Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Woodlands Place Rehabilitation Suites during CMS and state inspections, most recent first.
A facility failed to maintain clean, comfortable, and homelike conditions when residents were found with bed linen in poor condition. One resident with cerebral palsy and cognitive impairment was observed with a large hole in the top sheet, another resident with sclerosis and COPD had a threadbare fitted sheet, and multiple residents reported torn or hole-ridden linen at times. Surveyors also found all reviewed linen closets contained fitted sheets with tears, holes, threadbare areas, or stains.
The facility failed to provide needed ADL care for several residents. Three residents with varying levels of cognitive and physical impairment were observed with long, jagged fingernails, and one resident with fragile skin was scratching himself and had a skin tear. Another resident who was fully dependent for toileting hygiene and always incontinent was observed wet in his clothing while sitting at the nurses’ station, despite a care plan calling for frequent monitoring and prompt incontinent care.
Uncovered Leftover Sandwiches in Walk-In Refrigerator: Two gallon-size Ziplock bags containing grilled cheese sandwiches were found open and not sealed in the walk-in refrigerator. The DM stated the sandwiches were leftovers from dinner service, and a Dietary Aide said she did not close the bags all the way after using some of the sandwiches for dinner. Staff stated all food items should be covered appropriately, and the facility policy required leftovers to be covered, labeled, and dated.
Infection prevention and control failures occurred when staff contaminated a diabetic caddy and glucometer during a fingerstick blood sugar check, a medication aide handled and prepared medications without gloves and used unclean scissors, and an LVN and other staff failed to wear gowns during EBP care for residents with a G-tube and wounds. Staff acknowledged the missed PPE and cross-contamination issues during the observed care.
Care Plan Missing Contracture Interventions: A resident with dementia, parkinsonism, hemiplegia, and muscle weakness had documented contractures of the left hand and left elbow, but the comprehensive care plan did not include the contracture or any interventions for it. The ADON, DON, and MDS Nurse Coordinator all acknowledged the omission, and the MDS Nurse Coordinator stated the resident had no splint and no contracture interventions in the care plan.
Failure to manage a resident’s left-hand contracture after therapy discharge. A resident with CVA, hemiplegia, parkinsonism, and muscle weakness had orders noting contractures of the left hand and elbow, but no documented interventions. The resident could not open and close the left hand, reported using a hand roll at times without staff prompting, and multiple staff members stated they were unaware of any order, splint, or restorative plan for contracture management.
Failure to prime an insulin pen before administration led to a pharmacy services deficiency for a resident with Type 2 DM. An agency RN checked the resident’s blood sugar, determined the sliding-scale dose, and gave Humalog insulin lispro without priming the pen first. The DON stated the pen should be primed with 2 units before each injection, and the facility reference guide and manufacturer instructions both required priming before each use.
Unlabeled Insulin Pen in Medication Cart: A nurse administered Lispro insulin to a resident with Type 2 DM after retrieving an insulin pen from the med cart that had no open date on it. The nurse stated the pen should be dated when opened and discarded after 28 days, and the DON confirmed nurses were responsible for dating opened pens per facility policy.
A resident with dementia, DM2, heart disease, and gait/mobility issues had a BIMS of 15 and needed substantial to maximal ADL assistance, but the bathroom shower and toilet call lights were not working. The shower call light had tape on it, the resident said it had been out for a couple of weeks and that the Administrator and Maintenance knew about it, and an aide confirmed both bathroom call lights were nonfunctional. The Administrator said he was not aware of the issue until it was brought to his attention and that a contract company had to order a part to fix it.
A resident with moderate cognitive impairment and urinary issues underwent catheter insertion after staff obtained a physician's order, but the family and power of attorney were not notified or involved in the decision-making process, despite facility policy and the care plan emphasizing the importance of family involvement. Staff and administration acknowledged the oversight, and family members expressed concern about not being informed.
A nurse failed to maintain sterile technique during the insertion of an indwelling urinary catheter for a resident with multiple medical conditions, including not using a protective drape, not washing hands between glove changes, and not connecting the drainage bag prior to insertion. The facility lacked written policies for catheter insertion, and required sterile procedures outlined in the nursing manual were not followed.
A resident who was cognitively intact and used a wheelchair was given a cup of hot tea by a CNA who did not check the beverage's temperature or provide a lidded cup. While independently moving to a vending machine, the resident spilled the hot tea onto her lap, resulting in a second-degree burn. Staff interviews and record reviews confirmed that required safety protocols, such as temperature checks and the use of lids for hot beverages, were not followed at the time of the incident.
The facility's kitchen failed to properly label and date food items, including sliced smoked ham and bread, and left pies exposed to air. The Dietary Manager acknowledged these issues, noting the risk of serving expired or incorrect items. Additionally, soup was not consistently temperature-checked before serving, contrary to safety protocols.
The facility failed to maintain proper infection control practices, as observed in the actions of an RN and CNAs. An RN cross-contaminated medications by using a gloved hand, contrary to facility policy. A CNA neglected hand hygiene after assisting a resident with dressing and transferring, while two CNAs failed to change gloves and wash hands during incontinence care. These lapses in protocol highlight deficiencies in the facility's Infection Prevention and Control Program.
A facility failed to ensure proper pharmaceutical services for a resident with a G-tube, as an LVN did not check the residual volume before administering medication, contrary to physician orders. The resident, who was moderately cognitively impaired and received nutrition through a feeding tube due to cerebral palsy, was at risk of aspiration and other complications. The LVN used air auscultation instead of the required residual check, an outdated practice confirmed by the DON.
A resident experienced a delay in the diagnosis and treatment of a left intertrochanteric femoral fracture. The facility did not promptly inform the resident, consult with the physician, or notify the resident's family about the change in physical status. Despite complaints of severe pain and additional falls, the X-ray results indicating the fracture were not acted upon for 29 days. Interviews with various staff members, including an LVN, PTA, Nurse Practitioner, and ADON, revealed lapses in communication and follow-up procedures.
A resident experienced a significant delay in the diagnosis and treatment of a left femoral fracture due to multiple failures in communication, documentation, and follow-up. The ADON did not transcribe a physician's order for an X-ray, failed to assess the resident's pain adequately, and did not place the X-ray request on the 24-hour report. Additionally, the responsible party was not notified of the X-ray request and results, and the X-ray results were not effectively communicated to the physician. These deficiencies resulted in ongoing pain, delayed rehabilitation, and hospitalization for the resident.
A facility experienced a significant delay in diagnosing and treating a resident's left intertrochanteric femoral fracture due to a failure in promptly notifying the ordering physician of abnormal x-ray results. Despite the resident's complaints of severe pain and an additional fall, the positive x-ray findings were not communicated to the physician or family, resulting in a 29-day delay in treatment. The facility's system for receiving verbal notifications from the contracted Radiology company was ineffective, contributing to the communication breakdown. Interviews with staff, including the ADON, nursing staff, therapists, and NP, revealed a lack of awareness and follow-up regarding the resident's condition and x-ray results, highlighting gaps in the facility's communication and notification processes.
Worn and Damaged Bed Linen in Resident Rooms and Linen Closets
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment by allowing residents to have bed linen that was in poor condition. Resident #55, a male with cerebral palsy, mixed receptive-expressive language disorder, dysphagia, cognitive communication deficit, and ataxia, was observed in bed with his toes sticking out of a large hole in the top sheet, and his fitted sheet was described as very thin and threadbare in places. Resident #11, a female with sclerosis and COPD who was cognitively intact, requested that surveyors look at her bed linen, and her fitted sheet was observed to have large areas that were threadbare. In a confidential group interview, 5 of 13 residents stated their bed linen at times was torn and had holes, and they said the facility would run out of bed linen. Observation of 4 linen closets on resident halls showed all 4 contained fitted bed sheets that were not in good condition, including sheets with tears, holes, large thinned threadbare areas, and one stained sheet. The Contract Housekeeping Supervisor stated housekeeping was expected to place only linen free of holes, tears, and stains in the closets and said she had ordered 12 fitted bed sheets the prior week and needed to order more to replace linen not in good condition.
Failure to Provide ADL Assistance for Grooming and Incontinent Care
Penalty
Summary
The facility failed to provide necessary ADL assistance to maintain grooming and personal hygiene for four residents reviewed for ADLs. Resident #47, a female with hypertension, diabetes mellitus, hyperlipidemia, and severe cognitive impairment with a BIMS score of 5, required supervision for personal hygiene and extensive assistance with ADLs. During observation and interview, she had long, jagged fingernails on both hands measuring approximately 0.2 to 0.4 inches beyond the fingertips and stated she wanted her fingernails clipped. She did not recall staff offering nail care. Resident #66, a female with hypertension, peripheral vascular disease, and unspecified dementia, had a BIMS score of 15 and required supervision for personal hygiene and extensive assistance with ADLs. During observation and interview, she also had long, jagged fingernails on both hands measuring approximately 0.4 inches beyond the fingertips. She stated she wanted her nails clipped, said staff had not offered to clip them for a long time, and stated she was unable to trim her own nails. Resident #84, a female with hypertension, coronary artery disease, septicemia, and hyperlipidemia, had a BIMS score of 15 and required moderate assistance with personal hygiene. During observation and interview, she was scratching her left forehand with her nails and had a skin tear on that area. She had long, jagged fingernails on both hands measuring approximately 0.3 inches beyond the fingertips and stated she had fragile skin, often scratched herself, wanted her fingernails trimmed, and had not been offered fingernail care since admission. The facility also failed to provide timely incontinent care for Resident #55, a male with cerebral palsy, contracture of the knee, mixed receptive-expressive disorder, unspecified lack of coordination, anxiety disorder, and dependence on staff for toileting hygiene. He was fully dependent for toileting hygiene and always incontinent of bowel and bladder. His care plan directed staff to provide incontinent care as needed and to monitor for incontinent episodes frequently, changing him promptly and applying a skin barrier. However, during observation he was found sitting in his wheelchair at the nurses’ station with wet clothing on the front of his pants and t-shirt in the shape of an incontinent brief. The LVN stated he needed to be changed, and the CNA assigned to him stated she had changed him earlier in the day and had not checked him again after late morning. The CNA also stated he was not on a specific schedule for incontinent care and that she typically checked him every 2 to 3 hours, while the DON stated staff were checking him at least every 2 hours.
Uncovered Leftover Sandwiches in Walk-In Refrigerator
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety in its only kitchen when two gallon-size Ziplock bags containing 8-10 grilled cheese sandwiches each were observed in the walk-in refrigerator left open and not sealed shut. The bags were dated 2/23/2026 and were found during observation on 2/24/2026 at 9:38 AM. During interviews, the Dietary Manager stated the grilled cheese sandwiches had been made for dinner service and stored as leftovers for later use, and that the Dietary Aide left the bags open after helping serve dinner. She stated that everyone in the kitchen, including dietary aides and cooks, was responsible for covering food items and that she expected all kitchen staff to cover all food items. A Dietary Aide stated she had been working at the facility for about 6 months, used some of the sandwiches for dinner service, and did not close the zip lock bags all the way. Another staff member stated all food items in the kitchen should be covered appropriately and that uncovered food needed to be discarded because it posed a risk of cross contamination and food borne illness. The facility policy required leftovers to be covered, labeled, and dated, and the FDA Food Code was cited regarding food storage and date marking.
Infection Control and EBP Failures During Medication, G-Tube, and Transfer Care
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four residents observed for infection control. During a fingerstick blood sugar check for one resident, an Agency RN used a diabetic caddy with a clean side and dirty side, but after obtaining the blood sugar reading she placed the soiled glucometer back on the clean side next to the bottle of test strips. She then wiped the glucometer and returned it to the caddy without disinfecting the inside of the caddy or the bottle of test strips. The RN stated she knew the glucometer should have been placed on the dirty side and that placing it on the clean side contaminated the test strips and the caddy. During medication preparation for another resident, a medication aide separated capsules and tablets without using gloves. She opened a probiotic capsule with her bare hands, placed the contents with crushed medications, and used scissors to cut gel capsules and extract their contents into the medication mixture. She then wiped the scissors with a tissue. The medication aide stated she was supposed to wear gloves when separating the capsules and should have sanitized the scissors with a sanitizing cloth instead of a tissue. For a resident receiving G-tube medications and on EBP due to the tube, an Agency LVN washed hands and put on gloves but did not wear a gown while performing G-tube medication administration. For another resident on EBP due to wounds, a CNA and a hospice RN performed a mechanical lift transfer and wound-related care while wearing gloves but not gowns. Both staff members were present in the resident’s room during the transfer, and the hospice RN then checked the resident’s wound. The CNA and hospice RN stated they were aware that EBP required gowns and gloves for close contact care and that they should have worn a gown during the transfer and wound care.
Care Plan Missing Contracture Interventions
Penalty
Summary
The facility failed to ensure the comprehensive care plan described the services to be furnished to help Resident #7 attain or maintain his highest practicable physical, mental, and psychosocial well-being. Resident #7 was a [AGE]-year-old male with diagnoses including unspecified dementia, parkinsonism, hemiplegia and hemiparesis, and muscle weakness. His quarterly MDS showed a BIMS score of 15, upper and lower extremity impairment on one side, wheelchair use, and no therapy. Physician orders included contractures of the left hand and left elbow. Review of the comprehensive care plan showed a problem related to a history of CVA with hemiplegia, with a therapy referral as needed, but it did not include the resident’s contracture or any interventions for it. During interviews, the ADON stated the contracture and interventions should have been in the care plan. The DON stated a splint or any interventions for a contracture should have been included in a care plan. The MDS Nurse Coordinator stated the resident had a contracture but no splint, and that there were no interventions for the contracture in the care plan; he also stated he entered the contracture into the care plan later that day under the CVA section.
Failure to Manage Resident Contracture After Therapy Discharge
Penalty
Summary
The facility failed to ensure a resident with limited ROM received appropriate treatment and services to maintain or improve ROM and prevent further decline of a left-hand contracture. Resident #7 was a male with diagnoses including unspecified dementia, parkinsonism, hemiplegia and hemiparesis, and muscle weakness. His quarterly MDS reflected no cognitive impairment, upper and lower extremity impairment on one side, and wheelchair use. His physician orders included contractures of the left hand and left elbow, but no interventions were listed. Resident #7’s care plan identified a history of CVA with hemiplegia and included therapy referral as needed, but the record did not show contracture management interventions after therapy discharge. The OT discharge summary stated nursing should assess for a restorative nursing program, but restorative program and function maintenance program were not indicated at that time. During observation and interview, the resident was unable to open and close his left hand and stated he sometimes used a hand roll, but was unsure how often or how long to use it and said staff had not been prompting him to use it. Staff interviews reflected no clear plan or order for contracture management. A CNA stated she had never seen the resident with objects in his left hand and had not done exercises or placed a splint or object in the hand. An agency LVN, the Assistant Director of Rehab, the Restorative Aid, the ADON, and the DON all stated they could not find orders or documentation for contracture interventions, and several said therapy was responsible for the interventions or that a hand roll had been used in the past. The Director of Rehab stated the resident was discharged from OT with a hand roll as tolerated, but she was unsure who monitored its use and had not spoken with CNAs about it. The facility policy stated residents with joint mobility limitations, including contractures, should be assessed and restorative nursing implemented when therapy is not indicated or after discharge from skilled therapy.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
Pharmaceutical services failed to ensure accurate administration of insulin for one resident with Type 2 diabetes. Resident #15 was admitted with a physician order for insulin lispro pen 100 unit/ml to be given per sliding scale, including 4 units for a blood sugar of 181 to 220 before meals and at bedtime. During observation, Agency RN H obtained a fingerstick blood sugar of 214, checked the computer for the sliding scale dose, retrieved the insulin pen and a needle, and returned to the resident’s room to administer the medication. Agency RN H attached the needle and dialed in 4 units of Humalog insulin lispro without priming the pen first. In interview, the nurse stated she was unaware that the pen had to be primed before each injection and said she had never been told to do so. The DON stated the pen was to be primed with 2 units before each injection to remove air and confirm the pen was working correctly, and the facility’s reference material and manufacturer instructions both stated to prime before each injection.
Unlabeled Insulin Pen in Medication Cart
Penalty
Summary
The facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles for one of four medication carts reviewed, specifically the hall 300 cart. During observation on [DATE] at 11:05 a.m., Agency RN H obtained a fingerstick blood sugar for Resident #15, a [AGE]-year-old female admitted on [DATE] with a diagnosis of Type 2 diabetes. After the blood sugar reading was 214, the nurse retrieved Lispro insulin from the medication cart and the insulin pen was observed to have no date indicating when it had been opened. The nurse then attached a needle and administered 4 units of insulin to the resident. During interview, Agency RN H stated the insulin pen was supposed to be dated when a new pen was opened and that she was not sure who opened it or when it was opened. She stated insulin was to be discarded 28 days after opening and that failing to date it could result in giving a resident expired insulin that may be ineffective. The DON stated the insulin pen was to be dated once opened, that nurses were responsible for dating opened pens, and that failure to do so could result in expired medication and ineffective treatment. Record review of the facility policy, Medication Management Program, reflected that once a multi-dose packaged medication or biological is opened, nursing will mark it with the date opened and follow expiration guidelines, and that Humalog (lispro) U100 KwikPen in use storage is room temperature for 28 days.
Nonworking Bathroom Call Lights
Penalty
Summary
The facility failed to ensure that the resident call system was working in one resident’s bathroom and bathing area. Resident #23, an [AGE]-year-old female admitted with diagnoses including dementia, type 2 diabetes, heart disease, and abnormalities of gait and mobility, had an MDS assessment showing a BIMS score of 15 and required substantial to maximal assistance with ADLs. During observation and interview, the emergency shower and toilet call lights in her bathroom did not work when pulled, and the shower call light had tape on it. Resident #23 stated the shower call light had been out for a couple of weeks and that the Administrator and Maintenance were aware of it; she was not aware the toilet call light was also not working. An aide stated both the shower and toilet call lights in the bathroom were not working and she had not been aware of it until then. The Administrator later stated the Maintenance Supervisor had been on leave for about 3 weeks and he was assisting while Maintenance was out, and he was not aware of the shower and toilet call light issues until they were brought to his attention after surveyor notification. He stated a contract company had looked at the call light and needed to order a part to fix it. The facility policy stated the call-light is to be easily accessible to the patient.
Failure to Notify Resident's Representative Prior to Catheter Insertion
Penalty
Summary
The facility failed to ensure that a resident's responsible party was involved in the decision-making process prior to the insertion of a catheter. The resident in question was an elderly male with diagnoses including acute prostatitis, benign prostatic hyperplasia, mild cognitive impairment, and a cognitive communication deficit. His face sheet listed family members as emergency contacts, and the care plan indicated it was very important to involve family in care discussions due to his cognitive status. Despite this, when the resident experienced difficulty voiding, the nursing staff obtained a physician's order for a catheter and proceeded with the procedure without notifying or involving the resident's family or legal representatives. Interviews and record reviews revealed that the resident had a BIMS score indicating moderate cognitive impairment and had difficulty communicating his needs. The care plan specifically noted the need to assess the resident's capacity for medical decision-making and to encourage his participation in simple choices. On the day of the incident, the resident repeatedly expressed the need to urinate but was unable to void. After receiving the order for catheterization, the nurse explained the procedure to the resident, who then allowed the catheter to be inserted, despite initially refusing when approached by another nurse. At no point prior to the procedure was the family or the resident's power of attorney contacted, even though family members were present in the facility at the time. Facility policy required notification of the resident's representative or family member regarding significant changes in condition or treatment, and the admissions handbook reiterated this requirement. Both nursing staff and administration acknowledged during interviews that the family should have been contacted before the catheter was placed. The responsible party and family members confirmed they were not notified and expressed concern, especially given the resident's dementia and inability to remember events. The failure to notify and involve the resident's representative in the decision-making process constituted a violation of the resident's rights as outlined in facility policy.
Failure to Maintain Sterile Technique During Catheter Insertion
Penalty
Summary
A deficiency occurred when a nurse failed to follow sterile technique during the insertion of an indwelling urinary catheter for a male resident with a history of obstructive and reflux uropathy, diabetes, and recent orthopedic surgery. The nurse, after preparing supplies and donning personal protective equipment, was observed to be unsure of the procedure, did not use the protective drape, and failed to wash hands after removing dirty gloves before putting on sterile gloves. Additionally, the nurse did not connect the urine drainage bag to the sterile catheter tube prior to insertion, and the drainage bag was not pre-connected as required by standard procedure. The nurse admitted to not maintaining sterile technique and not following the facility's policy and procedure for catheter insertion. The Director of Nursing confirmed that the facility did not have written policies and procedures for catheter insertion and relied on a nursing manual for standards of care. Review of the manual indicated that several required sterile techniques were not followed during the procedure.
Failure to Prevent Burn Injury from Hot Beverage Due to Inadequate Supervision and Safety Measures
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate assistance devices to prevent accidents for two of five residents reviewed for accidents and hazards. Specifically, a cognitively intact female resident who used a wheelchair and required only setup assistance with eating was given a cup of hot tea by a CNA. The CNA prepared the tea using a hot water dispenser, did not check the temperature, and handed the cup directly to the resident while she was in her wheelchair. The resident, while independently moving to a vending machine and holding the cup, accidentally spilled the hot tea onto her lap, resulting in a second-degree burn on her left upper thigh. The incident was discovered when staff assisted the resident with a clothing and brief change and noticed a red, blistered area on her thigh. The resident reported that she had spilled hot tea on herself earlier. The injury was assessed as a 3 cm x 6 cm area with approximately 25% blistering. The resident did not initially report pain and continued her activities until the injury was discovered. The CNA involved acknowledged that she should have placed the tea on a table for the resident rather than handing it to her directly and admitted to not checking the temperature of the beverage before serving it. Interviews and record reviews revealed that prior to the incident, staff, including CNAs and dietary personnel, did not consistently check the temperature of hot beverages before serving them to residents, nor did they ensure the use of lidded cups for residents who were mobile or at risk for spills. The facility's policy required precautions to limit the risk of burns from hot beverages, including temperature checks and the use of lids for at-risk residents, but these procedures were not followed at the time of the incident. The failure to adhere to these safety protocols resulted in the resident sustaining a burn injury from the hot tea.
Food Safety and Labeling Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Specifically, food items in the refrigerator and freezer were not properly labeled or dated. An opened box of sliced smoked ham and an unopened loaf of white sliced bread were found without any date received or used by labels. Additionally, two apple lattice pies were left open to the air, and an opened bag of unidentified frozen squares was found in a box labeled for chicken breast tenders, lacking proper labeling and dating. The Dietary Manager acknowledged these lapses, stating that all items should be labeled with the date received and used within 14 days. Once opened, items should be dated and used within three days. The manager admitted that not labeling items appropriately could lead to residents consuming expired food, posing a risk of illness. The pies were discarded due to improper storage, and the unidentified frozen squares were identified as tater tots, which could lead to serving the wrong items to residents. Furthermore, during food preparation, the Dietary Manager reheated soup in the microwave and took its temperature, but subsequent servings were not temperature-checked before being served. The manager stated that all food should be temperature-checked before serving to ensure safety, as failing to do so could result in bacteria not being killed. The facility's policies and FDA guidelines emphasize the importance of proper labeling, dating, and temperature control to prevent food-borne illnesses.
Infection Control Deficiencies in Medication and Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by several observed deficiencies involving three residents. RN B was observed preparing medication for a resident without adhering to proper infection control protocols. Specifically, RN B used a gloved hand to pop medications from blister packs into a medication cup, which led to cross-contamination. Despite being aware of the facility's policy to avoid touching medications directly, RN B mistakenly believed that using a glove would prevent contamination, but acknowledged the error upon reflection. Another deficiency was observed with CNA D, who failed to perform hand hygiene after assisting a resident with dressing and transferring to a wheelchair. After removing the resident's hospital gown and transferring him, CNA D removed his own gown and gloves but neglected to wash his hands before leaving the room. This lapse was attributed to being rushed to meet a scheduled care plan conference, which led to the oversight in hand hygiene. Additionally, CNAs E and F were observed providing incontinence care to a resident without following proper hand hygiene protocols. Although they initially washed their hands and donned gloves, they failed to change gloves and perform hand hygiene when transitioning from dirty to clean tasks. After completing the care, both CNAs left the resident's room without washing their hands, acknowledging the risk of spreading infection due to their oversight. The facility's policies clearly outline the importance of hand hygiene, yet these practices were not consistently followed by the staff involved.
Failure to Verify G-tube Residual Volume Before Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for a resident receiving medication through a gastrostomy tube (G-tube). The incident involved a resident who was moderately cognitively impaired and received more than half of their total calories through a feeding tube due to cerebral palsy. The physician's orders required checking the residual volume in the stomach before administering medication through the G-tube. However, during a medication pass, the LVN did not check the residual volume as required but instead used air auscultation to verify tube placement. The LVN acknowledged the error, stating that she mistakenly believed that checking residual was no longer necessary. The Director of Nursing (DON) confirmed that the LVN was an experienced nurse but had reverted to an outdated practice of using air auscultation. The facility's procedure for enteral tube drug instillation required verifying tube placement using at least two methods, including aspirating tube contents. The failure to check residual volume before administering medication placed the resident at risk of aspiration, vomiting, or incomplete medication administration if the tube was blocked or obstructed.
Delayed Diagnosis and Treatment of Femoral Fracture
Penalty
Summary
The report details a significant deficiency in a long-term care facility where a resident (Resident #1) experienced a delay in diagnosis and treatment of a left intertrochanteric femoral fracture. The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident's family or representative about the change in the resident's physical status. Despite Resident #1's complaints of excruciating pain and additional falls, the facility did not act promptly on the X-ray results that showed the fracture. The Assistant Director of Nursing (ADON A) failed to read the X-ray results, notify/consult the physician, or inform the resident's family about the fracture, leaving Resident #1 with an undiagnosed and untreated fracture for 29 days. Various staff members, including LVN F, PTA S, the Nurse Practitioner, and the ADON A, were interviewed regarding the events leading to the deficiency. LVN F acknowledged the failure to follow up on the X-ray results and expressed surprise at the fracture diagnosis. PTA S mentioned reporting Resident #1's complaints of pain and falls but was unaware of the fracture. The Nurse Practitioner vaguely remembered Resident #1 and did not recall ordering the X-rays. ADON A admitted to not recalling the events leading to the X-ray request and acknowledged the lack of proper follow-up procedures.
Communication and Documentation Failures Lead to Delayed Diagnosis of Femoral Fracture
Penalty
Summary
The facility failed to ensure the resident's right to be free from neglect for Resident #1, as evidenced by multiple failures in communication, documentation, and follow-up related to the resident's care. ADON A did not transcribe a physician's order for an X-ray for Resident #1's left femur, failed to assess the resident's pain adequately, did not place the X-ray request on the 24-hour report, and did not notify the responsible party of the X-ray request and results. Additionally, facility staff did not effectively communicate the X-ray results to the physician, leading to a delayed diagnosis of a left femoral fracture for Resident #1. The deficiencies in communication and documentation resulted in a significant delay in the diagnosis and treatment of Resident #1's left femoral fracture. Despite Resident #1's complaints of excruciating pain and an additional fall on 01/15/24, the facility failed to investigate thoroughly and promptly. This failure led to a delayed diagnosis, ongoing pain, delayed rehabilitation, and ultimately, hospitalization for Resident #1. The lack of proper communication and follow-up also put the resident at risk of further harm, including death, bleeding, and increased severity of the initial fracture.
Delayed Notification of Abnormal X-Ray Results Leading to Prolonged Undiagnosed Fracture
Penalty
Summary
The facility failed to promptly notify the ordering physician of abnormal x-ray results for Resident #1, leading to a significant delay in diagnosing and treating a left intertrochanteric femoral fracture. Despite Resident #1's complaints of excruciating pain and an additional fall, the facility did not inform the physician or family about the positive x-ray results on 01/18/24, which showed the fracture. This lack of timely communication resulted in Resident #1 remaining undiagnosed and untreated for 29 days, ultimately leading to delayed medical treatment, ongoing pain, and increased risk of complications such as bleeding and death. The failure to have a system in place to ensure prompt receipt of verbal notification from the contracted Radiology company further exacerbated the situation. The facility's records indicated that the x-ray results were received on 01/18/24, but there were unsuccessful attempts to notify the facility of the positive findings. This breakdown in communication highlights a critical gap in the facility's processes for ensuring timely and accurate reporting of diagnostic test results to the ordering practitioner, ultimately compromising Resident #1's care and safety. Multiple interviews with facility staff, including the Assistant Director of Nursing (ADON A), nursing staff, therapists, and the Nurse Practitioner (NP), revealed a lack of awareness and follow-up regarding Resident #1's condition and the x-ray results. ADON A admitted to not recalling the events surrounding the x-ray request and failing to ensure proper documentation and notification procedures were followed. The NP vaguely remembered Resident #1 and did not recall ordering the x-rays, indicating a breakdown in communication and oversight among the facility's clinical staff. These interviews shed light on the various points of failure within the facility's communication and notification processes, ultimately resulting in the deficiency identified during the survey.
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 101 citations issued within 25 miles in the last 12 months — including the 5 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 Denison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Terrace At Denison | 1.3 mi | ★★★★★ | 23 | 0 |
| Denison Nursing And Rehab | 1.5 mi | ★★★★★ | 3 | 0 |
| The Homestead Of Denison | 1.6 mi | ★★★★★ | 9 | 0 |
| Beacon Hill | 2 mi | ★★★★★ | 10 | 0 |
| Avir At Sherman | 5.6 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Woodlands Place Rehabilitation Suites.
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 July 2026) and official state health department websites.