Deficiency Records for The Woodlands Health and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for The Woodlands Health and Rehab Center. 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? |
|---|---|---|---|---|
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-17 | 2023-08-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-04-17 | 2023-06-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-17 | 2023-06-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-17 | 2023-06-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-17 | 2023-06-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-17 | 2023-06-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-17 | 2023-06-16 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-17 | 2023-06-16 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-04-17 | 2023-06-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-13 | 2023-05-12 | 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 | 2023-04-13 | 2023-05-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-13 | 2023-05-12 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2023-04-13 | 2023-05-12 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-13 | 2023-05-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-13 | 2023-05-12 | 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 | 2021-07-28 | 2021-08-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-28 | 2021-08-31 | N |
| Post nurse staffing information every day. | Health | 2021-07-28 | 2021-08-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-28 | 2021-08-31 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-08-03 | 2021-08-25 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2021-08-03 | 2021-08-25 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-04-17 | 2019-04-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-17 | 2019-04-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-04-17 | 2019-04-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-04-03 | 2019-04-19 | 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 | 2019-04-03 | 2019-04-19 | N |
