Woodlands Healthcare Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Dec 17, 2021

  Based on observation, interview and document review, the facility failed to store and prepare food under sanitary conditions when: 1. There was outdated food in the kitchen refrigerator; 2. There was water leaking from a ceiling vent onto the kitchen freezer; 3. There was a brown substance inside the ice machine; and 4. Dietary staff used expired test strips and improper technique when testing the kitchen surface sanitizer (solution used to kill microorganisms on kitchen surfaces). These failures had the potential to result in foodborne illness (illness resulting from contaminated food) throughout the facility. Findings: 1. During an observation on [DATE] at 8:58 a.m., there was a plastic container of strawberries in one of the kitchen refrigerators. […]

• No harm, potential for more than minimal, patternF880Dec 11, 2024

  Based on interview and record review, the facility failed to follow it's Policy and Procedure titled Isolation-Categories of Transmission- Based Precautions, when the facility failed to provide evidence of implementing isolation precautions (process of creating barriers between people and germs to help prevent the spread of infectious microbes) during an outbreak of infectious gastrointestinal related illnesses for four of six sampled residents (Resident 1, Resident 2, Resident 3 & Resident 4). […]

• No harm, potential for more than minimal, patternF656Oct 13, 2023

  Based on observation, interview and record review, the facility failed to develop and implement comprehensive, person-centered, care plans for four of thirty-one residents investigated, (Residents 14, 41, 160 and 18) when: 1. Residents 14 and 41, the activity care plans did not specify the activities provided, there were no frequency of visits for the activities, and no measurable outcomes of the visits; 2. Resident 160, there were no interventions that were developed in the activity care plan, and 3. Resident 18, there was no care plan to address her excessive sleepiness issue. These failures had the potential to result in the residents, not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. […]

• No harm, potential for more than minimal, patternF658Oct 13, 2023

  Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for three of 15 sampled residents (Residents 16, 18, and 21) when: 1. Resident 16, there were two duplicated insulin orders without parameters; 2. Resident 18, the treatment nurse did not label the dressing with the date, time, and initial and; 3. Resident 21, the licensed nurse did not refill her eye drop medicine on time and caused six missed treatments. These failures had the potential to negatively affect the residents' health and well-being. Findings: 1. […]

• No harm, potential for more than minimal, patternF684Oct 13, 2023

  Based on observation, interview and record review, the facility failed to ensure the residents received the necessary care and services for five of 15 residents (2, 8, 20, 22, and 37) when: 1. Licensed nurses did not follow the physician's order for pain medication based on the resident's pain level for Resident 2; 2. A bottle of gel hand sanitizer was on Resident 8's night stand in her room; 3. Licensed nurse did not follow the physician's order for oxygen supplement for Resident 20; 4. Licensed vocational nurse G (LVN G) did not know how to monitor Resident 22's AV fistula (a special connection that is made by joining a vein onto an artery, usually in the arm) and what to do if it was bleeding; and 5. […]