The Woodlands Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF684Jun 17, 2025

  Based on interviews and records reviewed, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (CR #1) of 3 residents reviewed for quality of care. - The facility failed to ensure treatment and care was provided to CR #1 consistent with professional standards of practice. CR #1's left stump was found with maggots and roaches on 06/07/25. The wound was also found with roaches in addition to the maggots per the findings. CR #1 was transported to the hospital where she later had an above the knee amputation. An Immediate Jeopardy (IJ) was identified on 06/13/25. The IJ template was provided to the facility on [DATE] at 10:51 a.m. […]

• Actual harm, isolatedF550Apr 13, 2026

  Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one of eight residents (Resident #5) reviewed for resident rights. The facility failed to provide care in a manner that promoted maintenance of a resident's quality of life on 1/27/26 when Resident #5 was left in the shower alone, cold, and unclothed for approximately 5 minutes and was unable to call for help. […]

• Actual harm, isolatedF580Apr 13, 2026

  Based on interview and record review, the facility failed to immediately inform the physician when resident arrived to the facility for 1 of 14 residents (CR#1) reviewed for resident rights.1. The facility failed to contact the physician when CR#1 had an unwitnessed fall on 1/17/2026 that resulted in a head injury.2. The facility failed to notify physician of CR#1 unwitnessed fall with head injury3. The facility failed to call 911 emergency services when initially requested by family4. CR #1 was hospitalized from [DATE] to 01/25/26 with the admitting diagnosis being fall, initial encounter. These failures could place residents at risk of decline in health status, increase level of pain, and could lead to more serious injuries. […]

• Actual harm, isolatedF684Apr 13, 2026

  Based on interview, and record review, the facility failed to ensure that residents received treatment and necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with professional standards of practice and resident choices, for 1 to 14 (CR#1) residents reviewed for Quality of care.The facility failed to ensure that appropriate preventative measures, monitoring, and interventions were consistently implemented to reduce the risk of falls and ensure CR#1's safety in accordance with accepted standards of nursing practice.The facility failed to respond timely to CR#1 who was in distress after a fall on 1/17/26. […]

• No harm, potential for more than minimal, widespreadF812Aug 1, 2024

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility did not store, prepare, or distribute food in a safe and sanitary manner: Dry storage contained undated food/drink items; Refrigerator contained undated drink items; Freezer contained opened/not sealed food items. These failures could place residents at risk of foodborne illness. […]