Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Ridgewood At The Woodlands during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses was identified as needing a customized manual wheelchair through the PASARR process, but the facility failed to submit the required specialized service request through the appropriate portal within the mandated timeframe. Despite documentation of the need in care planning and PASARR meetings, staff interviews and record reviews revealed the request was not processed as required, and the wheelchair was ultimately obtained through Medicaid rather than PASARR.
Two residents who expressed a desire to die did not receive timely behavioral health assessments or interventions, and appropriate staff were not immediately notified or documented as required by facility policy. In both cases, staff failed to follow procedures for addressing changes in mood or suicidal ideation, resulting in a lack of necessary behavioral health care and services.
A resident with significant medical and cognitive impairments, who required partial to moderate assistance with ADLs, fell and sustained a head injury when the bed's locking mechanism failed during care. The malfunctioning bed lock was not addressed, and observations confirmed that other beds also lacked proper slip-resistant pads, allowing movement even when locks were engaged. Staff were aware of the faulty lock, and the facility's failure to maintain bed safety mechanisms led to the incident.
Three residents experienced abuse, including verbal abuse with profane and racial language by staff and physical abuse during care, as confirmed by witness statements, interviews, and record reviews. Residents involved had significant cognitive and physical impairments, and incidents included inappropriate language directed at a nonverbal resident, a staff member responding to a racial slur with another slur, and a resident allegedly handled roughly during a brief change.
A resident with Parkinsonism and tremors self-administered lubricant eye drops without being assessed for the ability to do so, as required by facility policy. The resident kept the eye drops at her bedside and used them independently, despite not being trained or evaluated for self-administration. The DON was unaware of this practice until it was identified by surveyors, and no documentation or care plan addressed the resident's self-administration of medication.
A resident with Parkinsonism did not receive Carbidopa/Levodopa within the required timeframe on multiple occasions, resulting in increased tremors and difficulty with daily activities. Additionally, an expired bottle of Aspirin was found on a medication cart, indicating lapses in medication storage and monitoring practices.
Surveyors identified that a resident with Parkinsonism and mild dementia had unsecured OTC eyedrops at her bedside and self-administered them without authorization or training. Additionally, a medication cart was found to contain expired medications, loose pills, and improperly labeled supplements. Staff interviews confirmed that required daily checks and labeling protocols were not followed, resulting in multiple deficiencies in medication storage and security.
Surveyors found that pureed and regular meals were not prepared according to facility policy, resulting in pureed food that was too thick and regular food that was excessively salty. The dietary manager confirmed that the cook did not use enough broth for the pureed dish and failed to taste the food before serving. Several residents with intact cognition and multiple medical conditions reported the food was too salty.
A CNA failed to use a gait belt during a transfer, instead lifting a resident by the arm, which caused the resident to express pain multiple times. The resident, who had dementia and required substantial assistance, was at risk for injury due to improper transfer technique. Facility policy and the resident's care plan required the use of a gait belt for all transfers, but this protocol was not followed, as confirmed by video footage and staff interviews.
Two residents were found to have inadequate access to the call light system, with one resident's call light discovered on the floor while she was in bed. The resident, who had dementia and muscle weakness, attempted to retrieve the call light herself, increasing her risk of falling. Staff interviews and facility policy confirmed that call lights should always be within reach to ensure timely assistance.
A resident with dementia and behavioral symptoms was transferred twice to a psychiatric hospital without the facility providing the required written notice to her or her representative, including reasons for transfer, effective date, location, appeal rights, and bed-hold policy. Verbal communication occurred, but written documentation as mandated by facility policy and regulations was not completed.
Two residents did not have their current diagnoses and treatments accurately reflected in their MDS assessments. One resident's diagnosis of Parkinson's Disease was omitted from the MDS and diagnosis list despite being documented in medical records and observed in care, while another resident's use of oxygen therapy was not recorded in the MDS even though it was ordered and administered. Staff interviews confirmed these omissions were errors in the assessment process.
A resident with multiple diagnoses, including respiratory issues, was receiving oxygen therapy as ordered by a physician, but the facility failed to include oxygen administration in the resident's care plan. The care plan addressed other medical needs but omitted this critical intervention, and the MDS assessments did not reflect the resident's oxygen use.
A resident with chronic pain conditions did not receive timely or effective pain management when her prescribed medication was ineffective, and staff failed to document or provide alternative interventions or notify the practitioner as required by facility policy.
The facility did not maintain the dining room ice and water dispenser in safe operating condition, as it was observed leaking water into the tray, drawer, and cabinet below. Staff placed an out of order sign on the machine after the issue was identified, and the Maintenance Director reported not being notified of the malfunction until later. The facility's policy on equipment maintenance was requested but not received.
A resident with advanced cancer and a sacral ulcer, who was on hospice and experiencing significant pain, was found to have a non-functioning call light. The resident reported using the call light for help without response, and the issue was confirmed by a surveyor. Staff were unaware of the malfunction until it was brought to their attention, and the call light was only restored after intervention by the administrator. Facility policy requires call lights to be accessible and functional at all times, but this was not met in this case.
Nursing staff did not use privacy curtains or close doors while providing incontinence care to a resident with severe cognitive impairment, resulting in exposure to both the hallway and a roommate. This occurred despite facility policies and care plans requiring privacy and dignity during personal care.
A resident with multiple diagnoses, including shortness of breath, was observed receiving oxygen therapy, but the facility failed to document the times PRN oxygen was administered. Interviews revealed that nurses sometimes missed documenting oxygen use, and the DON had to retrain staff on proper documentation. This lack of documentation placed the resident at risk of inadequate respiratory care.
A resident with a history of falls and poor cognition fell and sustained fractures after a CNA failed to ensure the resident was secured in bed before plugging in the bed. The incident occurred during incontinent care when the CNA noticed the bed was unplugged. The facility's investigation found a loose outlet contributed to the bed becoming unplugged.
A resident with end-stage renal disease was not provided with a proper meal during her dialysis day, leading to extreme weakness and fatigue. The facility failed to ensure that food was properly stored and that expired or spoiled food items were discarded. Staff interviews revealed a lack of communication and coordination between the dietary and nursing departments, resulting in the resident not receiving a bagged lunch or adequate meal substitutes.
The facility failed to ensure that a resident with ESRD received timely and adequate meals on dialysis days. The resident was sent to dialysis without a lunch, sometimes missed breakfast, and returned to find a cold dinner tray, which she refused. Staff interviews revealed lapses in communication and responsibility regarding meal preparation and delivery.
The facility failed to properly store and serve meals for dialysis patients, leading to a resident returning from dialysis to find a cold dinner tray that had been left out for an extended period. Another resident's uneaten lunch tray was also observed sitting on a bedside table. The facility did not have a system in place to ensure proper meal storage for dialysis patients, potentially exposing them to foodborne illnesses.
Failure to Incorporate PASARR Recommendations and Submit Specialized Service Request
Penalty
Summary
The facility failed to incorporate the recommendations from the PASARR Level II determination and evaluation report into a resident's assessment, care planning, and transitions of care. Specifically, the facility did not submit a request through the Simple LTC portal for a customized manual wheelchair for a resident within the required timeframe set by PASARR. This omission was identified through observation, interviews, and record review, which showed that the need for a customized wheelchair was documented during the PASARR IDT meeting and included in the resident's care plan, but the necessary request for specialized services was not processed as required. The resident involved was an elderly female with diagnoses including developmental disorder of speech and language, dementia, and rhabdomyolysis. She had severe cognitive impairment, was dependent on staff for multiple activities of daily living, and was identified as PASRR positive. The PASARR IDT meeting recommended a customized manual wheelchair as a specialized service, and this was reflected in the care plan and progress notes. However, review of the Simple LTC portal showed no submission of the NFSS (Nursing Facility Specialized Services) request for the wheelchair, despite ongoing documentation in quarterly meetings that the wheelchair was needed and later received. Interviews with facility staff revealed confusion and lack of follow-up regarding responsibility for submitting the NFSS request. The Director of Rehabilitation (DOR) and MDS nurse both indicated that the process was not completed as required, with the previous DOR and therapy staff unsure if the request was ever finalized or submitted. The administrator was not aware of the PASARR IDT's recommendation for the wheelchair and confirmed that the request was not sent through PASARR, but rather the wheelchair was eventually obtained through Medicaid benefits. The facility's policy requires that PASARR recommendations be incorporated into resident care, but this was not followed in this instance.
Failure to Provide Timely Behavioral Health Interventions After Residents Expressed Suicidal Ideation
Penalty
Summary
The facility failed to ensure that two residents received necessary behavioral health care and services after each expressed a desire to die. One resident, a female with terminal cancer on hospice care, made statements such as "let me die, leave me alone" and explicitly stated she wanted to die. Despite these statements, there was no documentation that the resident's physician was notified, nor was there evidence of a psychiatric evaluation, social services assessment, or any behavioral health intervention following her statements. Interviews with facility staff, including the DON, social worker, and LVN, confirmed that no immediate assessment or intervention was initiated, and the required notifications and documentation were not completed as per facility policy. Another resident, a male with a recent colostomy and a history of anxiety disorder, also stated he wanted to die, reportedly due to pain and a recent room change. Although a psychiatric consult was eventually ordered, there was no immediate assessment or documentation of behavioral health interventions or increased supervision following his statement. Staff interviews revealed a lack of awareness of the resident's statements and inconsistent understanding of the procedures to follow when a resident expresses suicidal ideation. The social worker did not assess the resident until hours after being notified and did not specifically address the resident's statement about wanting to die during her assessment. Both cases demonstrated a failure to follow the facility's behavioral health policy, which requires immediate assessment, notification of appropriate staff, and documentation when a resident expresses suicidal ideation or a significant change in mood. The lack of timely response and intervention placed the residents at risk of mental and psychosocial harm, as the facility did not provide the necessary behavioral health care and services in accordance with the comprehensive assessment and plan of care.
Failure to Maintain Bed Safety Mechanisms Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents. Specifically, the locking mechanism on the resident's bed was not operating properly, which resulted in the bed moving during care. This malfunction directly led to the resident falling from the bed, hitting her head, and sustaining a head injury, laceration above her right eye, and a skin tear on her forearm. The resident required emergency medical attention and received sutures for her injuries. The resident involved had a complex medical history, including cerebral infarction, dysphagia, hypertension, osteoarthritis, rheumatoid arthritis, chronic kidney disease, atrial fibrillation, repeated falls, and was prescribed anticoagulant medication. She was nonverbal, had moderate cognitive impairment, and required partial to moderate assistance with most activities of daily living. The care plan identified her as being at risk for falls and included interventions such as prompt assistance with ADLs, ensuring the call light was within reach, and using appropriate footwear. Despite these interventions, the malfunctioning bed lock was not addressed, which contributed to the accident. Observations and interviews confirmed that the bed's wheel locks were not functioning at the time of the incident and that other beds in the facility also lacked slip-resistant pads, allowing for movement even when locks were engaged. Staff interviews revealed that the bed's faulty lock was known and that the bed moved during care, directly causing the resident's fall. The facility's failure to maintain bed safety mechanisms and promptly address known hazards led to the incident and placed other residents at risk for similar accidents.
Failure to Protect Residents from Verbal and Physical Abuse
Penalty
Summary
The facility failed to protect three residents from abuse, including verbal and physical abuse, as evidenced by direct observations, interviews, and record reviews. One resident with severe cognitive impairment, expressive aphasia, and total dependence on staff for care was subjected to verbal abuse by a contract CNA, who used profane language and derogatory remarks while the resident was hollering out. Witnesses, including a medication aide and a PASRR provider, confirmed hearing the CNA use inappropriate language directed at or about the resident. The resident was unable to communicate effectively due to her condition, and her care plan emphasized the need for staff to use clear, simple instructions and alternative communication methods. Another resident with moderate cognitive impairment, dementia, and a history of making racial slurs towards staff alleged that a medication aide used a racial slur against her. The resident reported feeling insulted by the comment. The medication aide admitted to responding to the resident's use of a racial slur by asking how the resident would feel if called "white trash." The aide acknowledged the exchange and stated that it was prompted by the resident's offensive language. The facility's investigation included interviews with the resident, the accused staff member, and witnesses, but the incident was ultimately deemed unfounded by the former administrator. A third resident with severe cognitive impairment, mobility deficits, and a history of falls was allegedly subjected to physical abuse during a brief change. Family members reported hearing the resident scream in pain and observed, via partially obstructed camera footage, a CNA pulling a chuck from under the resident in a manner they believed was rough. The resident, due to memory loss, could not recall the incident. The CNA involved stated she was attempting to prevent the spread of feces and denied mistreatment. The facility's maintenance and equipment practices were also discussed, as bed movement was a concern during care. These incidents demonstrate failures in ensuring residents' rights to be free from all forms of abuse.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the ability to self-administer medication, specifically lubricant eye drops, as required when the interdisciplinary team determines this practice may be clinically appropriate. The resident, who had a history of Parkinsonism with associated tremors, anxiety disorder, mild dementia, and other conditions, had been self-administering over-the-counter eye drops from admission until the issue was identified by surveyors. There was no documentation of an assessment for self-administration of medication, nor was there a care plan focus addressing this practice for the resident. Observations revealed that the resident kept eye drops at her bedside and self-administered them without staff knowledge or training, despite experiencing tremors that could impact her ability to safely instill the drops. The DON confirmed that the resident had not been assessed for self-administration prior to the survey, and that the facility policy required such an assessment. The facility's medication administration policy did not address self-administration, and no specific policy for self-administration of medication was provided during the survey.
Failure to Administer Parkinson's Medication Timely and Maintain Medication Cart Standards
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, specifically by not ensuring the timely administration of medications and by not maintaining medication storage standards. For one resident with a diagnosis of Parkinsonism, the facility did not administer Carbidopa/Levodopa (both ER and IR formulations) within one hour of the scheduled times on numerous occasions, as documented in the Medication Administration Records. This medication is critical for controlling tremors and other symptoms associated with Parkinsonism, and the resident reported experiencing increased tremors when doses were delayed. The resident confirmed that late administration of her medication made it difficult for her to complete daily tasks, and observations corroborated the presence of tremors when medications were not given on time. Interviews with the Interim DON and the resident further established that the facility was aware of the importance of timely medication administration for Parkinson's Disease and related disorders. The Interim DON acknowledged that all medications should be administered within one hour of the scheduled time and that delays in administering Carbidopa/Levodopa could result in worsening symptoms such as tremors, rigidity, and pain. Despite this, there was no evidence that the facility had reviewed the records to determine the frequency or extent of late medication administration for this resident. Additionally, the facility failed to ensure that medication carts were free of expired medications. During an inspection of the 200 Hall Med Aide Cart, an expired, open, and in-use bottle of Aspirin 325 mg was found. Staff interviews confirmed that nursing staff are expected to check carts daily for expired medications, and that expired medications can lose potency and efficacy. The presence of expired medication on the cart indicated a failure to follow established procedures for medication storage and safety.
Deficient Medication Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to medication storage areas. During observation and interviews, it was found that a resident had over-the-counter (OTC) eyedrops stored unsecured at her bedside and self-administered them without having been trained or authorized to do so. The resident, who had a history of Parkinsonism, anxiety disorder, and mild dementia, reported that she had kept the eyedrops in her room since admission and was unaware that this was not permitted. Facility staff, including the DON, were not aware of the unauthorized medication storage until it was identified by surveyors. Additionally, inspection of a medication cart revealed several deficiencies in medication storage and labeling. The 200 Hall Med Aide Cart contained an expired, open bottle of Aspirin, an open bottle of liquid protein supplement without an open date, four loose pills of varying types, and an open bottle of Fish Oil with no visible expiration date. Staff interviews confirmed that nursing staff are expected to check carts daily for expired or inappropriately labeled medications, and that multidose containers must be labeled with the date opened. These expectations were not met, as evidenced by the presence of expired and improperly labeled medications, as well as loose pills in the cart. Facility policy requires that all drugs and biologicals be stored in locked compartments under proper temperature controls and that medications be kept in their original containers with appropriate labeling. The observed failures included unsecured resident medications, expired and unlabeled items in the medication cart, and lack of staff awareness or adherence to medication storage protocols. These actions and inactions led to the identified deficiencies in medication storage and security.
Failure to Prepare Palatable and Properly Textured Meals
Penalty
Summary
Surveyors identified that the facility failed to prepare both pureed and regular food in a manner that conserved nutritive value, flavor, texture, and appearance for three residents. During a test meal observation, the pureed okra was found to be too thick, and the regular pinto beans were excessively salty. The dietary manager confirmed these findings, stating that the cook did not use enough broth for the pureed okra and did not taste the food before serving. The dietary manager attributed the errors to the cook being nervous due to the surveyor's presence and preparing additional trays for taste testing. The facility's policy requires food to be prepared to preserve or enhance nutrition and hydration, and to follow standardized recipes and preparation methods that conserve nutritive value, flavor, and appearance. Interviews with the three residents involved, all of whom had intact cognitive abilities and various medical conditions such as diabetes, hypertension, dysphagia, chronic kidney disease, cerebrovascular disease, and neuropathy, confirmed that the pinto beans served were very salty. The dietary manager acknowledged that the excessive salt could impact residents' blood pressure, and that the thick consistency of the pureed food was due to not following the correct preparation method. The facility's own food preparation guidelines were not followed, resulting in food that was not palatable or prepared according to policy.
Failure to Use Gait Belt During Transfer Results in Resident Distress
Penalty
Summary
A certified nursing assistant (CNA) failed to provide appropriate treatment and care to a resident in accordance with professional standards, the resident's care plan, and the resident's preferences. The CNA did not use a gait belt as required during a transfer from the bed to a wheelchair. Instead, the CNA hooked her arm under the resident's armpit and pulled upward, which caused the resident to express pain multiple times during the transfer attempt. The resident's care plan and facility policy specified that a gait belt must be used for all sit-to-stand transfers and that residents should not be lifted by their arms. The resident involved had a history of dementia, stroke, muscle weakness, and required substantial to maximal assistance with transfers and toileting. The resident was frequently incontinent and used a wheelchair for mobility. The care plan indicated the resident was at risk for falls and injury due to gait and balance problems, poor safety awareness, and cognitive impairment. The resident's assessment and therapy notes confirmed the need for a one-person assist with a gait belt for transfers, and staff had been in-serviced on these requirements. The incident was observed on video footage, which showed the CNA attempting to transfer the resident without a gait belt, resulting in the resident repeatedly stating she was in pain. The CNA eventually sought assistance from a nurse, and the transfer was completed without further incident. Interviews with staff and the resident's roommate corroborated that the resident expressed pain during the transfer. The facility's investigation confirmed that the CNA did not follow the established protocols for safe resident handling and transfers.
Call Light Accessibility Failure for Two Residents
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as required by facility policy and the resident's care plan. During an observation, the call light for a female resident with dementia, anxiety disorder, schizophrenia, and generalized muscle weakness was found on the floor while she was in bed. The resident attempted to retrieve the call light by rotating her body, which placed her at risk of falling. The care plan for this resident specifically indicated that the call light should be within reach to mitigate the risk of falls and injury, and staff interviews confirmed that call lights are expected to be accessible to residents at all times. A CNA reported that she had last checked on the resident 30 minutes prior and that the call light had been within reach at that time. Upon discovering the call light on the floor, the CNA returned it to the resident's bed. The DON also confirmed that call lights should be within reach and functional, as failure to do so could result in delayed care or failure to identify changes in condition. Facility policy requires that the call system be accessible to residents in their beds and that staff report and address any issues with the call system immediately.
Failure to Provide Required Written Transfer Notices and Appeal Rights
Penalty
Summary
The facility failed to provide written notification to a resident and her representative regarding transfers to a psychiatric hospital, including the reasons for transfer, effective date, location, statement of appeal rights, and information about the bed-hold policy. The resident, who had diagnoses of dementia, diabetes type II, major depressive disorder, and multiple fractures, exhibited wandering and behavioral symptoms that interfered with her care and the privacy of others. She was transferred to a psychiatric hospital on two occasions due to these behaviors, but neither she nor her representative received the required written notice. Record reviews showed that while the facility's social worker and staff communicated verbally with the resident's representative about the transfers and the resident's behaviors, there was no documentation of written notices being provided. The facility's own policy required that such notices include specific information about the transfer or discharge, appeal rights, and contact information for the state ombudsman, but this was not followed. Interviews with the administrator confirmed that written notices were not provided for hospital transfers, and there was an assumption that residents would be allowed to return. The resident's care plan included interventions for impaired coping, knowledge deficit, and elopement risk, but these did not address the lack of written notification for transfers. The administrator acknowledged that the facility could not meet the resident's needs due to her behaviors and that the transfer was considered involuntary, yet the required written documentation was not completed or given to the resident or her representative.
Failure to Accurately Reflect Resident Diagnoses and Treatments in MDS Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the current status of two residents. For one resident, the facility did not identify a diagnosis of Parkinson's Disease in the Quarterly Minimum Data Set (MDS) and the list of medical diagnoses, despite multiple sources indicating the presence of this condition. The resident's face sheet, care plan, physician's orders, and medication administration record all referenced Parkinson's Disease, and the resident was observed experiencing tremors consistent with the diagnosis. However, the MDS listed only unspecified parkinsonism, omitting the specific diagnosis of Parkinson's Disease. For another resident, the facility did not document the use of oxygen therapy in the MDS, even though the resident was observed receiving oxygen via nasal cannula and had an active physician's order for oxygen administration as needed for respiratory symptoms. The care plan addressed related issues such as pneumonia and breathing treatments but did not include a focus area for oxygen administration. Both the Quarterly and Change of Condition MDS assessments failed to indicate the resident's use of oxygen. Interviews with facility staff confirmed that the MDS nurse was responsible for entering diagnoses and treatment information into the MDS and diagnosis list, using information from medical records and physician documentation. The nurse acknowledged that the omission of the Parkinson's Disease diagnosis and the failure to document oxygen use in the MDS were errors, as these were active problems being treated in the facility and should have been included in the residents' assessments.
Failure to Include Oxygen Therapy in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions. Specifically, the care plan did not include a focus area or interventions for the resident's use of oxygen, despite physician orders for oxygen administration at 4 L/min via nasal cannula as needed for symptoms such as shortness of breath and respiratory distress. The care plan addressed other issues such as pneumonia, nebulizer treatments, and hospice services, but omitted the resident's oxygen therapy needs. Record reviews showed that the resident had diagnoses including bone cancer, shortness of breath, anal cancer, cognitive communication deficit, difficulty swallowing, and a pressure ulcer. Observations confirmed the resident was receiving oxygen via nasal cannula, and interviews with the MDS nurse revealed that active problems treated in the facility should be reflected in the MDS and care plan. However, the MDS assessments did not indicate oxygen use, and the care plan was not updated to address this need.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
A deficiency was identified when the facility failed to provide safe and appropriate pain management for a resident with multiple chronic pain-related diagnoses, including cerebrovascular disease, chronic gout, contractures, and rheumatoid arthritis. The resident's care plan required staff to notify the physician if pain medications or non-pharmacological interventions were ineffective, and to maintain the resident's comfort without signs of unrelieved pain. However, medical records showed that after the resident reported pain levels of 6 and 7 out of 10 and stated that the prescribed pain medication was ineffective, no alternative interventions or additional medications were offered for several hours. Documentation did not reflect any follow-up actions or communication with the physician as required by the care plan and facility policy. Despite the resident later expressing satisfaction with her pain management and not recalling any instances where staff failed to assist her, the facility's records indicated a lack of timely and appropriate response when pain was not controlled by the current regimen. The administrator was unaware of why staff did not document interventions when the medication was ineffective. The facility's policy required staff to notify the practitioner if pain was not controlled, but this was not documented or carried out in the instances reviewed.
Failure to Maintain Ice and Water Dispenser in Safe Operating Condition
Penalty
Summary
The facility failed to maintain the ice and water dispenser in the dining room in safe operating condition. Observations revealed that the dispenser had a full tray of water below the spigots, and when the drawer beneath the machine was opened, water and dust were found in the bottom of the drawer, with additional water present in the cabinet below. On a subsequent observation, the machine was found with an out of order sign, and water was no longer present in the tray, drawer, or below the machine. Interviews indicated that the Dietary Manager was aware of the leak and had instructed staff not to use the machine, while the Maintenance Director reported not being informed of the malfunction until a specific date. The Maintenance Director then disconnected the machine, placed an out of order sign, and began emptying the tray and cleaning the affected areas. The facility's policy on maintaining equipment in safe operating condition was requested but not provided.
Failure to Ensure Functioning Call Light System for Resident in Pain
Penalty
Summary
A deficiency was identified when a resident with a history of bone cancer, anal cancer, cognitive communication deficit, and a sacral pressure ulcer was found to have a non-functioning call light in her room. The resident, who was on hospice care and experiencing significant pain, reported that she pressed the call light for assistance but did not receive a response. Upon observation, both the resident and the surveyor attempted to use the call light, but it did not work. The issue was only resolved after the facility administrator was notified and reset the call light by unplugging and re-plugging it, restoring its function. Interviews with facility staff, including a CNA and an LVN, revealed that they were unaware of the malfunctioning call light prior to the surveyor's observation. The CNA stated that the call light was working earlier in the day when she last checked on the resident, and the LVN was also unaware of any issues with the call system. The resident was noted to be in pain and required repositioning, but there was no indication that staff had been alerted to the malfunction before the surveyor's intervention. Facility policy requires that call lights be accessible and functional for residents at all times, including in bed, bathrooms, and bathing areas, and that any problems with the call system be reported immediately with alternative solutions provided until repairs are made. In this instance, the failure to ensure a working call system left the resident unable to summon assistance while experiencing pain, in direct violation of facility policy and regulatory requirements.
Failure to Maintain Resident Privacy and Dignity During Incontinence Care
Penalty
Summary
Nursing staff failed to maintain resident privacy and dignity during the provision of incontinence care for one resident with severe cognitive impairment and multiple medical conditions, including dementia, stroke, and incontinence. During observed care, staff did not use the privacy curtain between the resident and the hallway door, nor between the resident and a roommate, resulting in the resident being exposed while receiving peri care. In one instance, the door to the hallway was partially opened while the resident's pants were down, further compromising privacy. The resident required substantial to maximal assistance with activities of daily living due to her cognitive and physical limitations. Her care plan emphasized the need to promote dignity by keeping her clean, dry, and free from odor, and included interventions to communicate simply and provide necessary cues due to her confusion and disorientation. Despite these documented needs, staff did not follow facility policy or care plan interventions regarding privacy during care. Facility policy required staff to provide privacy by pulling curtains or closing doors during perineal care and to treat all residents with respect and dignity. Interviews with facility leadership confirmed the expectation that privacy should be maintained during care. However, video evidence and interviews indicated that these procedures were not followed, resulting in the resident being exposed to both the hallway and a roommate during personal care.
Failure to Document PRN Oxygen Administration
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required oxygen therapy. The resident, diagnosed with cerebral palsy, shortness of breath, epilepsy, dementia, and muscle wasting atrophy, was observed receiving oxygen via nasal cannula. However, the nurses did not document the times PRN oxygen was administered, despite the resident's oxygen levels occasionally dipping low. The resident's care plan included administering oxygen as ordered, but the comprehensive MDS did not note oxygen therapy, and the MAR from March to April 2024 showed no documentation of PRN oxygen administration. Interviews with the MDS Nurse and LVN A revealed that oxygen therapy was sometimes missed in documentation, and LVN A admitted to administering oxygen without documenting it due to being overwhelmed with other tasks. The DON emphasized the importance of documenting oxygen use for continuity of care and accurate assessments but acknowledged that the MAR might not be the best place for such documentation. The deficiency was further highlighted when the DON had to retrain LVN A on documenting changes in condition and reporting to the physician after learning that the resident's oxygen levels had dipped below 90% without proper documentation. The facility's policy on documenting oxygen use was requested but not provided before the survey exit. This lack of documentation placed the resident at risk of not receiving adequate respiratory care, as there was no clear record of when oxygen therapy was administered or needed.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for a resident, leading to a witnessed fall and subsequent injury. The resident, who had a history of falls and poor cognition, required assistance for all activities of daily living and had specific interventions in place to minimize fall risks. However, during an incident, a CNA did not ensure the resident was properly secured in bed before attempting to plug in the bed, resulting in the resident falling and sustaining fractures. The incident occurred when the CNA was providing incontinent care and noticed the bed was unplugged. The CNA attempted to plug the bed back in without ensuring the resident was safely positioned, leading to the resident rolling out of bed. The resident was found on the floor with a bruise and a small cut, and was later diagnosed with a hip and knee fracture at the hospital. The CNA was the only witness to the fall, and there was a discrepancy in the account of whether the resident was lying on her side or flat at the time of the fall. The facility's investigation revealed that the outlet in the resident's room was loose, which contributed to the bed becoming unplugged. The maintenance director confirmed the outlet was worn and replaced it after the incident. Despite the facility's policy on managing falls and fall risks, the failure to ensure the resident's safety during care led to the accident and subsequent injuries.
Failure to Provide Adequate Nutrition for Dialysis Resident
Penalty
Summary
The facility failed to provide Resident #1 with a nourishing, palatable, well-balanced diet that met her daily nutritional and special dietary needs. Resident #1, who had multiple serious health conditions including end-stage renal disease (ESRD), was not given a lunch when she went to dialysis during lunch time. The resident left the facility without a bagged lunch and did not receive any snacks at the dialysis center, leading to her feeling extremely weak and fatigued. Upon her return to the facility, she found a cold dinner tray that had been sitting out for an unknown period, which she refused to eat. She was then given a peanut butter and jelly sandwich, which she felt was an inadequate substitute for a meal, and went to bed without eating anything the entire day. This incident was corroborated by interviews with the resident, her family, and facility staff, who confirmed that the resident was not provided with a proper meal during her dialysis day and that the facility did not have an effective system in place to ensure this did not happen again. The facility also failed to ensure that food was properly stored and that expired or spoiled food items were discarded. This was observed during the survey, and it was noted that the facility did not have an effective system in place to ensure sufficient and routine replenishment of food for Resident #1. The resident's care plan indicated that she was at risk for weight loss and required a therapeutic diet, but the facility did not adhere to these dietary requirements. The resident's family and the resident herself expressed dissatisfaction with the quality of care, particularly regarding the meals provided during dialysis days. Interviews with facility staff, including the cook, CNAs, RNs, and the Administrator, revealed that there was a lack of communication and coordination between the dietary and nursing departments. The staff admitted to being aware of the policy that dialysis residents should be sent with a sack lunch but failed to follow through on this policy. The Administrator and Director of Nursing acknowledged the oversight and stated that they had conducted in-service training to address the issue, but the deficiency had already impacted the resident's well-being and satisfaction with the care provided by the facility.
Failure to Provide Timely and Adequate Meals for Dialysis Resident
Penalty
Summary
The facility failed to ensure that Resident #1 received at least three meals daily at regular times comparable to normal mealtimes in the community. Resident #1, who had multiple medical conditions including end-stage renal disease (ESRD), was sent to dialysis without a lunch and sometimes did not receive breakfast before leaving for dialysis. On one occasion, Resident #1 returned from dialysis hungry and found a cold dinner tray in her room, which she refused to eat because it had been sitting out for an extended period. The resident was then provided with a peanut butter and jelly sandwich, which she felt was an inadequate meal substitute. Interviews with staff revealed that there was a lapse in communication and responsibility regarding the preparation and delivery of meals for Resident #1 on dialysis days. Cook A prepared a sack lunch for the resident, but no nursing staff came to collect it. RN B admitted to forgetting to send the lunch with the resident. Additionally, CNA B stated that the resident did not request a meal alternative upon returning from dialysis, and RN A confirmed that the dinner tray was reheated for the resident, which she refused to eat. The facility's records and policies indicated that residents with ESRD should receive meals during dialysis that are nutritionally comparable to those provided in the nursing home. Despite this, the facility did not consistently ensure that Resident #1 received appropriate meals on her dialysis days, leading to her feeling hungry and uncared for. The facility's failure to provide timely and adequate meals for Resident #1 on dialysis days resulted in a diminished quality of life for the resident.
Failure to Properly Store and Serve Meals for Dialysis Patients
Penalty
Summary
The facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety, specifically for residents returning from dialysis. Resident #1, who had multiple medical conditions including end-stage renal disease (ESRD), returned from dialysis to find a cold dinner tray that had been left out for an extended period. The resident refused to eat the cold meal and was later given a peanut butter and jelly sandwich. This incident was corroborated by interviews with the resident, family members, and staff, who confirmed that the meal had not been properly stored or served in a timely manner. Additionally, another resident's uneaten lunch tray was observed sitting on a bedside table, indicating a broader issue with meal storage and distribution for dialysis patients. The facility did not have a system in place to ensure that meals for dialysis patients were properly stored until the residents returned. This lack of a system could potentially expose residents to foodborne illnesses. Interviews with staff and record reviews revealed that the facility had policies in place for providing meals to dialysis patients, but these were not followed. The facility's policy stated that residents receiving dialysis care outside the facility should receive a meal during dialysis that is nutritionally comparable to the nursing home meal. However, on the day of the incident, the staff failed to provide Resident #1 with a meal to take to dialysis, and the meal provided upon return was not satisfactory.
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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.
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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) |
|---|---|---|---|---|
| The Woodlands Nursing And Rehabilitation Center | 0.6 mi | ★★★★★ | 7 | 0 |
| The Broadmoor At Creekside Park | 2.1 mi | ★★★★★ | 11 | 1 |
| Park Manor Of The Woodlands | 3.6 mi | ★★★★★ | 7 | 0 |
| The Village At Gleannloch Farms | 6.2 mi | ★★★★★ | 4 | 0 |
| The Brightpointe | 7.8 mi | ★★★★★ | 0 | 0 |
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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.