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Complaint Investigation

The Woodlands Nursing And Rehabilitation Center

Inspection Date: August 19, 2025
Total Violations 1
Facility ID 455876
Location The Woodlands, TX
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Inspection Findings

F-Tag F0677

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

not being changed or given incontinent care can cause skin breakdown. She stated between CNA's and Nurses a resident should be seen every two hours and repositioned. She stated charge nurses should ensure this by checking the POC on the karmex (CNA documentation) at that beginning of resident shift, middle and end of CNA's shift. [NAME] shift nurse should check the POC between 12:00pm -1:00pm. In an

Interview with ADON on 8/19/25 at 1:45pm-She stated she is aware of the issues with Resident #1 not receiving in continent care on the 6am-2:00pm shift. She states the nurse completed a head-to-toe assessment after hearing about this. She stated the facility completed a report, investigation and training was provided to staff regarding this issue. She stated the negative outcome for a resident not receiving incontinent care can cause skin breakdown. In a telephone interview on 8/25/25 at10:43am CNA B, stated

she has been working with Resident #1 since January 2025. CNA B stated she has never observed Resident #1 in her chair for hours. She stated she has experience in the past few months that Resident #1 tends to have a bowel movement before getting showers. She stated she has observed Resident #1 with a bowel movement and pamper soiled; however, she is unable to say how long her pamper has been soiled, which is why she never brought this concern to the attention of the facility. In a telephone interview on 8/25/25 at12:37pm CNA C stated she has been working with Resident #1 since March 2025. CNA C stated

she has never observed Resident #1 in her chair for hours. However, she has noticed her pamper soiled when she and her partner arrives to give Resident #1 her shower. She stated she has not said anything to

the facility because they are giving her a shower anyway, and she cannot say how long Resident #1's pamper has been soiled. Record review of the facility's Activities of Daily Living (ADL) Policy dated based 5/26/23 revealed, the facility will, based on the resident's comprehensive assessment and consistent with

the residents needs and choices, ensure resident's abilities in ADL's do not deteriorate unless deterioration reaction is unavoidable. Care and services will be provided for the following activities of daily living:1.

Bathing, dressing, grooming and oral care;2. Transfer and ambulation;3. Toileting;4. Eating to include meals and snacks; and5. Using speech, language, or other functional communication systems.

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📋 Inspection Summary

THE WOODLANDS NURSING AND REHABILITATION CENTER in The Woodlands, TX inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

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 WOODLANDS NURSING AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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