnoses including Aftercare Following Joint Replacement Surgery and End Stage Renal disease. The Date of Discharge was listed as 04/12/2022 and discharged to a private home. [...]

Inspectors wroteBased on observation, record review, staff interview and facility policy review the facility failed to follow standards of practice for applying Zinc Oxide Barrier Cream for one (1) of (2) incontinent care observations. Resident #42.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to discard expired food items, date, and label opened items in the dry storage room and freezer for one (1) of two (2) kitchen observations. Findings Include: A review of the facility's policy Labeling and Dating Inservice (undated) revealed, .Importance of labeling and dating: Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First in First Out (FIFO) manner. This will minimize waste and ensure that items that are passed their due date are discarded . On 07/11/22 at 10:08 AM, the State Agency (SA) conducted an initial tour of the kitchen with the Dietary Manager (DM). There were several items identified that were not labeled or expired found on the initial tour. 1. [...]