WOODLAND MANOR NURSING AND REHABILITATION LP

Nursing Home Inspector

99 RIGBY OWEN RD
CONROE, TX 77304
Montgomery County
Phone: 936-756-1240
Provider Number: 675229
Last Inspection: 08/03/2017

About the Nursing Home

Number of Beds: 146
Number of Residents: 53
Beds Available: 93
Percent Occupancy: 36%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

20

Facility 		19

County 		22

TX 		20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 
20

2017		 20

2016		 19

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

8/3/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Pattern : Minimal 4 9/4/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 9/1/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 9/4/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 9/1/2017
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Pattern : Minimal 4 9/4/2017
 

7/8/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 8/4/2016
 
Failed To: Ensure that residents are safe from serious medication errors. Pattern : Minimal 4 8/4/2016
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Pattern : Minimal 4 8/4/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 8/4/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 8/4/2016
 

9/3/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 10/19/2015
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 10/19/2015
 
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 10/31/2015
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Pattern : Minimal 4 10/19/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 10/19/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

5/5/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. Pattern : Minimal 4 5/26/2017
 

9/15/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 10/3/2016
 

5/5/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Permit residents to remain in the facility and not be transferred or discharged without adequate reason. Pattern : Minimal 4 5/27/2016
 
Failed To: Provide timely notification to the resident before transfer or discharge. Pattern : Minimal 4 5/27/2016
 

4/5/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Minimal 4 5/2/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 5/2/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Pattern : Minimal 4 5/2/2016
 

2/16/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Widespread : Immediate 7 3/9/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Widespread : Immediate 7 3/9/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Immediate 7 3/9/2016
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Widespread : Immediate 7 3/9/2016
 

10/9/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 11/13/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 11/13/2015
 

6/24/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 7/13/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg TX State Avg
Number of Residents 53 78.60 75.11
Registered Nurses 0.38 0.56 0.59
Licensed Practical / Vocational Nurses 1.02 0.80 0.94
Certified Nursing Assistants 2.51 2.00 2.20
Total Staff Hours 3.90 3.35 3.73

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% TX State Avg%
of high risk long-stay residents with pressure ulcers 4 6 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 89 90 91
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 89 90 92
of long-stay residents experiencing one or more falls with major injury 2 3 3
of long-stay residents who have depressive symptoms 1 3 3
of long-stay residents who lose too much weight 9 6 5
of long-stay residents who received an antianxiety or hypnotic medication 24 24 26
of long-stay residents who received an antipsychotic medication 27 15 17
of long-stay residents who self-report moderate to severe pain 3 2 5
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 25 20 20
of long-stay residents whose need for help with daily activities has increased 19 16 18
of long-stay residents with a catheter inserted and left in their bladder 1 2 2
of long-stay residents with a urinary tract infection 1 3 3
of low risk long-stay residents who lose control of their bowels or bladder 34 49 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 49 72 77
of short-stay residents who had an outpatient emergency department visit 20 13 13
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 69 59 59
of short-stay residents who were rehospitalized after a nursing home admission 38 1 2
of short-stay residents with pressure ulcers that are new or worsened 0 8 12