Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Woodlands Healthcare Center during CMS and state inspections, most recent first.
The facility failed to provide timely ADL care, including toileting, bed mobility, and personal hygiene, to several dependent residents in accordance with its ADL policy and individual care plans. One CNA reported being the only CNA on a hall during the night shift, unable to complete all assigned duties or get multiple residents up in the morning, while CNAs on another hall stated they lacked time to assist outside their own hall. Surveyors observed a resident who required two-person assistance for bed mobility left with legs and feet dangling off the bed after a brief change, and other residents with severe cognitive impairment or total dependence were found with strong urine or BM odors, wet or soiled briefs, and an overfilled Foley catheter bag that had not been emptied. LPNs confirmed that residents needing ADL assistance should receive timely care and not remain in soiled briefs or with unmet ADL needs.
Two residents were found in rooms with strong urine and BM odors, soiled linens, and clothing with visible BM left on the bed and floor after staff had provided only partial incontinence care. One resident reported that staff had not checked on her before she got up, and an LPN confirmed that residents needing ADL assistance should be helped timely and that rooms should not contain soiled linens or clothing.
A resident reported that another resident entered her bathroom, shoved a door into her, pushed her against a wall causing her to fall, got on top of her, pulled her hair, and called her a derogatory name before staff intervened. The resident stated she informed an LPN of the physical and verbal abuse, but there was no documentation of the incident in her record and no internal incident or abuse report was initiated. The LPN and the RN weekend supervisor, both trained in abuse reporting, chose not to report the allegation to administration or complete required documentation because they did not witness the event and believed it did not require reporting, despite facility policy and definitions of abuse requiring that all such allegations be reported and investigated.
Two residents were not treated with dignity during meal and personal care routines. One resident, dependent on staff for eating, was left unserved at the dining table while others finished their meals, as her tray was intentionally prepared last due to her need for feeding assistance. Another resident, with severe cognitive impairment and incontinence, was repeatedly observed in a soiled brief and was offered breakfast without prior incontinence care, which staff acknowledged was inappropriate and could have affected the resident's willingness to eat.
A resident with severe dementia and a DNR order was found to have an outdated care plan that incorrectly listed her as Full Code. The discrepancy was confirmed by an LPN, who acknowledged that the care plan had not been updated after the resident's code status changed to DNR.
A resident with severe cognitive impairment, dysphagia, and a history of choking or coughing during meals had physician's orders for oral suctioning, but the care plan did not include suctioning as an intervention. This omission was confirmed by the DON during interview.
A resident with severely impaired cognition and a history of traumatic subdural hemorrhage had a physician order for DNR with selective treatment, but the care plan continued to indicate Full Code status. An LPN confirmed the care plan was not updated to reflect the current DNR order, resulting in inconsistency between the care plan and the resident's documented treatment preferences.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines. No further details about specific staff actions or resident involvement are provided.
A resident's nasal cannula used for oxygen therapy was repeatedly found lying on the floor without being stored in a bag, contrary to facility policy. An LPN confirmed the equipment was not properly labeled or stored between uses, despite the resident's recent use of oxygen.
A medication error rate above 5% was identified when an LPN crushed and administered DR and ER medications, including Pantoprazole, Tolterodine, and Potassium Chloride, inappropriately to a resident. The contract pharmacist confirmed these medications should not have been altered, and no supporting documentation was provided.
Surveyors found that a medication cart contained five unidentified, loose tablets and that two inhalers in use were not labeled with their open dates. An LPN confirmed the presence of the loose pills and the lack of labeling on the inhalers, and the facility's contract pharmacist stated that these inhalers require open-date labeling for proper disposal timelines.
Staff failed to follow infection prevention and control protocols, including not using required PPE for a resident with a gastrostomy tube, improper hand hygiene and glove use during meal service, and inadequate infection control during wound care. These actions resulted in multiple lapses in standard precautions and EBP requirements.
A medication cart was found unlocked and unattended in a high-traffic area, with keys left on top, accessible to unauthorized personnel. Staff interviews confirmed the oversight, with the responsible RN admitting to leaving the cart unattended. The incident posed a potential risk to the 137 residents in the facility.
A facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate. An LPN administered medications incorrectly to a resident, failing to give two medications as ordered and administering a discontinued medication. The LPN did not administer Ticagrelor and Lansoprazole as prescribed and gave Lasix 10 mg, which was discontinued. The error was confirmed through observation, interview, and record review.
A facility failed to maintain an effective infection prevention and control program, as a nurse did not follow proper hand hygiene during wound care for a resident with pressure ulcers. The nurse did not change gloves or sanitize hands after removing a soiled dressing. Additionally, the facility did not provide necessary signage for Enhanced Barrier Precautions (EBP) for the resident, who required such precautions due to pressure ulcers. The absence of EBP signage was confirmed by the Infection Preventionist.
Failure to Provide Timely ADL, Toileting, and Bed Mobility Assistance Due to Inadequate Staffing
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL services, including toileting, bed mobility, and personal hygiene, to multiple dependent residents in accordance with its own ADL policy and residents’ care plans. The facility’s policy stated that residents unable to carry out ADLs independently would receive appropriate support with hygiene, mobility, elimination, dining, and communication. Despite this, staff interviews and observations showed that residents who were dependent or required substantial/maximal assistance for ADLs were not consistently receiving timely assistance, particularly during the night shift when staffing on one hall was limited to a single CNA. One CNA working the 7:00 p.m. to 7:00 a.m. shift on X hall reported being the only CNA assigned there, stating she was overworked, received no help, and could not complete all assigned duties, including getting approximately seven residents up in the morning. She stated that residents had to wait for the day-shift CNAs, who first had to serve breakfast before assisting them. She also reported that she had repeatedly informed her supervisor about her inability to accomplish her duties alone, but staffing had not changed. Another CNA on Y hall stated that most residents on Y hall were gotten up before the day shift, and that they did not have time to help on X hall because they had to get their own residents up. Surveyor observations with staff confirmed multiple instances of unmet ADL needs. One resident, dependent on staff for toileting and requiring two-person assistance for bed mobility, was observed with both lower legs and feet dangling off the end of the bed after two CNAs had changed the resident’s brief and left him in that position, and the sole CNA on X hall stated she could not reposition him alone. Another resident, requiring substantial/maximal assistance for toileting and personal hygiene, was found with a strong urine odor and a wet brief because rounds had not yet been done. A totally dependent resident with neuromuscular bladder dysfunction, hemiplegia, and a stage 3 sacral pressure ulcer was observed with a strong BM odor, a soiled brief, and a Foley catheter bag containing 1300 cc of urine that had not been emptied. Additional residents who required assistance with toileting were observed with BM or urine odors and soiled or saturated briefs. LPNs on both halls confirmed that residents requiring ADL assistance should be assisted timely and should not remain in soiled briefs or with unmet ADL needs, and one LPN reported that when CNAs from Y hall left to assist on X hall, she was alone and unable to assist residents needing two-person help.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment by not ensuring timely and complete incontinence and housekeeping care for two residents. During an early-morning observation of one resident’s room, surveyors noted a strong bowel movement odor upon entry, and a CNA confirmed that the two CNAs assigned to that hall had just changed the resident. Further observation with the CNA revealed a large amount of smeared bowel movement throughout the resident’s bed linens, indicating the linens had not been changed when the resident’s brief was changed during toileting care, as the CNA stated should have occurred. In a separate room, surveyors observed a strong urine and bowel movement odor, uncontained soiled clothing near the door, and pants on the floor with visible bowel movement. The resident in that room reported that staff had not been by to check on her and that she was up and going to get coffee. An LPN later confirmed that residents who require assistance with ADLs should be assisted in a timely manner and that both residents’ rooms should have been free of soiled linens and bowel movement on clothing.
Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to identify and report an alleged incident of resident-to-resident abuse involving one sampled resident. A resident reported that while in bed she heard a noise, got up, and found another resident in her bathroom. She stated that the other resident shoved the bathroom door open on her, screamed at her to get out of his room, shoved her against the wall, causing her to fall, then got on top of her, pulled her hair, and called her a “stupid b*tch.” She reported that she yelled for help and that an LPN and a CNA responded and separated the residents. The resident further stated she slapped the other resident after being called a derogatory name and informed the LPN of the shoving, hair pulling, and verbal insult. Review of the medical record showed no documentation of an incident or abuse allegation between the two residents. Interviews with administrative and nursing staff revealed that no incident report or abuse allegation had been reported to the administrator, DON, or ADON, and there were no SIMS reports related to this event. The LPN who responded acknowledged receiving abuse and incident reporting training but stated she did not report or complete an incident report because she did not believe the situation required reporting, citing that she did not personally witness physical contact and did not think the verbal comment constituted abuse. The RN weekend supervisor stated she was informed by the LPN that the resident had reported the other resident “put his hands on” her, but she also did not report the allegation because there were no injuries and she had not witnessed the incident. Both the LPN and RN confirmed they had received abuse training and understood that abuse allegations require reporting, and the DON confirmed that any allegation of abuse required reporting so that an investigation could be completed, which did not occur in this case.
Failure to Maintain Resident Dignity During Meal and Incontinence Care
Penalty
Summary
The facility failed to ensure that two residents were treated with respect and dignity, and that their care promoted or enhanced their quality of life. One resident, who required substantial assistance with eating and was unable to communicate effectively, was observed sitting at a dining table during lunch while other residents were served, ate, and left the area. This resident was not served her meal along with the others, and staff interviews confirmed that her tray was intentionally prepared last because she required feeding assistance. The LPN on duty was unaware that the resident had not been served, despite all other residents at the table having completed their meals. Another resident, with severe cognitive impairment and a history of incontinence, was observed multiple times in bed with a soiled brief and a strong odor of feces in the room. Despite these observations, staff attempted to feed the resident breakfast without providing incontinence care beforehand. The LPN confirmed that the resident should have received incontinence care prior to being served breakfast and acknowledged that the lack of care could have contributed to the resident's refusal to eat. The DON also confirmed that incontinence care should have been provided before attempting to feed the resident.
Failure to Update Care Plan Following Change in Code Status
Penalty
Summary
A deficiency occurred when a resident's code status was not accurately reflected in the care plan. The resident, a 93-year-old female with diagnoses including traumatic subdural hemorrhage, severe unspecified dementia, and cognitive communication deficit, was admitted and later re-entered the facility. Her medical record indicated a DNR (Do Not Resuscitate) order with selective treatment, but the care plan continued to list her as having a Full Code status. This discrepancy was identified during a review of the resident's electronic chart and care plan documentation. An interview with an LPN and review of the care plan confirmed that the resident's code status had recently changed to DNR, but the care plan had not been updated to reflect this change. The care plan still instructed staff to treat the resident as Full Code, which was inconsistent with the current physician's order and the resident's wishes. This failure to update the care plan compromised the resident's right to have her treatment preferences honored.
Failure to Care Plan for Suctioning in Resident with Dysphagia and Cognitive Impairment
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident with significant medical needs. The resident was admitted with diagnoses including dysphagia, cerebral infarction, and unspecified convulsions, and had a BIMS score of 3, indicating severe cognitive impairment. The resident experienced episodes of coughing or choking during meals or when taking medications. Physician's orders dated 08/08/2025 indicated that oral suctioning may be performed for this resident. However, review of the resident's care plan showed that suctioning was not included as an intervention. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the resident should have been care planned for suctioning but was not.
Failure to Update Care Plan to Reflect DNR Status
Penalty
Summary
The facility failed to update the care plan for a resident to reflect a change in code status from Full Code to Do Not Resuscitate (DNR) as ordered by the physician. The resident, who had a history of traumatic subdural hemorrhage and was assessed as having severely impaired cognition, was admitted with a care plan indicating Full Code status. However, a physician order for DNR with selective treatment was initiated, and this change was not reflected in the resident's care plan. Staff interview confirmed that the care plan had not been revised to match the current physician order, resulting in a discrepancy between the resident's documented treatment preferences and the care plan.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report does not provide specific details about the actions or inactions of staff, the events leading to the deficiency, or information about any residents involved at the time of the incident.
Failure to Properly Store and Label Oxygen Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for one resident who required oxygen therapy. According to the facility's policy, oxygen equipment should be stored in a covered device, such as a plastic bag or kangaroo pouch, between uses to ensure safe administration and infection prevention. However, observations on two consecutive days revealed that the resident's nasal cannula was found lying on the floor without a bag. The resident confirmed recent use of the oxygen equipment, and an LPN acknowledged that the tubing was not properly stored or labeled as required by facility policy.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by direct observation of medication administration. During 29 observed medication administration opportunities, an LPN was seen crushing and administering Pantoprazole DR 40mg tablet and Potassium Chloride ER 10meQ tablet, as well as opening a Tolterodine ER 4mg capsule and providing its contents orally to a resident. The LPN confirmed these actions during an interview. The facility's contract pharmacist verified that these extended-release (ER) and delayed-release (DR) medications should not have been crushed or opened, and stated that no documentation existed to support altering these medications in this manner. This practice had the potential to affect all 145 residents receiving medications in the facility.
Improper Storage and Labeling of Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure drugs and biologicals were stored and labeled according to accepted professional principles. During an inspection of medication carts, one cart was found to contain five unidentified and loose tablets in two separate drawers. Additionally, two inhalers—Albuterol and Trelegy Ellipta—were found opened and in use without being labeled with the date they were opened. The LPN present confirmed the presence of the loose, unidentified tablets and acknowledged that the inhalers had been opened and used without proper labeling. The facility's contract pharmacist verified that both types of inhalers require labeling with the date opened to ensure timely disposal according to manufacturer guidelines.
Failure to Adhere to Infection Prevention and Control Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies in staff adherence to established protocols. In one instance, a resident with a gastrostomy tube, who was identified as requiring Enhanced Barrier Precautions (EBP) due to increased risk of multidrug-resistant organism (MDRO) acquisition, did not receive care in accordance with EBP guidelines. The assigned CNA provided a bed bath, oral care, brief change, and linen change to the resident while wearing only gloves, omitting the required gown. The CNA admitted to not using the correct PPE for all EBP-designated residents on her hall, citing lack of PPE availability at the point of care and uncertainty about where to obtain supplies, despite facility policy and signage indicating the need for both gown and gloves during direct care activities. During meal service on another hall, a CNA was observed repeatedly failing to follow proper hand hygiene and gloving procedures. The CNA served and prepared meals while wearing the same pair of gloves, touching various surfaces, utensils, and food items, including bread rolls, without changing gloves or performing hand hygiene between tasks. The CNA also used gloves obtained from a co-worker's pocket and handled clean utensils with unwashed hands after glove removal. The CNA confirmed these lapses in practice, acknowledging that she did not follow the required procedures for hand hygiene and glove use during meal service for multiple residents. Additionally, improper infection control practices were observed during wound care for a resident with pressure ulcers and blisters. The treatment nurse used gloved hands to move the bedside table and then proceeded to apply wound dressings without changing gloves or performing hand hygiene. The nurse also touched her gown and clothing before continuing wound care on a different site, again without changing gloves or sanitizing hands. The nurse confirmed these actions, recognizing that they did not align with proper infection control protocols as outlined in facility policy.
Unattended and Unlocked Medication Cart Found in High-Traffic Area
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with accepted professional principles. Specifically, an unattended medication cart, referred to as Cart A, was found unlocked in a high-traffic area on X Hall. The medication keys were left on top of the cart, making them accessible to unauthorized personnel. This oversight was observed on January 27, 2025, at 2:45 p.m., when residents were commuting through the area, posing a potential risk to the 137 residents residing in the facility. Interviews conducted with staff members confirmed the deficiency. S3 LPN acknowledged that Cart A was unlocked and unattended, with the medication keys left on top, and stated that the nurse responsible should have kept the keys with her. S2 RN admitted to leaving Cart A unattended and unlocked while she was in a nursing room, confirming that the keys were left on top of the cart. S1 DON also confirmed that medication carts should always be locked when unattended and that keys should not be left accessible to others.
Medication Administration Errors Result in 10% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate during a survey observation. This deficiency was identified when an LPN administered medications to a resident, failing to give two medications as ordered and administering a discontinued medication. Specifically, the LPN did not administer Ticagrelor 90 mg and Lansoprazole 30 mg as prescribed, and instead administered Lasix 20 mg and Lasix 10 mg, despite the latter being discontinued. The error was confirmed through observation, interview, and record review. The resident involved was observed receiving 8.5 tablets, including medications that were not ordered and one that was discontinued. The LPN confirmed the oversight, stating she was unaware of the discontinuation of Lasix 10 mg. The facility's policy requires medications to be administered according to prescriber orders, with checks to verify the right resident, medication, dosage, time, and method. The failure to adhere to these protocols led to the medication errors observed during the survey.
Infection Control Deficiencies in Wound Care and Signage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene during wound care for a resident with pressure ulcers. The treatment nurse did not follow the facility's wound care policy, which required removing gloves and sanitizing hands after removing a soiled dressing and before cleaning the wound. During an observation, the nurse was seen holding the resident's foot with one hand while discarding the soiled dressing with the other, and then proceeded to clean the wound without changing gloves or sanitizing hands. Both the treatment nurse and the Director of Nursing confirmed that the correct procedure was not followed. Additionally, the facility did not ensure proper signage for Enhanced Barrier Precautions (EBP) for the same resident, who had pressure ulcers requiring such precautions. The facility's policy required signage to communicate to staff the need for EBP and Personal Protective Equipment (PPE) before high-contact care activities. Observations revealed that there was no EBP signage in or outside the resident's room, and the Infection Preventionist confirmed the absence of signage, acknowledging that it should have been in place to alert staff to use EBP.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Leesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rosepine Retirement & Rehab Center, Llc | 13.6 mi | ★★★★★ | 9 | 0 |
| Westwood Manor Nursing Home, Inc | 18.4 mi | ★★★★★ | 0 | 0 |
| Deridder Retirement & Rehab Center | 19.6 mi | ★★★★★ | 9 | 0 |
| Sabine Retirement And Rehab Center | 31.1 mi | ★★★★★ | 6 | 0 |
| Many Healthcare And Rehabilitation Center | 32.7 mi | ★★★★★ | 14 | 0 |
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