Woodlands Health and Rehab Center

In the surveyor’s words

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

• Actual harm, isolatedF887Apr 8, 2026

  Based on record review, hospital/emergency department documentation, facility policy review, and staff interviews, the facility failed to ensure staff verified Resident #2's documented allergy (to the COVID-19 vaccine) prior to administering the vaccine. The facility also failed to provide timely clinical assessment and medical intervention after the vaccine was administered. This affected one resident (Resident #2) of five residents reviewed for vaccinations.On 11/07/25 at 12:10 P.M., staff administered a COVID 19 vaccination to Resident #2 despite the vaccine being listed as an allergy in the resident's medical record. No immediate assessment or monitoring was completed following administration of the contraindicated vaccine. […]

• Actual harm, isolatedF689Dec 4, 2023

  Based on closed record review, hospital record review, facility policy review and interview the facility failed to provide adequate supervision and assistance to prevent a fall with injury for Resident #80. Following the fall, the facility failed to complete a comprehensive assessment, provide ongoing monitoring and physician notification to ensure the resident received timely medical treatment. Actual Harm occurred on 11/25/23 at 5:45 P.M. when Resident #80, who was cognitively impaired, at high risk for falls and with a history of recent falls, sustained a fall from the wheelchair in the lounge area following dinner, resulting in a left hip fracture. […]

• Actual harm, isolatedF686Dec 29, 2022

  Based on interviews, record review and review of the facility Self-Reported Incident, the facility failed to ensure Resident #36's left heel wound was assessed and treated timely. Actual Harm occurred on 10/19/22 when the facility failed to comprehensively assess Resident #36's left heel wound, notify the physician, and implement timely would care, resulting in the resident developing an unstageable (full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) pressure ulcer to the left heel. This affected one resident (Resident #36) of three residents reviewed for pressure ulcers. […]

• No harm, potential for more than minimal, widespreadF880Apr 8, 2026

  Based on observation, interview, record review and review of the facility policy, the facility failed to follow their legionella water management plan and practice appropriate hand hygiene during medication administration and wound care. This affected two residents (Residents #8 and #100) observed for infection control and had the potential to affect all 79 residents in the facility. Findings include:1. Review of the facility's water management plan (WMP), dated 04/12/19 identified the ice machine as a risk factor. Control measures were listed as cleaning and disinfecting the ice machine based on equipment manufacturer's instructions. Change filter and clean if installed. Make sure to schedule and document all cleanings. […]

• No harm, potential for more than minimal, widespreadF812Jun 2, 2022

  Based on observations, interview and record review, the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect 72 residents who received meals from the kitchen, as one resident (#28) did not eat by mouth. The facility census was 73. Findings include: During the initial tour of the kitchen on 05/31/22 at 8:30 AM revealed the mixer used to make resident's food had dried food splatter on it. This was verified by Diet Aide #516 at 8:55 AM. A revisit to the kitchen on 06/01/22 at 10:30 A.M. revealed Dietary Manager (DM) #520 testing a sanitizer bucket containing a quaternary (quat) sanitizing solution. The bucket of quat sanitizer was used to sanitize food contact and preparation surfaces in the kitchen to prevent cross contamination of foods. […]