Woodlands Place Rehabilitation Suites

F 0551 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

catheter. RN-A said Resident #2 said it was hurting, but she explained it would hurt due to his enlarged prostrate. Admin stated they normally would have called the family before placing a catheter. He stated a family member was in the other family member's room on the next hall. He stated the family member was POA. Admin stated both RN-A and LVN-B were written up for not contacting the family. Interview on 12/23/25 at 11:58 a.m. with Resident #2 stated he had no problems with any staff. He shook his head yes when asked if he was going home today and then he fell asleep. Interview on 12/23/25 at 12:03 p.m. with

the RP revealed Resident #2 had felt like he had to use the restroom the entire time he had been at the facility due to his enlarged prostrate. She did not understand why the facility did not call them to let them know before they placed the catheter. RP stated she and another family member had POA. She stated Resident #2 had dementia and did not remember a lot of things. Interview on 12/23/25 at 12:15 p.m. with

the FM revealed the facility did not call any of the family. FM stated RP and another family member had power of attorney over Resident #2. Attempted interview with Physician on 12/23/25 at 3:25 p.m. a voice message was left on his office phone requesting a return call. Attempted interview with Physician on 12/23/25 at 3:37 p.m. to his cell phone number, a voice and text message were sent requesting a return call. Interview on 12/23/25 at 3:41 p.m. with RN-A, she stated she was the on-duty nurse on the weekend.

She stated Resident #2 always yelled he had to go to the bathroom. She stated he had been taken to the bathroom [ROOM NUMBER] times in 30 minutes. She had called the Doctor and received orders for Resident #2 for an in and out catheter. She said she delegated to LVN-B to do it since the resident was on her hall. RN-A went to check on Resident #2 and LVN-B had not placed the catheter. She explained the process to Resident #2 and started to insert the catheter. RN-A stated one thing they did wrong was nobody called the family first. RN-A stated she assumed LVN-B had called the family and vice versa. RN-A stated they should have called the family. RN-A stated she would usually call the family after she got an order but did not usually call to get permission to insert a catheter. RN-A stated she assumed LVN-B called

the family because it was her resident. She stated Resident #2's family was always in the building. Interview

on 12/23/25 at 4:18 p.m. with LVN-B, she stated she received a text from RN-A which stated Resident #2's doctor gave orders for a catheter to be placed. LVN-B stated RN-A had come in and placed the catheter.

LVN-B stated she was told 12/22/25 that she was written up for not informing the family of the orders for the catheter. She stated she was not the nurse who requested the order and did not put the catheter in, so she did not feel she was responsible for notifying the family. Interview on 12/23/25 at 5:55 p.m. with the Admin,

he stated Resident #2's family should have been called regarding the doctor's order. Record Review of the facility's Nursing Policies and Procedures with subject Physician and Other Communication/Change in Condition dated 5/5/23, reflected under policy was to provide guidance for the notification of patients/residents and their responsible party regarding changes in condition. Under Procedures: 1.

Complete assessment of the patient/resident which may include but is not limited to: .K.

Patient/resident/family wishes.5. The patient/resident and patient's/resident's family member/legal representative will be notified of any changes in medical condition or treatment plan as indicated by HIPPA directives. Record Review of Resident Rights in the facility's Admissions Handbook, dated March 2023, revealed under 18. Notice of Changes in Condition. The facility must.notify.resident representative or interested family member when: .it is necessary to alter treatments significantly (that is, a need to discontinue or change an existing form of treatment).

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodlands Place Rehabilitation Suites

5600 Woodlands Trail Denison, TX 75020

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

printed in 2023 was used for standards of nursing care. Skill check off for all nursing staff is done annually.

Review of the Lippincott Manual instructions for Indwelling Urinary Catheter Insertion indicated these areas were not followed. To use sterile techniques when inserting, manipulating, and maintaining the indwelling urinary catheter.Maintain a sterile, continuously closed drainage system.Place a fluid-impermeable pad on

the bed between the resident's legs and under the hips.Using sterile no-touch technique to open the insertion kit wrap.Wash hands prior to donning (putting on) sterile gloves.If the urine drainage bag is not preconnected, attach it to the other end of the catheter using sterile gloves.

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