Complete Care at Woodlands

In the surveyor’s words

From the most serious findings on record at Complete Care at Woodlands, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF640Feb 1, 2024

  Based on record review, interview, review of the Resident Assessment Instrument (RAI) manual and policy review, the facility failed to ensure ten residents out of 27 sampled resident's (Resident (R)16, R62, R6, R42, R44, R97, R72, R78, R2, R15) Minimum Data Set (MDS) assessments were transmitted in a timely manner. Findings include. Review of the facility policy titled, MDS Completion and Submission Timeframes, dated 10/22/23, revealed, . Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes . […]

• No harm, potential for more than minimal, patternF655Feb 1, 2024

  Based on observations, interviews, record review, and facility policy review, the facility failed to develop a baseline care plan for five of 27 residents (Resident (R) 159, R109, R160, 45, and R32) to include interventions to address current resident needs. Findings include: 1. Review of R159's Census, located in the electronic medical record (EMR) under the Clinical tab, revealed R159 was admitted to the facility on [DATE] and had diagnoses that included pressure ulcer of left buttock, stage 2; pressure ulcer of left hip, stage 2; non-pressure chronic ulcer of right ankle with unspecified severity; non-pressure chronic ulcer of other part of right foot with unspecified severity. During an observation on 01/29/24 at 12:46 PM, R159 was lying in bed groaning. […]

• No harm, potential for more than minimal, patternF880Aug 19, 2021

  Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to maintain infection control standards and procedures to address the risk of infection transmission by failing to: a) perform proper hand hygiene and perform a wound treatment in a safe and sanitary manner for 1 of 1 nurse observed providing a wound care treatment, to 1 of 1 resident, (Resident #51); b) perform proper hand hygiene during meal service for 1 of 3 dining rooms observed; and c.) perform proper hand hygiene to maintain sanitation in a safe and consistent manner to prevent food borne illness. 1. On 08/11/21 at 11:09 AM, the surveyor observed Resident #51 lying in bed, which had a pressure-relieving device attached to the end of the bed. […]

• No harm, potential for more than minimal, isolatedF686Nov 21, 2025

  Complaint # 2648672Based on observation, interview, and record review, it was determined that the facility failed to: a.) change an arterial ulcer treatment dressing in accordance with a physician order, b.) failed to document appropriately in accordance with professional standards of practice, c) failed to notify the physician that resident refused dressing change. This deficient practice was identified for 1 of 3 residents reviewed with pressure ulcers (Resident #2), and was evidenced by the following:A review of Resident #2's electronic medical record. […]

• No harm, potential for more than minimal, isolatedF759Jul 24, 2025

  Based on observation, interview, record review, and review of facility policy and manufacturer's instructions, the facility failed to ensure a medication error rate below five percent. During medication administration for one (Resident (R)133) of seven residents, two medication errors occurred out of 31 opportunities for error, or a medication error rate of 6.45%. This failure had the potential to increase or decrease the effectiveness of these medications.Findings include:Review of the facility's policy titled Medication Administration dated 06/01/2025 indicated, . 10. Ensure that the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, f. Right documentation.17. […]