Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Woodlands Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with scheduled pain-related medications did not receive his 4:00 p.m. doses of Baclofen, Tramadol, and Zanaflex because an LPN could not locate him and did not notify the charge nurse, DON, or ADON. The resident later requested the medications but was told he could not receive them because another dose was due soon after, and the physician, DON, ADON, and Administrator all stated they had not been informed of the missed doses.
A resident with significant mobility and continence issues, but intact cognition, reported inconsistent housekeeping and inadequate bathroom cleaning, which surveyors corroborated by observing debris, dirt, and dried hand sanitizer along a hall, as well as bathrooms with urine odor, dark urine left in toilets, toothpaste splatter on mirrors, black or brownish-red rings in toilet bowls, and fecal splashes on commodes and assisted toilet chairs. Staff interviews showed CNAs believed housekeeping was responsible for bathroom cleaning, while housekeeping and EVS described daily cleaning expectations and detailed procedures that were not reflected in observed conditions, despite a facility policy requiring regular cleaning and disinfection of toilets and maintenance of floors free from accumulations of dirt.
A resident with MS, major depressive disorder, and quadriplegia, who required total assistance for bathing and extensive assistance for personal hygiene per MDS and care plan, was taken to the shower by a CNA and another aide. After being placed in the shower chair and having his clothing and covering removed, the CNA left him alone in the shower room, stating she was giving him privacy and would return. The resident later documented that he was left naked and cold without a towel or hot water, unable to reach the faucet or bathe himself, with his catheter bag left in his lap causing urine to run onto his leg, and that he tried to call for help by yelling and banging the shower head on the wall. Facility leadership interviews showed the Administrator was unaware of the complaint, the DON acknowledged the resident would need assistance in the shower, and an LVN described that staff should normally provide showers with periodic checks, while facility policy required necessary ADL services for residents unable to perform self-care.
A resident with brain cancer, cerebral edema, seizure disorder, and a history of falls was admitted with elevated BP and multiple ordered meds, some of which were documented as unavailable, and there was no documented MD/NP confirmation of her medication regimen. In the early morning, she sustained an unwitnessed fall and developed a forehead hematoma; nursing notes show she was found on the floor and later transferred to the hospital, but her family reports they were not called, discovered the injury only after arriving on-site, and found her call light out of reach. The family also reported the RN was off the unit in his car, appeared unaware of the extent of the head injury, stated he was overwhelmed by his caseload, and initially resisted calling 911 despite the family’s request. The NP later confirmed she had not been notified of the fall or medication issues, and the administrator stated nurses are expected to assess, perform neuro checks, and immediately notify the physician and family after a fall, supporting the deficiency for failure to immediately inform the physician and family and to appropriately respond to the resident’s change in condition.
A resident with brain cancer, cerebral edema, left hemiparesis, seizure disorder, HTN, DM, CAD, and a history of multiple falls was admitted with a complex medication regimen, but key medications were documented as unavailable, and there was no clear evidence of timely medication reconciliation with the MD/NP. That evening, the resident had elevated BP and exhibited erratic behavior and frequent care needs, yet this behavior and any interventions were not documented. During the night, the resident fell while apparently unable to access a call light or phone, was found on the floor by a CNA, and was lifted back to bed with delayed RN response and without a clearly documented pre-lift assessment, neuro checks, or immediate vital signs, despite a subsequent large forehead hematoma and significantly elevated BPs recorded by EMS. The family learned of the fall directly from the resident rather than staff, reported that the resident said she had not received her medications, and described staff who were unaware of the head swelling and admitted feeling overwhelmed, while the MD/NP later confirmed they had not been notified of the admission medication review or the fall with head injury.
Surveyors found that two dining room emergency exits were not maintained in a safe and functional condition. One exit had its exterior sidewalk cluttered with items such as cleaning equipment, furniture, a grill, crates, and a large trash bin, obstructing the exit path. The other exit had its only accessible ramp blocked by a large pallet of medical supply boxes stacked on the sidewalk, leaving minimal clearance at the curb edge. Central supply staff reported that multiple pallets were delivered to the back of the building after a storage shed was condemned and acknowledged that supplies should not be left outside and that the blocked ramp was a problem. The Maintenance Director confirmed that the delivery company placed pallets on the walkway and that the area was obstructed, and the Administrator confirmed these doors were designated exits and that the ramp was primarily used for deliveries. The report noted that this practice could place residents at risk of falls, injuries, and confusion during evacuations.
A resident’s BiPAP mask was left uncovered when not in use, an empty portable O2 tank was left unsecured in another resident’s room, and a third resident was observed receiving O2 at 3 L instead of the ordered 2 L PRN. Staff and the DON acknowledged the mask should have been covered, empty tanks should be removed or secured in a stand or carrier, and the tank on the floor was unsafe.
Unsecured medication carts and loose unlabeled pills were found in 3 of 6 med carts, including carts on 200 hall, 300 hall, and the secured hall. Surveyors observed small white pills, and one red triangle-shaped pill, left loose in drawers without labels or identifying markers; one cart on 200 hall was also left unlocked and unattended. The ADON, MAs, DON, and Administrator stated meds should be stored in labeled blister packs or bottles, loose pills should be disposed of, and carts should be locked when not in use.
Food Storage and Leftover Handling Deficiencies: The facility failed to store and handle food in accordance with professional standards. Surveyors observed white gravy, scrambled eggs, and hot dogs at danger zone temperatures, and a case of canned chicken noodle soup stored on the floor in the storeroom. The Dietary Food Service Manager stated the leftover foods should have been discarded, and the facility policy required potentially hazardous leftovers to be covered, labeled, dated, refrigerated immediately, and discarded after 72 hours unless otherwise indicated.
Infection control practices were not followed for three residents. A MA used a blood pressure cuff and machine on one resident without cleaning it after use on another resident. For a resident with an indwelling urinary catheter and EBP, two CNAs provided catheter and perineal care while wearing gloves but not gowns, despite the posted sign requiring gowns and gloves for high-contact care. Another resident's oral suction Yankauer connected to the suction machine was observed on the floor without a plastic bag covering it.
Failure to Preserve Dignity During Meal Assistance: Two residents with severe cognitive impairment and meal assistance needs were observed in the memory care dining area while a CNA and an LVN stood over them and assisted or fed them instead of sitting next to them. The CNA and LVN said they were busy helping other residents, and the DON stated staff should have sat next to the residents to give respect and dignity.
Inaccurate MDS Prognosis Coding for Resident Receiving Hospice: A resident with severe cognitive impairment and diagnoses including CKD, AFib, and dementia was coded as receiving hospice in Section O of the quarterly MDS, but the prognosis item in Section J was marked No instead of Yes. The care plan and certification of terminal illness both documented hospice services and a physician certification that the resident had a condition or chronic disease with a life expectancy of less than 6 months. The MDS RN acknowledged the coding error and stated accurate coding was the MDS nurse’s responsibility.
Failure to Care Plan Oxygen Use: A resident with COPD had an active order for O2 via NC as needed for SOB and was observed using oxygen, but the care plan did not address her oxygen need. The MDS RN stated oxygen use should have been care planned, and the DON stated nursing should have included the resident's oxygen use and her tendency to adjust the concentrator so staff would know to check the ordered setting.
Incomplete Perineal Care for an Incontinent Resident: A resident with severe cognitive impairment and mixed bladder and bowel incontinence received partial perineal care when a CNA cleaned the genital and anal areas but did not clean the left and right buttock areas. The CNA acknowledged the omission, and the DON stated the buttock areas should have been cleaned to help prevent possible infection and skin breakdown. The resident’s care plan called for peri-area cleaning with each incontinence episode, and the facility policy required perineal care for incontinent residents to promote cleanliness and comfort and prevent infection.
Inaccurate eMAR Medication Documentation: A resident with severe cognitive impairment, multiple medical diagnoses, and a gastrostomy tube had a physician order for rosuvastatin 40 mg daily, but the eMAR listed 20 mg with the same directions. During observation, an RN administered 40 mg via G-tube, and both the RN and DON stated the eMAR was entered incorrectly and did not match the physician order.
A facility failed to report a suspicious, unwitnessed head laceration requiring hospitalization for a resident with dementia and a history of falls. Despite the injury being unexplained and meeting criteria for an injury of unknown source, the administrator did not submit the required report to the State Survey Agency, resulting in a deficiency in abuse and incident reporting procedures.
A resident with a chronic, necrotic BKA stump and a history of non-compliance with wound care was found with maggots and roaches in the wound after being outside, despite orders for regular wound care and dressing. Staff interviews revealed inconsistent wound coverage and monitoring, and the infestation was not detected until advanced, leading to hospital transfer and above-knee amputation. The facility did not ensure wound care was provided and monitored according to professional standards.
Two nurses failed to follow proper hand hygiene and glove-changing procedures during suprapubic catheter care for two residents, including not sanitizing hands or changing gloves before applying clean dressings. Both staff members acknowledged forgetting these steps, and the DON confirmed expectations for hand hygiene were not met, as outlined in facility policy.
A resident with multiple chronic conditions missed a scheduled dose of Testosterone Cypionate after nursing staff failed to reorder the medication in accordance with facility policy, resulting in a one-week delay before the medication was administered. Staff interviews and record reviews confirmed the lapse in the medication reordering process and a lack of documentation regarding the timing of the reorder.
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Undated food items were found in dry storage, the refrigerator, and the freezer, with some items improperly sealed and showing signs of freezer burn. The Dietary Supervisor was unaware of expiration dates, and the facility's policy on food storage was not being followed, potentially placing residents at risk of foodborne illness.
A medication aide failed to perform hand hygiene between administering medications to three residents, leading to a potential risk of cross-contamination. The residents involved had various health conditions, including Alzheimer's, diabetes, and respiratory issues. Despite having completed a competency evaluation, the aide admitted to forgetting to sanitize hands due to nervousness, highlighting a lapse in the facility's infection control practices.
A resident with complex medical conditions was administered Midodrine, a blood pressure medication, against physician orders, which specified holding the medication if systolic blood pressure (SBP) exceeded 130. Despite this, the medication was given on multiple occasions when the resident's SBP was above the threshold. Interviews with the involved RNs revealed awareness of the error, and the facility's policy required adherence to physician orders, but the monitoring process failed to prevent the mistake.
A facility failed to securely store medications, as a resident's Tramadol blister pack had torn seals, risking drug integrity and infection control. The nurse responsible did not routinely check packaging integrity, and the DON confirmed the importance of intact seals to prevent drug diversion and infection issues.
Missed Scheduled Pain Medications
Penalty
Summary
Pain management was not provided as scheduled for a cognitively intact resident who had orders for Baclofen 5 mg, Tramadol 50 mg, and Zanaflex 6 mg three times daily. The resident’s quarterly MDS documented a BIMS score of 15 and indicated he required varying levels of assistance with activities of daily living and mobility. His care plan identified pain and non-participation in the plan of care for medication, with a goal of no adverse outcomes and an approach to educate the resident on the risks and benefits of taking medications as prescribed. Record review showed the resident did not receive his 4:00 p.m. scheduled doses of Baclofen, Tramadol, and Zanaflex. The LVN stated she did not administer the medications because the resident was difficult to locate and that she did not notify the charge nurse or DON. The physician, DON, ADON, and Administrator each stated they were not notified of the missed medications, and the resident stated he later requested the medications at about 7:30 p.m. but was told he could not receive them because he was scheduled for medications again at 8:00 p.m.
Failure to Maintain Clean and Sanitary Resident Rooms and Hallways
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, including sanitary conditions in resident rooms and common areas. On Hall A of the long-term care unit, surveyors observed debris, dirt, food particles, and black sticky dried hand sanitizer beneath three dispensers along the hallway floor. These substances appeared adhered to the floor but could be partially lifted with slight pressure, indicating they had been present for some time and not adequately cleaned. One resident, a man with quadriplegia, neuromuscular bladder dysfunction, CHF, full fecal incontinence, colostomy status, multiple sclerosis, hypertension, and hemiplegia, was identified as affected. His care plan documented an ADL self-care performance deficit and noted that he refused to use the sink in his room, instead using a public sink near the dining room, and that he had limited mobility due to multiple sclerosis. Despite having normal cognitive function (BIMS score of 15), he reported that housekeeping was inconsistent, stating that one housekeeper mopped without sweeping first and that his bathroom had not been thoroughly cleaned, resulting in a black ring in the toilet from prolonged unclean conditions. In his bathroom, surveyors observed balled-up dirty gloves left on the counter, toothpaste splatter on the mirror, and a strong urine odor from a toilet containing dark yellow urine, even though the resident did not use the toilet due to a catheter and relied on staff to empty his handheld urinal. Another room on Hall A was also found to be unclean. In that bathroom, the mirror had visible water and toothpaste splashes, the toilet bowl had a black ring, and there were dark brown fecal splashes on the commode and assisted toilet chair. A CNA stated that CNAs were responsible for bed-making and patient care while housekeeping cleaned bathrooms, and reported that she flushed the toilet after emptying the resident’s urinal, later attributing any failure to flush to a malfunctioning handle; however, the toilet flushed fully when tested, and a brownish-red ring remained in the bowl. A housekeeper described a cleaning process that included sweeping before mopping, disinfecting surfaces, and thoroughly scrubbing toilets, but when shown a picture of the toilet bowl, she acknowledged the ring could be from mildew or buildup and that it could have been present for a while. The DON stated she had not received complaints from the resident and expected housekeeping to keep things clean, and the EVS supervisor stated that housekeeping was to clean rooms daily with a focus on sanitation, consistent with the facility’s general housekeeping policy requiring the facility to be kept free from accumulations of dirt and to clean and disinfect toilets, including the bowl and base.
Resident Left Unattended, Unclothed, and Unable to Self-Bathe in Shower
Penalty
Summary
The deficiency involves the facility’s failure to provide care in a manner that promoted maintenance of a resident’s quality of life and to treat the resident with respect and dignity. A resident with multiple sclerosis, major depressive disorder, and quadriplegia was admitted with significant ADL self-care performance deficits and required total assistance of two staff for tub bath/shower three times weekly, as well as extensive assistance of one person for personal hygiene and oral care. His quarterly MDS showed a BIMS score of 15, indicating no cognitive impairment, and documented that he was dependent on others for bathing, including washing, rinsing, and drying, and had functional limitations in range of motion in both lower extremities and one upper extremity. On the day of the incident, a CNA reported that she and another CNA assisted the resident into a shower chair and took him to the shower room, which was initially occupied. After the other resident left, the CNA and the resident entered the shower room. The CNA stated she got him situated in the shower, placed the call light within reach, and asked if he needed help; the resident told her he needed help with his legs and feet. The CNA said she told him she would give him privacy and return, then left to use the restroom and came back about five minutes later. She stated that when she returned, the resident was upset, had not started showering himself, and that she believed he was safe in the shower without supervision and not a fall risk, and that she thought he could wash himself. In contrast, the resident’s contemporaneous note on his phone described being left naked and cold in the shower, unable to do anything to help himself, with no towel or covering, and no hot water. He documented that his catheter bag was left in his lap, causing him to urinate on his leg, and that he used the shower head to bang on the wall and yelled as loudly as he could but the CNA was gone. He reported this to the former ADON. The Administrator later stated he was not aware of a complaint regarding this incident. The DON, who had only recently started working at the facility, stated that whether residents could be in the shower independently would depend on their capabilities, and acknowledged that this resident would need assistance in the shower. An LVN stated that for this resident, staff would normally provide the shower as he wanted it, including closing the curtain for privacy if requested and checking on him every 3–5 minutes. The facility’s ADL policy required that residents unable to carry out ADLs receive necessary services for bathing, grooming, and personal hygiene based on their comprehensive assessment and needs.
Failure to Notify Physician and Family and Appropriately Respond After Unwitnessed Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the physician and family, and to appropriately respond, after a resident experienced an unwitnessed fall with a head injury shortly after admission. The resident was an older female admitted on 1/16/26 with multiple serious diagnoses, including grade 4 glioblastoma multiforme with chemo and brain resection, cerebral edema, left hemiparesis after cerebral infarct, CAD with two stents, diabetes mellitus, hypertension, seizure disorder, arthritis, and a history of multiple falls at home. On admission, her blood pressure was documented at 164/100 by LVN A, but no interventions were put in place. Several of her ordered medications, including dexamethasone and cyclosporine eye drops, were documented as "Medication Unavailable" the evening of admission. LVN A stated she called the MD or NP to verify medications but did not leave a voicemail and there was no documentation of this contact in the nursing notes, while the NP later reported she had not been notified about the resident or any medication review. In the early morning hours of 1/17/26, RN A documented that around 1:20 a.m. the resident was found on the floor, brought back to bed, and had vital signs assessed, with no swelling or bruising initially noted; 30 minutes later, a small swelling was observed on the left side of her forehead. A later nursing note at 4:18 a.m. documented a change of condition, stating the resident had fallen and had a bruise on her left forehead and was transferred to the hospital. However, the resident’s family member reported that no one from the facility called her about the fall or the head injury; she learned of the incident directly from the resident and arrived at the facility around 1:40 a.m. to find the resident with a significantly swollen knot on the left side of her head. The family member also stated the resident’s call light had been behind the bed and out of reach, and that the resident’s phone was not within reach when the fall occurred. The family member reported that when she arrived, RN A was not on the unit and had to be located outside in his car by CNA A. She stated that RN A appeared surprised by the extent of the resident’s head swelling and told her he was overwhelmed by the number of residents he was responsible for, and that the resident was not the only one who had fallen. The family member demanded that the resident be sent to the hospital, but reported that RN A initially refused to call 911, stating he needed permission from the DON and instead sought authorization to use a regular ambulance service. EMS records show multiple elevated blood pressure readings during transport. The NP later confirmed she had not received any call, message, or text from LVN A regarding medication review or from RN A regarding the fall with head injury, and only learned of the situation days later from a voicemail from the DON. The administrator stated that the expectation is that after a fall, especially an unwitnessed fall, the nurse should assess the resident, perform neuro checks and vital signs before moving the resident, and immediately notify the family and physician, and that if a family requests hospital transfer, the resident should be sent out. The resident was hospitalized with an admitting diagnosis of fall, initial encounter, from [DATE] to 01/25/26. The facility’s own Promoting/Maintaining Resident Dignity policy states that all staff must protect and promote resident rights, treat residents with respect and dignity, report and document information regarding resident preferences, and speak respectfully to residents. The family member’s email to the facility and corporate office described the environment as dangerous, alleged that an inexperienced nurse admitted to sleep deprivation and inability to manage his caseload, and complained that support staff prioritized their phones over patient safety. She specifically questioned why she was not called immediately after the fall, why a resident with a seizure history was left without a call button, and why a nurse who reported being sleep-deprived was caring for her mother. The NP’s and MD’s interviews, combined with the lack of documentation of physician notification and the family member’s account of not being notified, support the finding that the facility failed to immediately inform the physician and the family of the resident’s fall with head injury and did not follow its own expectations for post-fall assessment and communication.
Failure to Provide Timely Post-Fall Assessment, Medication Management, and Safe Call-Light Access
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services, including fall prevention, timely response, and appropriate post-fall assessment, for a newly admitted resident with complex medical conditions. The resident, an older female admitted with grade 4 glioblastoma multiforme status post brain resection, cerebral edema, left hemiparesis after cerebral infarct, CAD with stents, DM, HTN, seizure disorder, arthritis, and a history of multiple falls at home, arrived on 1/16/26. Hospital discharge paperwork listed numerous medications, including antihypertensives, seizure medication, steroids, and others. Facility records showed some medications (dexamethasone and cyclosporine) documented as “medication unavailable” on the evening of admission, and there was no documented medication reconciliation or confirmation with the MD/NP regarding all admission medications. The NP later reported she had not been contacted about the admission or medication review, and the pharmacy reported medications ordered on 1/16/26 were never picked up and were returned to stock after 14 days, with no record of transfer to a closer store. On the evening and night of admission, the resident was documented as having elevated blood pressure (164/100) at 7:57 p.m., with no documented interventions. Interviews indicated the resident exhibited erratic behavior, spoke incoherently, and required frequent assistance, but this behavior was not documented in the nursing notes. CNA and family interviews described that the resident did not consistently use the call light and often called out verbally for help. CNA A reported that the roommate complained about the resident’s noise and requested a room change, and that she asked the resident to quiet down but did not report this behavior to the charge nurse. CNA A stated she assisted the resident to the restroom and back to bed, placing the call light, water, and phone within reach, while the family member later reported the call light was behind the bed and the phone unplugged and out of reach. The family member stated the resident told her she had not received all of her medications that night. In the early morning hours of 1/17/26, the resident experienced a fall. Nursing notes by RN A at 1:20 a.m. documented that the resident was found on the floor, brought back to bed, and had vital signs assessed, with no swelling or bruising initially noted and a small swelling on the left forehead noted 30 minutes later. A later note at 4:18 a.m. documented a change of condition, a fall with a bruise on the left forehead, and transfer to the hospital. However, CNA A reported that when she first found the resident on the floor and notified RN A, he delayed going to the room, stating he needed to enter information in the computer, and that when he arrived, he helped lift the resident back to bed without performing any assessment or vital signs before or immediately after the lift. CNA A stated she did not observe RN A perform neuro checks or vitals, and that the resident’s swelling was not noted until the family arrived. The family member reported receiving a distress call directly from the resident around 1:16 a.m., stating she had fallen, hit her head, and was bleeding, and that no staff had called her. Upon arrival around 1:40 a.m., the family member found CNA A at the nurses’ station on her phone, and then was escorted to the room where CNA A stated she had cleaned blood from the resident’s head and applied a cold towel but had not escalated the issue to the nurse. The family member described a large swollen knot on the resident’s left forehead and stated RN A was initially not in the building and was later found outside in his car. The family member reported that RN A appeared unaware of the head swelling, admitted being overwhelmed and responsible for many residents, and stated that residents fall frequently. The family member also stated that the resident reported not receiving her medications and that RN A said medications would arrive around 3:00 a.m., but no medications arrived by the time EMS transported the resident. Further interviews revealed inconsistencies in RN A’s account of post-fall care. RN A stated he took vital signs after putting the resident back in bed and completed neuro checks every 15 minutes, documenting them either on sticky notes or in nursing notes, but he could not clearly recall the method. He also stated he could not remember if he checked whether the resident was on anticoagulants before moving her and acknowledged he did not perform range-of-motion assessment while the resident was on the floor. The NP reported receiving no call or message about the fall or head injury, and the MD/NP had no record of being notified at the time of the incident. EMS records documented significantly elevated blood pressures during transport. The administrator later stated that the expectation for an unwitnessed fall is to perform an assessment, neuro checks, and vital signs before lifting the resident from the floor and to notify the family and physician immediately afterward, which contrasted with the actions described in staff and family interviews. The facility’s own investigation summary noted that the family member alleged verbal abuse by CNA A, including telling the resident to go to sleep because she was bothering the roommate, and alleged that the resident had not received all her medications on the night of admission. CNA A confirmed asking the resident to quiet down due to the roommate’s complaints but denied verbal abuse. The DON acknowledged that the resident’s disruptive behavior was not documented and that the LVN who received the resident should have completed a medication review with the MD or NP. The facility’s Promoting/Maintaining Resident Dignity policy required staff to treat residents with respect, pay attention to residents as individuals, and speak respectfully, but the family’s allegations and staff interviews described interactions and omissions that did not align with these expectations. Overall, the report documents failures in fall prevention measures, timely response to a resident in distress, post-fall assessment and monitoring, medication reconciliation and availability, and communication with the family and practitioner, all contributing to the cited quality of care deficiency.
Obstructed Dining Room Emergency Exits Due to Stored Supplies and Clutter
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a safe, functional, sanitary, and comfortable environment related to two dining room emergency exits. During observation of dining room exit door #1, surveyors noted that the sidewalk area immediately outside the door was obstructed with multiple items, including a cooler on wheels, a bucket and mop, a scrubbing brush, a piece of wood furniture, a grill, two stacked crates, another mop bucket, and a large trash bin on wheels next to the ramp. These items created clutter in the designated exit area. The facility’s own Emergency Preparedness Plan identified evacuation as a prime consideration in any disaster or emergency directly affecting the facility. For dining room exit door #2, surveyors observed that the sidewalk leading to the only ramp accessible from this exit was obstructed by a large pallet of medical supply boxes. The pallet consisted of boxes stacked approximately three across and five high, with additional rows behind, leaving only about one foot of space between the pallet and the edge of the sidewalk where the curb dropped off. Central supply staff reported that medical supplies were now delivered to the back of the facility after a storage shed had been condemned about eight months earlier, and that she received multiple pallets at a time and could not bring all boxes inside in one day. She acknowledged knowing that supplies should not be left outside and recognized that the blocked ramp was a problem. The Maintenance Director confirmed that the supply company placed pallets on the walkway and agreed that the area outside dining room exit door #2 was obstructed. The Administrator confirmed that dining room exit doors #1 and #2 were designated exits, with the ramp mainly used for deliveries, and stated that if the ramp could not be used due to obstruction, residents and staff would use another exit door. The report stated that this deficient practice could place residents at risk of falls, injuries, and confusion during evacuations.
Respiratory Equipment and Oxygen Therapy Not Managed as Ordered
Penalty
Summary
Provide safe and appropriate respiratory care for residents when needed. Based on observation, interview, and record review, the facility failed to ensure respiratory equipment and oxygen therapy were managed according to professional standards for 3 residents reviewed for respiratory care. The deficiencies involved a BiPAP mask left uncovered when not in use, an empty portable oxygen tank left unsecured in a resident’s room, and a resident not receiving oxygen at the ordered 2 liters per minute setting. Resident #185 was a male with diagnoses including sleep apnea, type 2 diabetes mellitus, hypertension, and muscle wasting and atrophy. His physician ordered BiPAP at 14 IPAP/10 EPAP at bedtime. During observation, his BiPAP mask connected to the machine was sitting uncovered on the nightstand. An LVN stated the mask was without a plastic bag and should have been covered when not in use to prevent possible infection. The DON also stated the mask should have been covered in a plastic bag when not used and that the facility followed standard nursing care. Resident #55 had diagnoses including COPD and chronic respiratory failure with hypoxia, and her MDS showed moderate cognitive impairment. She had an oxygen intervention of 2 LPM via nasal cannula PRN. During observation, an empty portable oxygen tank was seen on the back of her wheelchair, another portable tank was in a stand beside the bed, and a third portable oxygen tank was sitting on the floor by the wall. The resident stated staff had changed the tank on her wheelchair the day before and left the empty tank. Staff and leadership stated empty tanks should be removed from the room and portable tanks should be secured in a stand or carrier. Resident #49 had diagnoses including COPD and chronic bronchitis, with intact cognition. Her physician ordered oxygen at 2 L/min via nasal cannula PRN for shortness of breath, but during observation the oxygen concentrator was set at 3 liters. An LVN stated the resident sometimes adjusted the liters herself and then changed the concentrator from 3 liters to 2 liters. Her care plan did not reflect her use or need for oxygen.
Unsecured Medication Carts and Loose Unlabeled Pills
Penalty
Summary
Drugs and biologicals were not stored in locked compartments for 3 of 6 medication carts observed: the med aide cart on 200 hall, the med aide cart on 300 hall, and the med aide cart for the secured hall. Surveyors observed loose, unidentified pills in medication drawers, including one small round white pill in the bottom drawer of the 200 hall cart, two loose pills in the top drawer of the 300 hall cart, and one small round white pill in the bottom drawer of the secured hall cart. The pills were not labeled and had no identifying markers to show what they were. The 200 hall medication cart was also observed left unlocked and unattended in an out cove across from the nurses station. During interview, the ADON, medication aides, DON, and Administrator stated medications were supposed to be stored in labeled blister packs or bottles and that loose pills were to be disposed of per facility policy. The ADON and facility leadership stated the medication aides were responsible for keeping the carts clean, storing medications properly, and securing the carts when not in use. The medication aides involved were unable to explain how loose pills in the carts could have harmed residents, and one medication aide stated residents could have accessed the unlocked cart and taken medications that were not theirs. Facility policy titled Medication Administration stated the medication cart is locked at all times when not in use.
Food Storage and Leftover Handling Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. During observation of the kitchen, a pan of white gravy was found at 45.7 degrees Fahrenheit, a plastic container of scrambled eggs was found at 55 degrees Fahrenheit, and a pan of hot dogs was found at 50 degrees Fahrenheit, all with temperatures in the danger zone. A case of canned chicken noodle soup was also observed stored on the floor in the storeroom. The Dietary Food Service Manager stated that the leftover foods with danger zone temperatures were to be used the following day and should have been discarded, and she stated she would in-service dietary staff on proper handling, storing, and dating leftover food for compliance. Record review of the facility's Food Safety policy dated 2018 stated that potentially hazardous leftover foods are to be properly covered, labeled, dated, and refrigerated immediately and discarded after 72 hours unless otherwise indicated.
Infection Control Practices Not Followed During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection control program for 3 residents reviewed for infection control practices. For one resident with heart failure, hypertension, muscle wasting and atrophy, and atherosclerotic heart disease, a MA measured blood pressure using a cuff and machine that had just been used on another resident without cleaning the equipment first. The MA later stated she should have cleaned the blood pressure cuff and machine before measuring the resident's blood pressure and acknowledged it was her mistake. For another resident with atrial fibrillation, hypokalemia, muscle wasting and atrophy, acute kidney failure, heart failure, moderate cognitive impairment, and an indwelling urinary catheter, the care plan required Enhanced Barrier Precautions with gowns and gloves for high-contact care activities including catheter care. During observed catheter care and perineal care, two CNAs wore gloves but did not wear gowns for the entire procedure, even though the precaution sign and PPE were posted on the door. For a third resident, the oral suction Yankauer connected to the suction machine was observed on the floor without being covered with a plastic bag.
Failure to Preserve Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat each resident with respect and dignity and to care for residents in a manner that promotes maintenance or enhancement of quality of life for 2 of 17 residents reviewed for resident rights. Resident #151 was a female with diagnoses of senile degeneration of brain, dementia, and Alzheimer's disease, and her quarterly MDS showed a BIMS score of 0 out of 15 with setup or clean-up assistance needed for eating. Resident #140 was a female with diagnoses of Alzheimer's disease, dementia, and type 2 diabetes mellitus, and her annual MDS also showed a BIMS score of 0 out of 15 with setup or clean-up assistance needed for eating. Both residents' care plans identified that they required one-person assistance or set up and clean up assistance for meals. On 12/16/2025 in the memory care dining area, Residents #151 and #140 were observed sitting next to each other while CNA-A stood in front of them assisting and sometimes feeding them. At 12:30 p.m., LVN-B was also observed standing over the two residents while assisting them to eat, rather than sitting next to them, while CNA-A helped other residents. During interview, CNA-A and LVN-B stated they were standing over the residents because they were busy helping residents in the memory care unit, and said they should have sat next to the residents to give respect and dignity. The DON later stated staff should have sat next to the residents while helping them eat to give respect and dignity, and that all staff were trained on resident rights.
Inaccurate MDS Prognosis Coding for Resident Receiving Hospice
Penalty
Summary
The facility failed to ensure that Resident #166’s assessment accurately reflected the resident’s status on the quarterly MDS. The resident’s record showed a face sheet identifying an older female with diagnoses including fracture of the neck, chronic kidney disease, atrial fibrillation, and dementia, and the quarterly MDS documented a BIMS score of 4 out of 15, indicating severe cognitive impairment. In Section O of the MDS, the resident was coded as receiving hospice care. However, in Section J, the item asking whether the resident had a condition or chronic disease that may result in a life expectancy of less than 6 months was coded No instead of Yes. The resident’s care plan stated that the resident was under the care of hospice services, and the certification of terminal illness stated that the physician certified the resident had a condition or chronic disease that may result in a life expectancy of less than 6 months. During interview, the MDS nurse stated the quarterly MDS showed hospice care but the prognosis item was coded No instead of Yes, and said coding accurately was the MDS nurse’s responsibility. The nurse also stated the facility did not have a policy for MDS accuracy and followed CMS RAI Manual guidelines.
Failure to Care Plan Oxygen Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #49 that included measurable objectives and timeframes to meet her identified medical, nursing, and mental needs. Resident #49 was admitted with diagnoses including chronic obstructive pulmonary disease, unspecified, simple chronic bronchitis, and other disorders of the lung. Her Quarterly MDS assessment showed a BIMS score of 13, indicating intact cognition. Record review of her O2 Sats Summary showed oxygen values were taken and that she was receiving oxygen via nasal cannula from 10/18/2025 to 12/18/2025, and the Physician Order Summary showed an order for oxygen administration at 2 L/min via nasal cannula as needed for shortness of breath related to COPD, with a start date of 09/10/2025. Review of Resident #49's care plan, revised 11/11/2025, showed no care plan reflecting her use or need for oxygen. During observation on 12/17/2025, she was seen sleeping in bed wearing oxygen with the concentrator set to 3 liters, and an LVN adjusted it to 2 liters after stating the resident sometimes adjusted the liters herself. During observation and interview on 12/19/2025, the MDS RN stated she did not see oxygen use addressed in the care plan and said oxygen use would have been something that should have been care planned. The DON stated nursing should have care planned the resident's oxygen use and that the behavior of adjusting the oxygen concentrator should also have been care planned so staff would know to check the ordered setting. The facility policy stated it was the policy to develop and implement a comprehensive person-centered care plan for each resident, including measurable objectives and timeframes and the services to be furnished to attain or maintain the resident's highest practicable well-being.
Incomplete Perineal Care for an Incontinent Resident
Penalty
Summary
The facility failed to ensure appropriate incontinence care for a resident who was frequently incontinent of both bladder and bowel. Resident #22 was a female with diagnoses including acute kidney failure, hyperkalemia, type 2 diabetes mellitus, and elevated white blood cell count. Her annual MDS showed a BIMS score of 0 out of 15, indicating severe cognitive impairment, and she was dependent for toilet hygiene, sit-to-stand, and chair-to-bed transfer. Her care plan identified mixed bladder and bowel incontinence related to dementia and impaired mobility, with an intervention to clean the peri-area with each incontinence episode. During observation, CNA-D provided perineal care by washing hands, donning gloves and a gown, opening the resident’s soiled brief, cleaning the genital area and groin, and then turning the resident on her side to clean the anal area. CNA-D did not clean the resident’s left and right buttock areas. CNA-D later acknowledged she forgot to clean those areas because she was nervous and stated they should have been cleaned to prevent possible infection. The DON stated CNA-D should have cleaned the buttock areas to prevent possible infection and skin breakdown. The facility policy for perineal care stated incontinent residents are to receive perineal care to promote cleanliness and comfort, prevent infection to the extent possible, and help prevent and assess for skin breakdown.
Inaccurate eMAR Medication Documentation
Penalty
Summary
The facility failed to maintain medical records that were complete and accurately documented for Resident #86. The resident was an older male with diagnoses including syncope and collapse, acute kidney failure, muscle wasting and atrophy, and atherosclerotic heart disease of the native coronary artery. His admission MDS showed a BIMS score of 0 out of 15, indicating severe cognitive impairment, and he was dependent for most activities of daily living and had a gastrostomy tube. Record review showed a physician order for Rosuvastatin Calcium Tablet 40 mg, 1 tablet via gastrostomy tube daily for lipid control, but the electronic medication administration record listed Rosuvastatin Calcium Tablet 20 mg with the same directions and start date. During observation, RN-E administered Rosuvastatin Calcium Tablet 40 mg via gastrostomy tube to the resident. RN-E stated the physician had ordered 40 mg but the eMAR showed 20 mg, and she thought a facility nurse may have entered the medication incorrectly when the resident returned from the acute hospital. The DON confirmed the eMAR was incorrect and stated it should have matched the physician order.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately as required. Specifically, staff did not submit a report to the State Survey Agency regarding a resident who was found on the floor with a deep 10 cm laceration to the top of his head, which required hospitalization and 15 staples. The injury was unwitnessed, and the source could not be explained by the resident, who had a history of dementia and repeated falls. Despite the severity and unexplained nature of the injury, the incident was not reported through the required channels. The resident involved was an elderly male with diagnoses including heart failure, dementia, depression, abnormal gait, and a history of falls. On the day of the incident, staff heard a loud thump and found the resident on his back with a significant head laceration and uncontrolled bleeding. The resident was unable to explain what happened, and staff could not identify any object or surface in the room that could have caused the injury. The facility's investigation included interviews, room inspection, and review of the resident's care plan and medical records, but the cause of the injury remained undetermined. Interviews with facility staff, including the administrator and DON, revealed that the injury met the criteria for an injury of unknown source, as it was unwitnessed, unexplained by the resident, and suspicious due to its extent. However, the administrator did not report the incident, believing it was not suspicious after internal review. This decision was made despite the facility's policy and state guidance requiring immediate reporting of such injuries. The failure to report the incident as required constituted a deficiency in the facility's abuse, neglect, and incident reporting procedures.
Failure to Provide Wound Care per Orders Resulting in Infestation and Amputation
Penalty
Summary
A deficiency occurred when a resident with a history of peripheral vascular disease, cardiac arrest, and a left below-knee amputation (BKA) with chronic infection did not receive treatment and care in accordance with professional standards of practice. The resident's care plan included interventions for a left BKA stump infection, antibiotic therapy, and regular wound care, with specific orders for wound cleansing, dressing, and monitoring. Despite these orders, the resident's left stump was found to be infested with maggots and roaches, and the wound was described as necrotic, hard, and covered with eschar. The infestation was discovered after the resident had been outside in the smoking area, and staff interviews revealed that the wound was often left open to air, and the resident was known to be non-compliant with keeping dressings in place and with some aspects of care. Multiple staff members, including nurses and CNAs, reported that the resident frequently refused wound care and would remove dressings, particularly when going outside to smoke. There were also indications that the wound was not always covered as ordered, especially when the resident left the building. Staff interviews indicated that the presence of maggots was not immediately identified, and there was uncertainty about when the last wound care was performed. The wound care doctor and facility staff acknowledged the resident's non-compliance and the chronic necrotic state of the wound, but the infestation was not detected until it had progressed, resulting in the need for hospital transfer and subsequent above-knee amputation. Documentation and interviews confirmed that the facility failed to ensure consistent wound care and monitoring in line with professional standards, particularly regarding wound coverage and inspection for pests. The resident's care plan and physician orders were not fully implemented, and there was a lack of timely identification and response to the wound infestation. The failure to provide appropriate treatment and care as ordered and to monitor for changes in the wound condition led to the identification of an Immediate Jeopardy situation by surveyors.
Failure to Follow Hand Hygiene and Infection Control Procedures During Catheter Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding hand hygiene and glove use during suprapubic catheter care for two residents. During catheter care for one resident with a history of acute cystitis and an indwelling suprapubic catheter, an LVN applied a clean dressing without sanitizing her hands or changing gloves after cleaning the catheter site. This was observed directly and later confirmed in an interview, where the LVN acknowledged forgetting to perform hand hygiene and glove change before dressing application. In a separate incident, an RN initiated catheter care for another resident with a suprapubic catheter and flaccid hemiplegia without washing or sanitizing her hands prior to donning gloves. The RN also failed to remove gloves and perform hand hygiene throughout the procedure, including before applying a clean dressing. The RN admitted in an interview that she forgot to wash or sanitize her hands before starting care and before dressing application, recognizing the potential for infection as a result. The Director of Nursing confirmed that there was no specific procedure for suprapubic catheter care beyond routine ADL care, but stated that her expectation was for staff to perform hand hygiene before care, after removing dirty gloves, and before applying clean dressings. Facility policy also required hand hygiene before resident contact, before donning gloves, and after glove removal, emphasizing that glove use does not replace hand hygiene. These lapses in following established hand hygiene protocols were observed and acknowledged by the staff involved.
Missed Dose Due to Failure in Medication Reordering Process
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident diagnosed with multiple complex conditions, including Multiple Sclerosis, quadriplegia, and hypogonadism. The resident was prescribed Testosterone Cypionate to be administered intramuscularly every two weeks. The medication was not administered as scheduled on one occasion due to a lapse in the medication reordering process. The lapse was identified when the nurse responsible for administering the medication on the scheduled date found that no medication was available. The nurse reported that the previous dose had been the last available, and the medication had not been reordered in time. The nurse stated that he typically reordered medications when only one dose remained but did not follow up to ensure the medication was delivered before the next scheduled administration. The facility's policy required that maintenance medications be reordered before the last dose was given, specifically 3 to 4 days in advance, to prevent any lapse in therapy. Interviews with nursing staff and facility leadership revealed confusion regarding the reordering process, particularly for controlled substances, and a lack of documentation regarding when the medication was reordered. The resident missed a scheduled dose and did not receive the medication until one week later. The incident was confirmed through record review, staff interviews, and resident interview, which indicated the resident was aware of the missed dose and the delay in administration.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in its only kitchen. During an initial tour, surveyors observed multiple food and drink items in the dry storage, refrigerator, and freezer that were not labeled with expiration dates. Specifically, undated items included cans of diced red peppers, packages of various drink mixes, and crackers in the dry storage. In the refrigerator, packages of unknown sandwich meat were found without expiration dates. In the freezer, several opened and unsealed food items, such as fish patties, catfish nuggets, turkey breakfast sausage patties, pork sausage, and beef liver, were discovered, some of which showed signs of freezer burn. The Dietary Supervisor, who had been working at the facility for a year, was interviewed and admitted to not knowing the expiration dates or the required use-by dates for the undated food items. She mentioned a policy that required food to be labeled and stored appropriately upon delivery, but it was not being followed. The facility's policy on food storage, which was reviewed, stated that all food should be stored according to state and federal guidelines, with items labeled and dated. The failures in food storage and labeling could place residents at risk of foodborne illness, as acknowledged by the Dietary Manager.
Infection Control Lapse During Medication Pass
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a medication aide (MA S) who did not perform hand hygiene between administering medications to three residents. This lapse in protocol was observed during a medication pass, where MA S administered medications to Resident #4, Resident #14, and Resident #10 without sanitizing hands between each resident. This failure to adhere to hand hygiene practices could potentially lead to cross-contamination and the spread of infections among residents. Resident #4, a female with severe cognitive impairment and multiple health conditions including Alzheimer's disease and diabetes, was one of the residents involved. She was dependent on staff for all activities of daily living (ADLs) and had specific medication orders for hypertension. Resident #14, a male with intact cognition and conditions such as diabetes and heart failure, was independent with most ADLs and had orders for cardiac medications. Resident #10, a female with moderate cognitive impairment and high risk for respiratory infections, required supervision for most ADLs and had orders for medications related to her respiratory and nutritional needs. The Director of Nursing (DON) and the Infection Preventionist (IP) acknowledged the importance of hand hygiene in preventing infection spread. The facility's policy required handwashing before and after medication administration, which MA S failed to follow. Despite having completed a competency evaluation that included hand hygiene, MA S admitted to forgetting to sanitize hands due to nervousness. The DON and IP indicated that staff are regularly monitored for compliance with infection control practices, but this incident highlighted a lapse in adherence to established protocols.
Failure to Administer Medication According to Physician's Orders
Penalty
Summary
The facility failed to administer Midodrine, a blood pressure medication, according to the physician's orders for a resident with complex medical conditions, including hypertension and atrial fibrillation. The resident was supposed to receive Midodrine only when her systolic blood pressure (SBP) was below 130. However, the medication was administered on multiple occasions when the resident's SBP was above this threshold, specifically on three separate days by two different registered nurses (RNs). The resident's care plan and physician orders clearly indicated that Midodrine should be held if the SBP exceeded 130 to prevent the risk of elevated blood pressure. Despite this, the medication was given when the SBP was recorded at 133 and 139. Interviews with the involved RNs revealed that they were aware of the physician's parameters but failed to adhere to them, resulting in the medication being administered incorrectly. Both RNs acknowledged the error and the potential risk of causing the resident's blood pressure to rise too high. The facility's policy on medication administration required licensed nurses to follow physician orders and record vital signs, holding medications if vital signs were outside prescribed parameters. The Director of Nursing (DON) and the pharmacist confirmed that the medication administration was monitored monthly, and any issues were addressed with staff. However, in this instance, the monitoring process did not prevent the medication error, and the resident's SBP was not properly managed according to the physician's instructions.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely, as evidenced by the condition of the medication blister pill card for a resident's Tramadol HCL 50mg. During an observation and interview, it was found that the protective seals on several tablets within the blister card were torn. The nurse responsible for the medication cart acknowledged that torn seals should not be taped closed or left in the pack, as this could lead to the replacement of pills with different tablets and pose an infection control risk. Despite this, the nurse admitted that she did not routinely check the integrity of the packaging during narcotic counts. The resident involved was an elderly female with a history of Alzheimer's disease, dementia, depression, anxiety, arthritis, and stroke, who required moderate assistance with daily activities and received scheduled pain medication. The facility's Director of Nursing (DON) confirmed that nurses should check blister card seals for integrity to prevent drug diversion and infection control issues. The facility's policy on medication administration emphasized the importance of preventing contamination or infection, and staff training reinforced that compromised medications should not be administered.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 346 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | 0.6 mi | ★★★★★ | 1 | 0 |
| The Broadmoor At Creekside Park | 1.6 mi | ★★★★★ | 11 | 1 |
| Park Manor Of The Woodlands | 4.1 mi | ★★★★★ | 7 | 0 |
| The Village At Gleannloch Farms | 5.9 mi | ★★★★★ | 0 | 0 |
| Tomball Rehab & Nursing | 7.7 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Woodlands Nursing And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.