Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodlands Place Rehabilitation Suites during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and urinary issues underwent catheter insertion after staff obtained a physician's order, but the family and power of attorney were not notified or involved in the decision-making process, despite facility policy and the care plan emphasizing the importance of family involvement. Staff and administration acknowledged the oversight, and family members expressed concern about not being informed.
A nurse failed to maintain sterile technique during the insertion of an indwelling urinary catheter for a resident with multiple medical conditions, including not using a protective drape, not washing hands between glove changes, and not connecting the drainage bag prior to insertion. The facility lacked written policies for catheter insertion, and required sterile procedures outlined in the nursing manual were not followed.
A resident who was cognitively intact and used a wheelchair was given a cup of hot tea by a CNA who did not check the beverage's temperature or provide a lidded cup. While independently moving to a vending machine, the resident spilled the hot tea onto her lap, resulting in a second-degree burn. Staff interviews and record reviews confirmed that required safety protocols, such as temperature checks and the use of lids for hot beverages, were not followed at the time of the incident.
The facility's kitchen failed to properly label and date food items, including sliced smoked ham and bread, and left pies exposed to air. The Dietary Manager acknowledged these issues, noting the risk of serving expired or incorrect items. Additionally, soup was not consistently temperature-checked before serving, contrary to safety protocols.
The facility failed to maintain proper infection control practices, as observed in the actions of an RN and CNAs. An RN cross-contaminated medications by using a gloved hand, contrary to facility policy. A CNA neglected hand hygiene after assisting a resident with dressing and transferring, while two CNAs failed to change gloves and wash hands during incontinence care. These lapses in protocol highlight deficiencies in the facility's Infection Prevention and Control Program.
A facility failed to ensure proper pharmaceutical services for a resident with a G-tube, as an LVN did not check the residual volume before administering medication, contrary to physician orders. The resident, who was moderately cognitively impaired and received nutrition through a feeding tube due to cerebral palsy, was at risk of aspiration and other complications. The LVN used air auscultation instead of the required residual check, an outdated practice confirmed by the DON.
A resident experienced a delay in the diagnosis and treatment of a left intertrochanteric femoral fracture. The facility did not promptly inform the resident, consult with the physician, or notify the resident's family about the change in physical status. Despite complaints of severe pain and additional falls, the X-ray results indicating the fracture were not acted upon for 29 days. Interviews with various staff members, including an LVN, PTA, Nurse Practitioner, and ADON, revealed lapses in communication and follow-up procedures.
A resident experienced a significant delay in the diagnosis and treatment of a left femoral fracture due to multiple failures in communication, documentation, and follow-up. The ADON did not transcribe a physician's order for an X-ray, failed to assess the resident's pain adequately, and did not place the X-ray request on the 24-hour report. Additionally, the responsible party was not notified of the X-ray request and results, and the X-ray results were not effectively communicated to the physician. These deficiencies resulted in ongoing pain, delayed rehabilitation, and hospitalization for the resident.
A facility experienced a significant delay in diagnosing and treating a resident's left intertrochanteric femoral fracture due to a failure in promptly notifying the ordering physician of abnormal x-ray results. Despite the resident's complaints of severe pain and an additional fall, the positive x-ray findings were not communicated to the physician or family, resulting in a 29-day delay in treatment. The facility's system for receiving verbal notifications from the contracted Radiology company was ineffective, contributing to the communication breakdown. Interviews with staff, including the ADON, nursing staff, therapists, and NP, revealed a lack of awareness and follow-up regarding the resident's condition and x-ray results, highlighting gaps in the facility's communication and notification processes.
Failure to Notify Resident's Representative Prior to Catheter Insertion
Penalty
Summary
The facility failed to ensure that a resident's responsible party was involved in the decision-making process prior to the insertion of a catheter. The resident in question was an elderly male with diagnoses including acute prostatitis, benign prostatic hyperplasia, mild cognitive impairment, and a cognitive communication deficit. His face sheet listed family members as emergency contacts, and the care plan indicated it was very important to involve family in care discussions due to his cognitive status. Despite this, when the resident experienced difficulty voiding, the nursing staff obtained a physician's order for a catheter and proceeded with the procedure without notifying or involving the resident's family or legal representatives. Interviews and record reviews revealed that the resident had a BIMS score indicating moderate cognitive impairment and had difficulty communicating his needs. The care plan specifically noted the need to assess the resident's capacity for medical decision-making and to encourage his participation in simple choices. On the day of the incident, the resident repeatedly expressed the need to urinate but was unable to void. After receiving the order for catheterization, the nurse explained the procedure to the resident, who then allowed the catheter to be inserted, despite initially refusing when approached by another nurse. At no point prior to the procedure was the family or the resident's power of attorney contacted, even though family members were present in the facility at the time. Facility policy required notification of the resident's representative or family member regarding significant changes in condition or treatment, and the admissions handbook reiterated this requirement. Both nursing staff and administration acknowledged during interviews that the family should have been contacted before the catheter was placed. The responsible party and family members confirmed they were not notified and expressed concern, especially given the resident's dementia and inability to remember events. The failure to notify and involve the resident's representative in the decision-making process constituted a violation of the resident's rights as outlined in facility policy.
Failure to Maintain Sterile Technique During Catheter Insertion
Penalty
Summary
A deficiency occurred when a nurse failed to follow sterile technique during the insertion of an indwelling urinary catheter for a male resident with a history of obstructive and reflux uropathy, diabetes, and recent orthopedic surgery. The nurse, after preparing supplies and donning personal protective equipment, was observed to be unsure of the procedure, did not use the protective drape, and failed to wash hands after removing dirty gloves before putting on sterile gloves. Additionally, the nurse did not connect the urine drainage bag to the sterile catheter tube prior to insertion, and the drainage bag was not pre-connected as required by standard procedure. The nurse admitted to not maintaining sterile technique and not following the facility's policy and procedure for catheter insertion. The Director of Nursing confirmed that the facility did not have written policies and procedures for catheter insertion and relied on a nursing manual for standards of care. Review of the manual indicated that several required sterile techniques were not followed during the procedure.
Failure to Prevent Burn Injury from Hot Beverage Due to Inadequate Supervision and Safety Measures
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate assistance devices to prevent accidents for two of five residents reviewed for accidents and hazards. Specifically, a cognitively intact female resident who used a wheelchair and required only setup assistance with eating was given a cup of hot tea by a CNA. The CNA prepared the tea using a hot water dispenser, did not check the temperature, and handed the cup directly to the resident while she was in her wheelchair. The resident, while independently moving to a vending machine and holding the cup, accidentally spilled the hot tea onto her lap, resulting in a second-degree burn on her left upper thigh. The incident was discovered when staff assisted the resident with a clothing and brief change and noticed a red, blistered area on her thigh. The resident reported that she had spilled hot tea on herself earlier. The injury was assessed as a 3 cm x 6 cm area with approximately 25% blistering. The resident did not initially report pain and continued her activities until the injury was discovered. The CNA involved acknowledged that she should have placed the tea on a table for the resident rather than handing it to her directly and admitted to not checking the temperature of the beverage before serving it. Interviews and record reviews revealed that prior to the incident, staff, including CNAs and dietary personnel, did not consistently check the temperature of hot beverages before serving them to residents, nor did they ensure the use of lidded cups for residents who were mobile or at risk for spills. The facility's policy required precautions to limit the risk of burns from hot beverages, including temperature checks and the use of lids for at-risk residents, but these procedures were not followed at the time of the incident. The failure to adhere to these safety protocols resulted in the resident sustaining a burn injury from the hot tea.
Food Safety and Labeling Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Specifically, food items in the refrigerator and freezer were not properly labeled or dated. An opened box of sliced smoked ham and an unopened loaf of white sliced bread were found without any date received or used by labels. Additionally, two apple lattice pies were left open to the air, and an opened bag of unidentified frozen squares was found in a box labeled for chicken breast tenders, lacking proper labeling and dating. The Dietary Manager acknowledged these lapses, stating that all items should be labeled with the date received and used within 14 days. Once opened, items should be dated and used within three days. The manager admitted that not labeling items appropriately could lead to residents consuming expired food, posing a risk of illness. The pies were discarded due to improper storage, and the unidentified frozen squares were identified as tater tots, which could lead to serving the wrong items to residents. Furthermore, during food preparation, the Dietary Manager reheated soup in the microwave and took its temperature, but subsequent servings were not temperature-checked before being served. The manager stated that all food should be temperature-checked before serving to ensure safety, as failing to do so could result in bacteria not being killed. The facility's policies and FDA guidelines emphasize the importance of proper labeling, dating, and temperature control to prevent food-borne illnesses.
Infection Control Deficiencies in Medication and Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by several observed deficiencies involving three residents. RN B was observed preparing medication for a resident without adhering to proper infection control protocols. Specifically, RN B used a gloved hand to pop medications from blister packs into a medication cup, which led to cross-contamination. Despite being aware of the facility's policy to avoid touching medications directly, RN B mistakenly believed that using a glove would prevent contamination, but acknowledged the error upon reflection. Another deficiency was observed with CNA D, who failed to perform hand hygiene after assisting a resident with dressing and transferring to a wheelchair. After removing the resident's hospital gown and transferring him, CNA D removed his own gown and gloves but neglected to wash his hands before leaving the room. This lapse was attributed to being rushed to meet a scheduled care plan conference, which led to the oversight in hand hygiene. Additionally, CNAs E and F were observed providing incontinence care to a resident without following proper hand hygiene protocols. Although they initially washed their hands and donned gloves, they failed to change gloves and perform hand hygiene when transitioning from dirty to clean tasks. After completing the care, both CNAs left the resident's room without washing their hands, acknowledging the risk of spreading infection due to their oversight. The facility's policies clearly outline the importance of hand hygiene, yet these practices were not consistently followed by the staff involved.
Failure to Verify G-tube Residual Volume Before Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for a resident receiving medication through a gastrostomy tube (G-tube). The incident involved a resident who was moderately cognitively impaired and received more than half of their total calories through a feeding tube due to cerebral palsy. The physician's orders required checking the residual volume in the stomach before administering medication through the G-tube. However, during a medication pass, the LVN did not check the residual volume as required but instead used air auscultation to verify tube placement. The LVN acknowledged the error, stating that she mistakenly believed that checking residual was no longer necessary. The Director of Nursing (DON) confirmed that the LVN was an experienced nurse but had reverted to an outdated practice of using air auscultation. The facility's procedure for enteral tube drug instillation required verifying tube placement using at least two methods, including aspirating tube contents. The failure to check residual volume before administering medication placed the resident at risk of aspiration, vomiting, or incomplete medication administration if the tube was blocked or obstructed.
Delayed Diagnosis and Treatment of Femoral Fracture
Penalty
Summary
The report details a significant deficiency in a long-term care facility where a resident (Resident #1) experienced a delay in diagnosis and treatment of a left intertrochanteric femoral fracture. The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident's family or representative about the change in the resident's physical status. Despite Resident #1's complaints of excruciating pain and additional falls, the facility did not act promptly on the X-ray results that showed the fracture. The Assistant Director of Nursing (ADON A) failed to read the X-ray results, notify/consult the physician, or inform the resident's family about the fracture, leaving Resident #1 with an undiagnosed and untreated fracture for 29 days. Various staff members, including LVN F, PTA S, the Nurse Practitioner, and the ADON A, were interviewed regarding the events leading to the deficiency. LVN F acknowledged the failure to follow up on the X-ray results and expressed surprise at the fracture diagnosis. PTA S mentioned reporting Resident #1's complaints of pain and falls but was unaware of the fracture. The Nurse Practitioner vaguely remembered Resident #1 and did not recall ordering the X-rays. ADON A admitted to not recalling the events leading to the X-ray request and acknowledged the lack of proper follow-up procedures.
Communication and Documentation Failures Lead to Delayed Diagnosis of Femoral Fracture
Penalty
Summary
The facility failed to ensure the resident's right to be free from neglect for Resident #1, as evidenced by multiple failures in communication, documentation, and follow-up related to the resident's care. ADON A did not transcribe a physician's order for an X-ray for Resident #1's left femur, failed to assess the resident's pain adequately, did not place the X-ray request on the 24-hour report, and did not notify the responsible party of the X-ray request and results. Additionally, facility staff did not effectively communicate the X-ray results to the physician, leading to a delayed diagnosis of a left femoral fracture for Resident #1. The deficiencies in communication and documentation resulted in a significant delay in the diagnosis and treatment of Resident #1's left femoral fracture. Despite Resident #1's complaints of excruciating pain and an additional fall on 01/15/24, the facility failed to investigate thoroughly and promptly. This failure led to a delayed diagnosis, ongoing pain, delayed rehabilitation, and ultimately, hospitalization for Resident #1. The lack of proper communication and follow-up also put the resident at risk of further harm, including death, bleeding, and increased severity of the initial fracture.
Delayed Notification of Abnormal X-Ray Results Leading to Prolonged Undiagnosed Fracture
Penalty
Summary
The facility failed to promptly notify the ordering physician of abnormal x-ray results for Resident #1, leading to a significant delay in diagnosing and treating a left intertrochanteric femoral fracture. Despite Resident #1's complaints of excruciating pain and an additional fall, the facility did not inform the physician or family about the positive x-ray results on 01/18/24, which showed the fracture. This lack of timely communication resulted in Resident #1 remaining undiagnosed and untreated for 29 days, ultimately leading to delayed medical treatment, ongoing pain, and increased risk of complications such as bleeding and death. The failure to have a system in place to ensure prompt receipt of verbal notification from the contracted Radiology company further exacerbated the situation. The facility's records indicated that the x-ray results were received on 01/18/24, but there were unsuccessful attempts to notify the facility of the positive findings. This breakdown in communication highlights a critical gap in the facility's processes for ensuring timely and accurate reporting of diagnostic test results to the ordering practitioner, ultimately compromising Resident #1's care and safety. Multiple interviews with facility staff, including the Assistant Director of Nursing (ADON A), nursing staff, therapists, and the Nurse Practitioner (NP), revealed a lack of awareness and follow-up regarding Resident #1's condition and the x-ray results. ADON A admitted to not recalling the events surrounding the x-ray request and failing to ensure proper documentation and notification procedures were followed. The NP vaguely remembered Resident #1 and did not recall ordering the x-rays, indicating a breakdown in communication and oversight among the facility's clinical staff. These interviews shed light on the various points of failure within the facility's communication and notification processes, ultimately resulting in the deficiency identified during the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Denison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Terrace At Denison | 1.3 mi | — | 21 | 0 |
| Denison Nursing And Rehab | 1.5 mi | — | 3 | 0 |
| The Homestead Of Denison | 1.6 mi | — | 9 | 0 |
| Beacon Hill | 2 mi | — | 8 | 0 |
| Texoma Healthcare Center | 6.2 mi | — | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.