Woodlands Place Rehabilitation Suites

In the surveyor’s words

From the most serious findings on record at Woodlands Place Rehabilitation Suites, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Apr 18, 2024

  Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority the resident representative when there was a a significant change in the resident's physical status for one of six residents (Resident #1) reviewed for change of condition. ADON A failed to read Resident #1's x-ray results received at the facility on 01/18/24 and failed to notify/consult the Physician about the resident's femur (thigh bone) fracture and change of condition using the facility's approved notification methods leaving Resident #1 with an undiagnosed /untreated fracture for 29 days (01/18/24 to 02/13/24). Resident #1 fell on [DATE] at 03:15 a.m. […]

• Immediate jeopardy, isolatedF600Apr 18, 2024

  Based on interviews and record reviews, the facility failed to ensure the resident has the right to be free from neglect for one of six residents(Resident #1) reviewed for neglect. 1. ADON A failed to follow the facility's process for documentation, transcription and notifications when she failed to transcribe the physician's order on 01/18/24 for an X-ray request for Resident #1's left femur (thigh bone), failed to document an assessment of Resident #1's pain to determine the location, duration, and scale of Resident #1's pain, failed to place the X-ray request for 01/18/24 on the 24-hour report for follow-up, and failed to notify the responsible party of the X-ray request and results. 2. […]

• Immediate jeopardy, isolatedF777Apr 18, 2024

  Based on interview and record review the facility failed to promptly notify the ordering physician, results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner for one of six residents (Resident #1) reviewed for diagnostic services in that. 1.ADON A failed to read Resident #1's x-ray results received at the facility on 01/18/24 and failed to notify/consult the Physician about the resident's femur (thigh bone) fracture and change of condition using the facility's approved notification methods leaving Resident #1 with an undiagnosed /untreated fracture for 29 days (01/18/24 to 02/13/24). 2. […]

• Actual harm, isolatedF689Oct 22, 2025

  Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate assistance devices to prevent accidents for 2 of 5 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure CNA A and the dietary staff checked the temperature and sealed Resident #1's cup of hot tea, which resulted in Resident #1 spilling tea in her lap on 10/13/25 acquiring a second-degree burn (partial thickness burn, damages the outer and middle layers of skin. Characterized by blistering-typically heal in 7 to 21 days) to her left upper thigh. The noncompliance was identified as PNC. The non-compliance began on 10/13/25 and ended on 10/14/25. […]

• No harm, potential for more than minimal, patternF584Feb 26, 2026

  Based on observation, interview and record review the facility failed to ensure residents had a safe, clean, comfortable and homelike environment including clean bed linen in good condition for seven (Resident #55, Resident #11, and 5 confidential residents in group interview) of 16 residents and 4 of 4 bed linen closets reviewed for resident rights and homelike environment. 1. The facility failed to ensure Resident #55 and #11's and 5 confidential residents' in group interview fitted bed sheets were in good condition free of holes, tears and threadbare areas. 2. The facility failed to ensure 4 of 4 bed linen closets on resident halls did not have clean fitted bed sheets with holes, tears and threadbare areas. […]