The Broadmoor At Creekside Park
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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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The Broadmoor at Creekside Park in The Woodlands, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in The Woodlands, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Broadmoor at Creekside Park or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.