Woodlands the

In the surveyor’s words

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

• Actual harm, isolatedF600Dec 2, 2022

  Based on observation, interview and record review, the facility failed to prevent staff to resident abuse for 2 of 2 residents reviewed for abuse (Resident G and C). Using the reasonable person concept, it is likely this deficient practice would lead to anxiety and fearfulness (Resident G). Findings include: 1. Resident G's clinical record was reviewed on 12/1/22 at 11:49 a.m. Diagnoses included, but were not limited to, communication deficit, unspecified focal traumatic brain injury without loss of consciousness, sequela, need for assistance with personal care, and major depressive disorder, single episode. Physician orders included citalopram hydrobromide (antidepressant) 20 mg (milligram) daily. […]

• Actual harm, isolatedF622Jun 8, 2021

  Based on interview and record review, the facility failed to ensure a resident received required notification for an involuntarily transferred, a resident was not involuntarily transferred without medical necessity. This deficient practice resulted in a resident being involuntarily moved 77 miles from the facility and a decline in the residents mobility level for 1 of 3 residents reviewed for transfer service. (Resident C) Findings include: During an interview on 6/8/2021 at 11:27 a.m., Resident C indicated 3 different aides entered her room (at the Woodlands) on the morning of 5-21-2021 and told the resident to get up and get dressed because she was leaving the facility. The resident indicated she told the staff she was not going anywhere. […]

• No harm, potential for more than minimal, widespreadF812Mar 7, 2025

  Based on observation, interview and record review, the facility failed to ensure food was prepared and served using safe sanitary food preparation and handling methods. This deficient practice has the potential to impact 69 of 69 residents who received their meals from the kitchen. Findings include: During the lunch meal preparation and service on 3/6/25 from 11:48 a.m. to 12:10 p.m., the following concerns were observed: At 11:51 a.m.,Cook 6 touched the refrigerator door with her gloved hands. Using the same contaminated gloves, she removed two hot dogs from a plastic bag and placed them on plates to put them in the microwave. At 11:52 a.m., she used her same gloved hands to pull up her pants. […]

• No harm, potential for more than minimal, widespreadF801Feb 6, 2025

  Based on interview and record review, the facility failed to employ a qualified Food Services Director. This deficient practice had the potential to impact 70 of 70 facility residents. Finding includes: Review of the employee record form, completed by the facility following the entrance conference on 2/4/25, indicated the Food Services Director had been employed by the facility since 8/6/20. During an interview on 2/5/25 at 10:58 a.m., the Administrator indicated the Food Services Director had been enrolled in a dietary manager program, but failed to obtain the certification. The Food Services Director had since re-enrolled in the program. […]

• No harm, potential for more than minimal, widespreadF812Jan 30, 2023

  Based on observation, interview, and record review, the facility failed to maintain cooking equipment in a clean, sanitary manner and failed to ensure dishes were washed in a manner to prevent cross contamination. This deficient practice had the potential to impact 67 of 67 residents who received meals from the kitchen. Findings include: During the initial kitchen observation, on 1/23/23 at 10:12 a.m., the following concerns regarding kitchen cleanliness were observed: a. The ledge of the oven hood had a heavy, thick, gummy, dark brown/black residue covering the hood's ledge. When using a paper towel to sweep across the ledge of the hood, the towel was covered with a thick black Play-Doh like residue. b. […]