The Broadmoor At Creekside Park
The Broadmoor at Creekside Park in The Woodlands, TX — inspection on November 20, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
check and look at everything.
She said she was trained on head-to-toe skin assessments and should look at the person and review for any abnormalities or anything suspected.
She said the purpose of the head-to-to-toe skin assessment was to prevent any open areas, which would be reported to the supervisor and wound care nurse.
She was unsure of what could happen if every part of the resident's body was not examined during a head-to-toe skin assessment. In an interview on 11/19/25 at 1:52 p.m. the DON said they believed CR #1's tinge of blood was a UTI but found out he had an abscess that had not ruptured yet.
She said the facility staff had not seen an abscess on CR #1.
She said nurses should look at the creases, moist areas, folds, and every inch of the body during a head-to-toe skin assessment.
She said those areas of the body were more susceptible to bacteria.
She said as a result of the incident with CR #1, the facility conducted in-services, conducted a QAPI, PIP and a very thorough skin sweep.
She said the ADON, wound care nurse, and unit managers were overseeing the skin assessments.In an interview on 11/19/25 at 2:15 p.m. the Administrator said the facility was treating CR #1's small blood as a possible UTI and a UA was ordered.
She said the area was a boil and the resident would not allow the staff to wash him.
She said during his shower there was nothing on the washcloth.
She said the facility always investigated concerns and 99% of the time she would take the time and re-educate staff.
She said head to toe assessments were conducted on all residents and the facility QAPI'd the incident.
She said the conclusion of their investigation was that something may have been festering but the abscess just popped out.
She said head to toe skin assessments should be completed regularly and were based on the patients' behavior and compliance. In an interview on 11/19/25 at 3:33 p.m. CR #1's MD J said an abscess just popped up on CR #1 and CR #1's family member noticed it. He said the abscess was in the groin area and if it was small, it could be hard to feel. He said an abscess could absolutely pop up overnight and the resident would show signs that something was there. He said signs and symptoms of an abscess could be fever, pain, and being uncomfortable.In an interview on 11/20/25 at 10:35 a.m. CNA S said she assisted CR #1 with a shower on 8/29/25.
She said CR #1 washed in between his private area and underneath his balls (testicles) and there was no blood on the white bath towel or in his pull up. He dried the front and back of his body with no concerns and no pain expressed.
She said she did not see his private area.
She said CR #1's sitter rechanged his pull up, dressed him, and took him to a doctor's appointment. CR #1 did not complain of any pain to her on Friday 8/29/25.
She said she would have reported any areas of concern to the nurse.
Record review of the facility's Skin Assessment policy dated 10/1/25 read in part, . policy: it is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management.
This policy includes the following procedural guidelines in performing the full body skin assessment.
Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. 2.
Procedure. e. begin head to toe, thoroughly examining the resident's skin for condition.
Pay close attention to pressure points, bony prominences, and underneath medical devices.
Record review of the facility's Ad Hoc QAPI Plan dated 9/4/25 read in part, Problem: External reportable to HHSC for allegation of neglect.
Abscess to resident groin.
Resident refuses care and toilets himself.
Facility action: patient safe surveys on interviewable patients, safe survey follow up if appropriate, head to toe assessments, in-service on ANE, in-service on skin, Inservice on continence, in-service on ADLs and dealing with difficult residents, medical director notification, psychosocial well being assessment if resident returns to the facility, accident/incident report, pain monitoring audit, head to toe evaluations audit.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.