Woodlands Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 28, 2025

  Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent Resident #1, a vulnerable resident, from leaving the facility premises unsupervised for one (1) of six (6) residents reviewed. Resident #1. On 3/22/25 at 8:17 AM, Resident #1, who has a Brief Interview for Mental Status (BIMS) score of 7, left the facility unsupervised. The facility's transportation aide let the resident out of the front door to sit on the porch. Licensed Practical Nurse (LPN) #1 encountered Resident #1 in the facility parking lot and attempted to redirect the resident back to the facility. She left the resident unsupervised to get help from additional staff. […]

• Immediate jeopardy, isolatedF600Feb 3, 2025

  Based on interviews, record review, and facility policy review, the facility failed to protect the residents' right to be free from physical abuse from a staff member for one (1) of five (5) sampled residents. Resident #1 Resident #1 was physically and emotionally abused on 12/25/24 when Certified Nursing Aide (CNA) #1 handled him roughly, sprayed cold water on his face, and turned out the lights in the shower room, while laughing. The facility's failure to protect resulted in Resident #1 reporting he felt sad, taken advantage of, and a little afraid. Additionally, the facility's failure to immediately remove CNA #1 from the facility placed this resident and other residents in a situation that was likely to result in ongoing serious injury, serious harm, serious impairment, or death. […]

• Immediate jeopardy, isolatedF609Feb 3, 2025

  Based on interviews, record review, and facility policy review, the facility failed to report an allegation of abuse within the required two (2) hour timeframe for one (1) of five (5) sampled residents. Resident #1 Licensed Practical Nurse (LPN) #1 witnessed physical and emotional abuse of Resident #1 on 12/25/24, however, the facility did not report it to the State Agency (SA) until 12/30/24, delaying the facility's ability to protect the resident from further harm. The facility's failure to ensure immediate reporting increased the risk of further harm which left Resident #1 and other residents in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. […]

• Actual harm, isolatedF580Jun 6, 2024

  Based on record review, resident and staff interview, and facility policy review the facility failed to notify the physician of a resident's severe pain rated initially at a ten (10) on a pain scale of (0-10) with 10 being the most severe for one (1) of four (4) sampled residents. Resident #2. Findings include: Record review of the facility policy titled Medication Policies, revised 10/1/19, revealed, .Procedure .12. When contacting the attending physician regarding a change in condition where it is likely the physician will order a medication, the nurse is to inform the physician of the availability of remote medications in the facility (i.e. the contents of the remote drug supply). This will facilitate timely drug administration . […]

• Actual harm, isolatedF697Jun 6, 2024

  Based on staff and resident interview, record review and facility policy review, the facility failed to respond and administer pain medication timely for a resident's complaint of severe pain rated initially at a ten (10) on a pain scale of (0-10) with 10 being the most severe for one (1) of four (4) sampled residents. Resident #2. Findings Include: Record review of the facility policy titled, Pain Management Program Policy, revised 10/22, revealed, The facility will ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management . Monitoring . 5. […]