Inspection Reports for
The Woodlands Healthcare Center
144 THAD BAILES RD, LEESVILLE, LA, 71446
Back to Facility Profile6 Reports
Inspection Report — Sep 4, 2025
Routine CMS
Date: Sep 4, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, infection control, care planning, respiratory care, and other professional standards at The Woodlands Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care and timely assistance with meals and incontinence care, incomplete and outdated care plans, improper respiratory care including unlabeled wound dressings and oxygen orders not followed, inadequate infection prevention practices including improper use of PPE and hand hygiene, and failure to maintain proper wound care procedures.
Deficiencies (7)
F 0550: The facility failed to ensure Resident #2 received incontinence care before meal service and Resident #27 was served her meal with other residents at the lunch table.
F 0578: The facility failed to honor Resident #7's right to request, refuse, or discontinue treatment and to formulate an advance directive, as the care plan did not reflect the resident's DNR status.
F 0656: The facility failed to develop and implement a complete care plan for Resident #9 that included suctioning as ordered by the physician.
F 0657: The facility failed to revise Resident #7's care plan within 7 days of the comprehensive assessment to reflect the DNR order.
F 0658: The facility failed to ensure proper physician orders for oxygen therapy for Resident #100 and proper labeling of wound dressings for Resident #100.
F 0695: The facility failed to provide respiratory care consistent with professional standards for Resident #73, as oxygen tubing was found on the floor without proper storage.
F 0880: The facility failed to maintain an infection prevention and control program, including failure to use Enhanced Barrier Precautions for Resident #102, improper hand hygiene and glove use during meal service, and failure to follow infection control practices during wound care for Resident #2.
Report Facts
Residents sampled: 39
Residents affected: 14
Residents served improperly: 11
Oxygen therapy dates: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S13 CNA | Certified Nursing Assistant | Named in failure to serve Resident #27 meal with others |
| S12 LPN | Licensed Practical Nurse | Unaware Resident #27 was not served with other residents |
| S10 CNA | Certified Nursing Assistant | Attempted to feed Resident #2 breakfast |
| S9 LPN | Licensed Practical Nurse | Confirmed Resident #2 should have received incontinence care before breakfast |
| S2 DON | Director of Nursing | Confirmed care plan and infection control deficiencies and expectations |
| S15 LPN | Licensed Practical Nurse | Confirmed Resident #7's care plan not updated to reflect DNR status |
| S4 LPN | Licensed Practical Nurse | Confirmed wound dressing unlabeled and oxygen orders not followed for Resident #100 |
| S5 TX Nurse | Treatment Nurse | Observed improper wound care glove use for Resident #2 |
| S11 LPN | Licensed Practical Nurse | Confirmed oxygen tubing improperly stored for Resident #73 |
| S6 CNA | Certified Nursing Assistant | Admitted failure to wear gown and gloves for Enhanced Barrier Precautions |
| S3 IP Nurse | Infection Prevention Nurse | Confirmed staff education and expectations for Enhanced Barrier Precautions |
| S7 CNA | Certified Nursing Assistant | Observed failing to follow proper hand hygiene and glove use during meal service |
| S8 DM | Dietary Manager | Confirmed proper meal service hygiene procedures and deficiencies observed |
Inspection Report — Sep 4, 2025
Routine CMS
Date: Sep 4, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, dignity, and respiratory care at The Woodlands Healthcare Center.
Findings
The facility failed to ensure two residents received proper dignity and care during meal service and incontinence care, and failed to provide safe respiratory care by not properly labeling and storing oxygen equipment.
Deficiencies (2)
F 0550: The facility failed to ensure Resident #2 received incontinence care before meal service and Resident #27 was served her meal with other residents at the lunch table, compromising dignity and quality of life.
F 0695: The facility failed to provide safe respiratory care for Resident #73 by not properly labeling and storing oxygen tubing, which was found lying on the floor without a bag.
Report Facts
Residents sampled: 39
Residents affected: 2
Residents reviewed for respiratory care: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S13 CNA | Interviewed regarding meal service for Resident #27 | |
| S12 LPN | Interviewed regarding meal service for Resident #27 | |
| S10 CNA | Interviewed regarding feeding Resident #2 | |
| S9 LPN | Confirmed incontinence care omission for Resident #2 | |
| S2 DON | Confirmed Resident #2 should have received incontinence care prior to feeding | |
| S11 LPN | Confirmed oxygen tubing was not properly stored for Resident #73 |
Inspection Report — Jan 29, 2025
Routine CMS
Date: Jan 29, 2025
Visit Reason
The inspection was conducted to assess compliance with medication storage and administration policies in the facility.
Findings
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that medication carts were locked when unattended. Medication keys were left accessible to unauthorized personnel, posing a risk to resident safety.
Deficiencies (1)
F 0761: The facility failed to store all drugs and biologicals in locked compartments and left an unattended medication cart unlocked with keys accessible to unauthorized personnel. This practice affected 137 residents currently residing in the facility.
Report Facts
Residents affected: 137
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3 LPN | Licensed Practical Nurse | Confirmed medication cart was unlocked and unattended |
| S2 RN | Registered Nurse | Responsible for medication cart left unattended and unlocked |
| S1 DON | Director of Nursing | Confirmed medication carts should always be locked when unattended |
Inspection Report — Jun 25, 2024
Routine CMS
Date: Jun 25, 2024
Visit Reason
The inspection was conducted to assess compliance with medication administration protocols and infection prevention and control standards at The Woodlands Healthcare Center.
Findings
The facility failed to maintain a medication error rate below 5%, with a 10% error rate observed involving failure to administer two medications as ordered and administering a discontinued medication. The facility also failed to maintain an effective infection prevention and control program by not performing proper hand hygiene during wound care and not posting required Enhanced Barrier Precautions signage for a resident with pressure ulcers.
Deficiencies (2)
F0759: The facility failed to maintain a medication error rate below 5% by not administering two medications as ordered and administering a discontinued medication to Resident #37 during medication administration.
F0880: The facility failed to perform proper hand hygiene during wound care and did not post Enhanced Barrier Precautions signage for Resident #292, compromising infection prevention and control.
Report Facts
Medication error rate: 10
Medication opportunities observed: 30
Medication errors observed: 3
Residents reviewed for Enhanced Barrier Precautions: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S4 LPN | Administered medications incorrectly to Resident #37 and unaware of discontinued medication. | |
| S1 Treatment Nurse | Failed to perform proper hand hygiene during wound care for Resident #292. | |
| S2 DON | Confirmed proper hand hygiene protocol during wound care. | |
| S3 Infection Preventionist | Responsible for ensuring staff awareness of Enhanced Barrier Precautions and confirmed lack of signage for Resident #292. |
Inspection Report — Oct 25, 2023
CMS
Date: Oct 25, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to resident rights, food service quality and safety, and food storage practices at The Woodlands Healthcare Center.
Findings
The facility failed to respond to resident grievances regarding cold food served at meal stations, served food at unsafe temperatures below regulatory standards, and improperly stored and labeled food items including expired and contaminated products. These deficiencies posed potential harm to residents.
Deficiencies (3)
F 0565: The facility failed to ensure a response and rationale for grievances reported during Resident Council Meetings regarding cold food served at hall serving stations.
F 0804: The facility failed to ensure food served to residents was palatable and served at a safe temperature, with multiple hot food items served below 135 degrees Fahrenheit.
F 0812: The facility failed to store and serve food in accordance with professional standards, including the presence of expired, moldy, and improperly labeled food items.
Report Facts
Residents reviewed for dietary services: 5
Resident Council Meetings reviewed: 4
Food temperature readings below standard: 7
Expired or contaminated food items observed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Acknowledged lack of response to resident grievances and confirmed food temperature monitoring deficiencies |
| S3 Dietary Manager | Dietary Manager | Confirmed failure to address resident complaints about cold food and provided food temperature logs |
| S10 Activity Director | Activity Director | Reported resident complaints about cold food during Resident Council meetings |
| S11 CNA | Certified Nursing Assistant | Reported checking food temperatures and stated hot foods should be served at 120 degrees or above |
| S9 RN | Registered Nurse | Confirmed hot foods served below required temperature and that items should have been reheated |
| S8 [NAME] Help | Food Service Helper | Confirmed observations of expired and contaminated food items in storage |
Inspection Report — Jun 13, 2023
Routine CMS
Date: Jun 13, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of quality and respiratory care for residents, including medication administration and oxygen therapy.
Findings
The facility failed to ensure proper physician orders for nebulizer treatments and oxygen therapy for certain residents. Additionally, respiratory equipment such as humidified water bottles, nasal cannulas, and nebulizer masks were not properly maintained, dated, or stored according to policy.
Deficiencies (2)
F 0658: The facility failed to obtain a physician's order to administer a nebulizer treatment for Resident #121, despite the treatment being given.
F 0695: The facility failed to provide safe and appropriate respiratory care for Residents #108 and #136, including lack of physician orders for oxygen therapy and improper maintenance and storage of respiratory equipment.
Report Facts
Residents reviewed for respiratory care: 4
Total sample size: 47
Ampules of Duo-neb nebulizer treatments: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 DON | Interviewed regarding lack of physician order for nebulizer treatments for Resident #121 and oxygen therapy orders for Resident #108 | |
| S3 LPN | Nurse for Resident #121 who administered nebulizer treatments without a current order | |
| S2 LPN | Interviewed about improper storage and maintenance of oxygen equipment and nebulizer masks | |
| S1 DON | Confirmed issues with oxygen orders and equipment maintenance for Resident #108 |
Viewing
Loading inspection reports...
