Woodlands Nursing & Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of oxygen therapy for 1 of 1 resident reviewed for oxygen therapy (Resident #4).The findings included:Resident #4 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen. The MDS dated [DATE] indicated Resident #4 was cognitively intact and was not coded for oxygen therapy. The Care Plan, last revised 7/21/25, included the focus of requiring oxygen therapy with an intervention that specified to give medications as ordered by physician. An observation and interview with Resident #4 were conducted on 8/7/25 at 10:55 AM. He was observed lying in his bed with oxygen being administered via nasal canula tubing (a tube with nasal prongs that allows oxygen delivery from an oxygen source) which was connected to an oxygen concentrator. He was awake and alert. When asked if he knew…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) application for a resident with newly evident mental health diagnoses for 1 of 1 sampled resident reviewed for PASRR (Resident #62). The findings included:Resident #62 was readmitted to the facility on [DATE] with diagnoses including major depressive disorder, post-traumatic stress disorder, and adjustment disorder with anxiety.The admission Minimum Data Set, dated [DATE] had Resident #62 coded as cognitively intact and was not currently considered by the state level II PASRR process to have serious mental illness.A review of the North Carolina Medicaid Uniform Screening Tool (NC MUST) for PASRR screenings dated 01/26/2010 revealed a negative PASRR level I determination.An interview with the Social Worker was conducted on 08/08/2025 at 11:15 AM. She stated Resident #62 did not have any mental health diagnoses in 2010 when the PASRR level I was completed but she did have the diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to administer significant medications to 4 out of 16 residents (Resident #1, #18, #21, and #48) reviewed for medication administration. The facility also failed to follow medication administration guidelines for not crushing certain medications for 1 out of 16 residents reviewed for medication administration (Resident #42). Findings included: 1a) Resident #1 was admitted originally into the facility 01/31/22 and was readmitted on [DATE] with the diagnoses of cerebral infarction, chronic systolic congestive heart failure, hypothyroidism, hypertensive heart and chronic kidney disease with heart failure, epilepsy, and type 2 diabetes mellitus. A review of Resident #1's quarterly Minimum Data Set, dated [DATE]included that she is severely cognitively impaired, has diagnoses of heart failure, diabetes mellitus, stroke, dementia, seizure disorder, and schizophrenia. It further revealed that she had received insulin injections on 7 days and was taking high…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interviews the facility failed to maintain documentation of current Covid-19 vaccination status, eligibility screening, education, and offering of Covid-19 vaccination for facility staff. The failures regarding education, offering the vaccine, and maintaining records were found for 4 of 12 facility staff (Staff #1, Staff #2, Staff #3, and Staff #4) reviewed for infection control. The findings included: Facility Covid-19 Staff Vaccination Policy last revised 8/2023 indicated all newly hired employees will be offered the Covid-19 Vaccine. Current employees will be offered the vaccine when there is a change in the vaccine content or if they previously refused and now would like to obtain the vaccine. The facility Staff Vaccination Policy also indicated a master tracker would be created to list all current staff who routinely enter the facility and updated on an ongoing basis as new staff are onboarded. The tracker will include vaccination status and proof of vaccination will be maintained in a secured location. Review of facility records revealed Staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide a CMS-10123 (Centers for Medicare and Medicaid Services) Notice of Medicare Non-Coverage (NOMNC) at least two days prior to discharge from Medicare part A services for 1 of 3 sampled residents (Resident #127). The findings included: Resident #127 was admitted to the facility under skilled Medicare Part A services to receive physical, occupational and speech therapy on 11/02/2023. Review of the admission Minimum Data Set (MDS) dated [DATE] indicated the resident's cognition was intact. She was dependent on staff for eating, toileting and personal hygiene. Review of the Physical Therapy discharge summary note indicated the date of services started on 11/03/2023 until 11/22/2023. Review of the Occupational Therapy discharge summary note indicated the date of services started on 11/03/2023 until 11/23/2023. A review of the medical record revealed a CMS-10123 NOMNC letter was issued, and the Responsible Party (RP) was notified on 11/28/2023…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff, pharmacist, and Nurse Practitioner (NP) interviews the facility failed to respond to the consultant pharmacist's recommendations for 1 out of 5 residents reviewed for unnecessary medications (Resident #42). Findings include: Resident #42 was admitted into the facility on 3/11/24 with multiple diagnoses including atrial fibrillation (an irregular rapid heart rate that commonly causes poor blood flow), gastroesophageal reflux disease, and arthritis. A review of Resident #42's admission Physician orders for March 2024 included the following: Cardizem Controlled Delivery 120 milligrams (mg) daily, enteric coated aspirin 81 mg daily, Protonix delayed release 40 mg tablet daily, Tylenol 8 hour extended release one tablet every 8 hours as needed for pain, and pentoxifylline extended release 400 mg tablet twice daily. A review of Resident #42's Pharmacy Consultant review dated 3/21/24 included the following: the electronic medical record indicates medications are crushed. Please consider the following alternatives: 1) Change Cardizem CD 120 milligram (mg)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, Physician interview, and Responsible Party interview the facility failed to implement a discharge planning process that identified changes resulting in modifications to a resident's discharge plan for one (Resident # 1) of three residents reviewed for discharge. The facility failed to follow up on a pending x-ray result before discharging a resident home. When the results came in after the resident was discharged , they showed the resident had a fracture. The findings included: Resident # 1 was admitted to the facility on [DATE]. The resident had diagnoses which in part included dementia, hypertension, diabetes, a history of metabolic encephalopathy, and debility. Resident # 1's care plan, dated 7/13/23, noted the plan was for Resident # 1 to discharge home after therapy was completed. Resident # 1's admission Minimum Data Set assessment, dated 7/21/23, coded the resident as cognitively impaired. She was assessed to need extensive assistance with her transfers and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews with resident and staff, the facility failed to ensure residents diagnosed with Post-Traumatic Stress Disorder (PTSD) had person-centered care plans developed with individualized approaches that direct staff on how to care for their assessed needs for 2 of 3 residents (Resident #24 and Resident #52) reviewed for PTSD. The findings included: 1. Resident #24 was admitted to the facility on [DATE] with multiple diagnoses that included depression and Post Traumatic Stress Disorder (PTSD). A review of the Trauma-Informed Care and Diverse Resident admission Assessment. dated 03/10/2021 revealed Resident#24 was identified with a traumatic life altering circumstances of war. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #24's cognition was intact. He had no behaviors and no rejection of care. A review of Resident #24's care plan revised on 09/16/22. Revealed Resident #24 was not care planned for individualized approaches related to her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interviews with facility staff, the facility failed to date opened food items stored for use in the reach-in refrigerator and to discard foods past their use by date for 1 of 1 reach-in refrigerator. This practice had the potential to affect foods served to the residents. The findings included: On 11/28/22 at 10:36 AM an observation of the of the reach-in refrigerator was conducted with the Dietary Manager. The observation revealed a plastic container of what appeared to be left over pudding unlabeled and there was no date or time noted, and a cheese sandwich unlabeled with no date. There was also a plastic container of leftover sliced mixed fruit dated 11/17/22 and peaches with date of 11/17/22. On 11/28/22 at 10:50 AM the Dietary Manager stated food items that did not contain a label should have been labeled properly. She added the items past seven days old should have been discarded by the dietary staff. The Dietary Manager also continued to explain that staff had called out the weekend and one of cooks had quit so someone had forgot to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to have code status in the medical record for 1 of 1 resident reviewed for code status (Resident #46). Findings included: Resident #46 was readmitted to the facility on [DATE] with diagnoses which included anemia, coronary artery disease, heart failure and hypertension. Review of Resident #46' significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was moderately impaired. An interview with Resident #46 was conducted on 11/28/2022 at 11:29AM. The resident indicated she did not recall any staff member reviewing code status with her. A review of Resident #46's physician orders for the month of November 2022 revealed no order for code status. An interview with Nurse #1 was conducted on 11/30/22 at 9:20 AM. She stated Resident #46's code status should be in the electronic medical record. Resident #46's electronic record was reviewed with Nurse #1, and she indicated the code status should be at the top of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.