The Woodlands Health and Rehab Center

In the surveyor’s words

From the most serious findings on record at The Woodlands Health and Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Jul 28, 2021

  Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow infection control practices to prevent the potential spread of COVID-19 on one of two units, the west unit. Droplet precautions were not implemented at the time of entry for an unvaccinated new admission, facility staff was not aware of the proper PPE (personal protective equipment) to wear while in contact with a resident on droplet precautions, and one staff member was not aware of where to find proper PPE. Findings were: Initial tour of the facility was conducted on 07/26/2021 beginning at approximately 7:00 p.m. Observed outside of Resident #205's room was a white trifold, cloth covered partition. The partition was not around the door but sitting at an angle. […]

• No harm, potential for more than minimal, isolatedF635Apr 13, 2023

  Based on clinical record review, the facility staff failed to obtain physician orders for the care of an implanted cardiac defibrillator for one of 21 residents, Resident #153. Findings were: Resident #153 was admitted to the facility with the following diagnoses, including but not limited to: Acute respiratory failure with hypoxia cardiomegaly, atherosclerotic heart disease, mitral valve insufficiency, presence of automatic implantable cardiac defibrillator (AICD), heart failure, dysphagia, and hypertensive heart disease. The admission MDS (minimum data set) with an ARD (assessment reference date) of 01/27/2023 assessed Resident #153 as cognitively intact, with a summary score of 13 out of 15. The clinical record was reviewed on 04/12/2023, beginning at approximately 11:00 a.m. […]

• No harm, potential for more than minimal, isolatedF655Apr 13, 2023

  Based on staff interview and clinical record review, the facility staff failed to provide a baseline care plan for one of 21 residents in the survey sample. Resident #53 was not presented with a completed copy of the baseline care plan. This was a closed record review. The Findings Include: Diagnoses for Resident #53 included; Dementia, anxiety, depression, epilepsy, insomnia, and muscle wasting. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/19/21. Resident #53 was assessed with a cognitive score of 15 indicating cognitively intact. On 4/12/23 review of Resident #53's clinical record evidenced that a baseline care plan was completed on 8/14/21 after the admission on 8/13/21. […]

• No harm, potential for more than minimal, isolatedF656Apr 13, 2023

  Based on observation, staff interview, and clinical record review, the facility staff failed to develop comprehensive care plans for two of 21 residents. Resident # 153 did not have a care plan in place for nutrition and a physician ordered treatment was not listed on the care plan for pressure ulcers. Resident #119 did not have a care plan for the use of a life vest. Findings were: 1. Resident #153 was admitted to the facility with the following diagnoses, including but not limited to: Acute respiratory failure with hypoxia cardiomegaly, atherosclerotic heart disease, mitral valve insufficiency, presence of automatic implantable cardiac defibrillator (AICD), heart failure, dysphagia, and hypertensive heart disease. […]

• No harm, potential for more than minimal, isolatedF657Apr 13, 2023

  Based on observation, staff interview, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 21 residents. Resident # 14's care plan was not updated to include the use of a specialty mattress. Findings were: Resident #14 was admitted to the facility with the following diagnoses, including but not limited to: Vascular dementia, urine retention, hypertension, Parkinson's disease, and cerebrovascular disease. The most recent MDS (minimum data set) was an annual assessment with an ARD (assessment reference date of 01/23/2023. […]