Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 Park Manor Of The Woodlands during CMS and state inspections, most recent first.
Surveyors found that the facility failed to update and post the required daily nursing staffing information, leaving the staffing sheet at the nursing station dated for the previous day. The posting, which lists census and numbers of RNs, LVNs, CNAs, CMAs, and RNAs for each shift, was not revised when the staffing coordinator was absent, despite the Administrator’s and DON’s acknowledgment that the DON assumes this responsibility in such cases. Facility policy requires the shift supervisor to compute and post direct care staffing and census within two hours of each shift’s start, but this was not completed as required.
Food storage and handling practices were not followed in the kitchen. Surveyors observed 10 pounds of raw fish thawing at room temperature with an internal temp of 64 degrees, scoops stored inside sugar and flour bins, and 4 gallons of milk stored only 4 1/2 inches off the floor. The Dietary Manager stated that frozen food should not be thawed at room temperature, scoops in food bins could cause cross-contamination, and food should be stored 6 inches off the floor.
The facility failed to maintain infection control during resident care and kitchen practices. A MA entered a resident’s room on EBP without PPE and checked BP, an LVN provided PEG-tube medication care without PPE and did not verify tube placement, and a CNA performed incontinent/Foley care without hand hygiene and without cleaning around the buttocks. The record also noted kitchen storage and temperature concerns related to food safety.
Improper Incontinent Care and Perineal Cleaning: A resident with an indwelling Foley catheter and total ADL dependence did not receive complete incontinent care when a CNA cleaned the groin and labia but failed to clean around the buttocks before applying a clean brief. The CNA said she was nervous and forgot, and the DON stated poor incontinent care could lead to infection, skin breakdown, and UTI.
A resident with an indwelling Foley catheter and multiple chronic conditions received improper incontinent care when a CNA did not perform hand hygiene, did not clean the catheter insertion site, and left the Foley unsecured; another CNA also did not fully clean the resident during bowel care. The DON stated the CNAs had been trained, and the CNA acknowledged she did not clean the catheter site and that this could cause a UTI.
Feeding Tube Placement Not Verified Before Med Administration: An LVN did not verify PEG placement before giving medication to a resident with a GT, dysphagia, and multiple serious medical conditions. During the observed med pass, the nurse crushed Sucralfate, attempted to dissolve and administer it through the tube, noted return of milky gastric contents, and discarded the medication when it would not go down the tube. The DON stated tube placement should be verified before use.
A resident with a suprapubic catheter, diabetes, neurogenic bladder, RA, and ESBL resistance had physician orders for catheter output to be recorded every shift, but the MAR showed missing output documentation on two shifts. Staff told surveyors they measured the output but overlooked entering it into the EMR, and the DON stated that without documentation the facility would not know whether output was present or whether interventions were needed.
A resident received incorrect doses of Potassium Chloride and Ferrous Sulfate, and Acetaminophen ER was improperly crushed and administered via g-tube by an LVN, leading to a 16% medication error rate. The resident had severe cognitive impairment and multiple health conditions, requiring staff assistance for daily activities.
Failure to Update and Post Daily Nursing Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the daily nurse staffing information was updated and posted as required. On 02/05/26 at 9:08 AM, surveyors observed the "Daily Nursing Staff Direct Responsible for Resident Care" posting at the center nursing station facing the front door, and the document was dated 02/04/26 instead of the current date. The posting listed three shifts for nurses and CNAs (6 AM–2 PM, 2 PM–10 PM, 10 PM–6 AM), and two shifts for CMAs and RNAs (6 AM–2 PM, 2 PM–10 PM), and included the facility census, numbers of RNs, LVNs, CNAs, CMAs, RNAs, and total hours worked for all shifts. The posting was not updated for the current day, contrary to the facility’s policy. During an interview later that day, the Administrator stated that the staffing coordinator was responsible for updating the daily staffing posting around 6:30 AM and that, in her absence, the DON was responsible for this task. The Administrator acknowledged that the posting serves to notify everyone in the building of the type and number of staff available for resident care on a particular day and confirmed that the posting still showed the prior day’s date. In a separate interview, the DON confirmed that the staffing coordinator normally updates the posting and that she is responsible when the coordinator is absent, and stated that the posting is typically updated before the first shift. Review of the facility’s policy "Posting Direct Care Daily Staffing Numbers" (revised 07/2016) showed that within two hours of the beginning of each shift, the shift supervisor must compute the number of direct care staff, complete the staffing form, date it, record the census, and post the information in a prominent, accessible location, which was not done for the observed date.
Food Storage and Handling Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in the kitchen. During observation and interview, 10 pounds of raw fish were found thawing on a pan at room temperature, and the internal temperature was 64 degrees Fahrenheit. The Dietary Manager stated that food held in the danger zone could place residents who ate it at risk of food borne illness and disease, and that frozen food should not be thawed at room temperature. The same observation identified scoops with handles submerged in the sugar bin and flour bin, and 4 gallons of milk stored on a rack 4 1/2 inches off the floor in the walk-in refrigerator. The Dietary Manager stated that scoops in food bins could cause cross-contamination and that food should be stored 6 inches off the floor. Record review showed the facility's policy required cold foods at 40 degrees Fahrenheit or below, hot or potentially hazardous foods at 140 degrees Fahrenheit or above, scoops not stored inside dry storage bins or product bags, and all foods kept at least 6 inches off the floor.
Infection Control Failures During Resident Care and Food Handling
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for three residents and one kitchen area reviewed. For Resident #75, who had diagnoses including hypertension, chronic kidney disease, diabetes, and moderate cognitive impairment, the record showed enhanced barrier precautions were in place. During observation, MA E entered the room without PPE, touched the resident, and checked blood pressure twice without donning PPE. MA E later stated she forgot to don PPE and knew it should have been worn to protect the resident and herself from infection. For Resident #78, who had a gastrostomy tube, dysphagia, moderate cognitive impairment, and was totally dependent on staff for multiple activities of daily living, the record showed enhanced barrier precautions were also in place. During observation of PEG-tube medication administration, LVN K did not don PPE, did not verify PEG placement, and did not palpate the resident’s stomach. She crushed Sucralfate, attempted to dissolve it, removed the syringe plunger, checked residual, and discarded medication and cups after the medication would not go down the tube. LVN K stated she forgot to don PPE before providing GT medication administration and knew not doing so could cause infection. For Resident #79, who had an indwelling Foley catheter, multiple medical diagnoses, and required assistance with ADLs, CNA B was observed providing incontinent and Foley catheter care. CNA B did not open the labia to clean it, did not clean around the buttocks before placing a clean brief, and changed gloves three times without washing hands or using hand sanitizer. CNA B stated she was nervous, forgot to wash or sanitize her hands, used the same wipes to clean the groin and labia, and did not clean around the buttocks. The report also included kitchen-related infection control concerns, with the Dietary Manager stating that food held in the danger zone could place residents at risk of food-borne illness and disease, frozen food should not be thawed at room temperature, scoops should not be stored in food bins, and food must be stored at least 6 inches off the floor.
Improper Incontinent Care and Perineal Cleaning
Penalty
Summary
The facility failed to ensure proper incontinent and Foley catheter care for a resident who had multiple diagnoses including obesity, hypothyroidism, hyperlipidemia, GERD, pneumonia, acute kidney failure, hypertension, atrial fibrillation, COPD, insomnia, osteomyelitis, absence of the left leg above the knee, type 2 diabetes, chronic systolic heart failure, ulcer of the anus and rectum, peripheral vascular disease, anemia, hypotension, and acute and chronic respiratory failure with hypoxia. The resident’s admission MDS showed a BIMS score of 14, indicating no impairment in thinking, and documented an indwelling catheter. The care plan stated the resident was totally dependent on staff for all ADLs and required assistance to remain clean, dry, without odor, and comfortable each shift. During observation of incontinent and Foley catheter care, CNA B cleaned the resident’s groin and opened the labia, but did not clean around the buttocks before placing a clean brief and fastening it. In interview, CNA B stated she was nervous, used wet wipes to clean the groin twice, used the same wipes to clean the labia, and forgot to clean around the buttocks. She acknowledged that inadequate cleaning could cause itchiness, skin breakdown, urinary tract infection, and odors. The DON stated that poor incontinent care could result in infection, skin breakdown, and UTI, and the facility policy on perineal care stated the purpose was to provide cleanliness and comfort, prevent infections and skin irritation, and observe the resident’s skin condition.
Inadequate Foley and Incontinent Care
Penalty
Summary
The facility failed to ensure appropriate incontinent and Foley catheter care for Resident #79, who was admitted on 8/27/25 and readmitted later, with diagnoses including type 2 diabetes mellitus, chronic systolic heart failure, COPD, obesity, hypertension, atrial fibrillation, and other significant medical conditions. The resident’s MDS dated 8/29/25 showed a BIMS score of 14 and indicated an indwelling catheter. The care plan stated the resident was totally dependent on staff for all ADLs and required assistance to remain clean, dry, without odor, and comfortable each shift. Physician orders included keeping the catheter free of kinks and the drainage bag lower than the bladder at all times. During observation on 9/24/25, CNA B performed Foley catheter and incontinent care but did not wash hands or use hand sanitizer before care. CNA B donned clean gloves, removed the soiled brief, and cleaned the resident’s groin, but did not clean the indwelling catheter or open the labia to clean around the insertion site. The Foley catheter was also not secured. CNA A then assisted with care after a small bowel movement, cleaned in between the buttocks, and fastened a clean brief, but did not clean around the buttocks. CNA B later stated she was nervous and did not open the labia to clean the catheter insertion site, and acknowledged that not cleaning the catheter from the insertion site could cause a UTI. The DON stated she provided initial training and monitored CNAs randomly monthly, and that poor incontinent care could result in infection and UTI.
Feeding Tube Placement Not Verified Before Medication Administration
Penalty
Summary
The facility failed to ensure appropriate care for a resident with a feeding tube when LVN K did not verify placement of the resident’s PEG tube before administering medication. The resident was an older male admitted and readmitted to the facility with diagnoses including gastrostomy tube, dysphagia, hypertension, hyperlipidemia, depression, anemia, obesity, narcolepsy, pulmonary embolism related to multiple sclerosis, interstitial pulmonary disease with fibrosis, acute respiratory failure with hypoxia and hypercapnia, dyskinesia of the esophagus, lung abscess, and pulmonary fibrosis. His MDS showed a BIMS score of 08 and total dependence for bed mobility, transfers, locomotion, dressing, eating, toileting, and personal hygiene. Physician orders dated 09/11/25 directed that he remain NPO with GT bolus feedings of Isosource 1.5 five times daily, residual checks every shift, and flushing of the GT before and after medications. During observed PEG-tube medication administration on 09/23/25 at 11:09 AM, LVN K did not verify tube placement and did not palpate the resident’s stomach. She crushed Sucralfate 1 gm in a pill crusher, attempted to dissolve it with water, and then tried to administer it through the PEG tube. The resident stated he was too full of breakfast, and LVN K said she was holding the bolus feeding. During the same observation, there was milky substance flowing back from the stomach into the tubing and the medication was not going down despite milking the PEG tube. LVN K poured the residual with water into a cup, checked the residual after rinsing the syringe, found about 10 cc, and did not return it to the stomach. She then tried again to administer Sucralfate, but it still would not go down the PEG tube, and she discarded the cups in the trash. When questioned, LVN K stated the medication was not given in totality because she was not able to dissolve it and the family member did not want the medication changed. The DON later stated that feeding tube placement should be verified and that failure to do so could result in infection, bloating, or discomfort.
Incomplete Documentation of Suprapubic Catheter Output
Penalty
Summary
The facility failed to ensure medical records were complete and accurately documented for one resident with a suprapubic catheter. Resident #144 was a cognitively intact female with diagnoses including type 2 diabetes mellitus, neuromuscular dysfunction of the bladder, rheumatoid arthritis, and ESBL resistance. Her physician orders required suprapubic catheter output to be recorded every shift, and her care plan included checking catheter patency and urinary output every shift, along with monitoring and communicating sudden changes in condition while she was being treated for a UTI. Record review showed no documented catheter output on one night shift and one morning shift, despite the order to measure and record output each shift. During interviews, the resident stated staff emptied and measured her catheter output two or three times a day. The DON stated aides could empty catheters and report urine output to the nurse, and that if output was not documented the facility would not know whether residents had output or whether interventions were needed. An RN and an LVN both stated they measured output but overlooked documenting it in the medical record, and both acknowledged that failure to document could delay care or cause things to be missed.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 16% due to 4 errors out of 25 opportunities. These errors involved a resident who was administered incorrect doses of Potassium Chloride and Ferrous Sulfate liquid by LVN N, contrary to the physician's orders. Additionally, LVN N crushed and administered Acetaminophen ER, an extended-release formulation that should not be crushed, via a g-tube instead of the prescribed Acetaminophen. This was observed during a medication administration session, where LVN N prepared and administered the medications incorrectly. The resident involved was an elderly female with multiple diagnoses, including gastrostomy status, type 2 diabetes, hypertension, and cerebrovascular disease. Her cognitive skills were severely impaired, and she was dependent on staff for activities of daily living. The facility's policy on administering medications required verification of the right resident, medication, dosage, time, and method before administration. However, LVN N admitted to not realizing the incorrect dosages and was unsure about the crushing of Acetaminophen ER, which was not specified on the bottle. The Director of Nursing confirmed that Acetaminophen ER should not be crushed due to its slow-release formulation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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Nursing homes near The Woodlands
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ridgewood At The Woodlands | 3.6 mi | ★★★★★ | 1 | 0 |
| The Woodlands Nursing And Rehabilitation Center | 4.1 mi | ★★★★★ | 7 | 0 |
| Park Manor Of Conroe | 4.9 mi | ★★★★★ | 3 | 0 |
| The Brightpointe | 5.1 mi | ★★★★★ | 0 | 0 |
| The Broadmoor At Creekside Park | 5.5 mi | ★★★★★ | 11 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.