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Deficiency Records for The Woodlands
A list of the most recent deficiencies for The Woodlands. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for The Woodlands. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-07-10 | 2024-08-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-10 | 2024-08-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-10 | 2024-08-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-07-10 | 2024-08-15 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-07-10 | 2024-08-15 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-07-10 | 2024-08-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-10 | 2024-08-15 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-07-10 | 2024-08-15 | Y |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-07-18 | 2023-12-13 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-07-18 | 2023-10-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-18 | 2023-10-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-18 | 2023-10-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-09 | 2023-10-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-09 | 2023-10-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-09 | 2023-10-10 | Y |
| Have policies on smoking. | Health | 2023-10-09 | 2023-10-10 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-08 | 2023-10-10 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-18 | 2023-10-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-08 | 2023-10-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-08 | 2023-10-04 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-08 | 2023-10-04 | Y |
| Have policies on smoking. | Health | 2023-08-10 | 2023-09-01 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-10 | 2023-08-29 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-07-25 | 2023-08-17 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-10 | 2023-08-11 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-07-18 | 2023-08-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-18 | 2023-08-10 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-04 | 2023-05-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-04 | 2023-05-26 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-05-04 | 2023-05-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-04 | 2023-05-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-04 | 2023-05-26 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-03-20 | 2023-04-07 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-09-22 | 2022-09-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-22 | 2022-09-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-25 | 2022-04-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-25 | 2022-04-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-25 | 2022-04-25 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-03-25 | 2022-04-22 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-03-25 | 2022-04-22 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-03-25 | 2022-04-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-25 | 2022-04-22 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-03-25 | 2022-04-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-25 | 2022-04-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-25 | 2022-04-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-03-25 | 2022-04-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-25 | 2022-04-06 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-03-25 | 2022-03-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-25 | 2022-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-25 | 2022-03-31 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-03-25 | 2022-03-31 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-03-25 | 2022-03-30 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2022-03-25 | 2022-03-26 | Y |
| Provide information about how to apply for and use Medicare and Medicaid benefits. | Health | 2022-03-25 | 2022-03-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-12 | 2022-02-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-28 | 2022-01-21 | Y |
| Post nurse staffing information every day. | Health | 2021-12-28 | 2022-01-21 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-10-14 | 2021-11-14 | Y |
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