I'm glad we chose Woodlands - the facility is clean, odor-free, welcoming, and comfortable. The staff were professional, compassionate, and responsive (special thanks to Adrienne Moore, Tammy Reed, Laquita Clark, Adam, Roberta Jones and Maria); nursing, PT and OT provided excellent rehab and personalized care. Overall I was very pleased with the respectful safety measures and family-feel service and would recommend Woodlands for rehab or long-term care.
Loved one of resident
Jul 2026
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Amenities
Healthcare services
Activities of daily living assistance
Assistance with bathing
Assistance with dressing
Assistance with transfers
Medication management
Mental wellness program
Healthcare staffing
12-16 hour nursing
24-hour call system
24-hour supervision
Meals and dining
Diabetes diet
Meal preparation and service
Restaurant-style dining
Special dietary restrictions
Room
Air-conditioning
Cable
Fully furnished
Housekeeping and linen services
Kitchenettes
Private bathrooms
Telephone
Wifi
Transportation
Community operated transportation
Transportation arrangement
Transportation arrangement (non-medical)
Common areas
Beauty salon
Computer center
Dining room
Fitness room
Gaming room
Garden
Outdoor space
Small library
Wellness center
Community services
Concierge services
Fitness programs
Move-in coordination
Activities
Community-sponsored activities
Planned day trips
Resident-run activities
Scheduled daily activities
Reviews
3.99·(147)
Overall rating
5
4
3
2
1
Care
2.9
Staff
3.9
Meals
2.6
Amenities
3.0
Value
1.5
Pros
Strong physical and occupational therapy services
Compassionate and attentive direct-care staff
Friendly and helpful front-desk and administrative team
Clean, well-maintained common areas and rooms
Accessible therapy gym and rehabilitation equipment
Efficient rehabilitation coordination and discharge assistance
Supportive social-services assistance
Skilled individual clinicians in wound care and nursing
Prompt clinical medication adjustments by advanced practitioners
Comfortable semi-private rooms with natural light
Available activities and engagement options
Helpful admissions and paperwork support
Cons
Inconsistent staffing levels and high staff turnover
Delays in responding to call lights and medication administration
Gaps in clinical documentation and family communication
Weak safety and supervision practices for residents with cognitive impairment
Inconsistent wound-care and infection-control practices
Security and personal-property controls deficiencies
Variable staff conduct and professionalism
Inconsistent meal quality and portioning practices
Housekeeping and laundry service inconsistencies
Front-desk and telephone communication inefficiencies
Summary of reviews
Reviews of Woodlands Rehabilitation and Healthcare Center present a polarized picture: many accounts praise the facility’s rehabilitation capabilities and individual caregivers, while other accounts raise substantive operational and safety concerns. Physical and occupational therapy services receive consistent positive remarks for helping patients regain function; reviewers frequently cited an accessible therapy gym, effective therapy staff, and good discharge coordination. Several families and patients also singled out specific clinicians and administrative staff for helpfulness, assistance with paperwork, and responsiveness to clinical questions.
Care quality and clinical practice show wide variability across accounts. Positive reports describe compassionate, attentive nursing and CNAs and timely clinical adjustments by advanced practitioners. Conversely, other reviews describe delays in call-light responses and medication timing, inconsistent wound care, and concerns about supervision of residents with dementia or mobility limitations. There are also serious individual allegations, including concerns following a resident’s death and an allegation of improper restraint linked to a cardiac event; these items underscore the need for careful review of clinical-incident handling and documentation.
Staffing and staff conduct emerge as recurrent themes. Many reviewers praised friendly front-desk and administrative personnel and named CNAs and nurses who provided exceptional care. At the same time, there are repeated complaints about inconsistent staffing levels, high turnover, rude or unprofessional interactions, and instances where night coverage or CNAs did not respond promptly. These patterns suggest uneven training, supervision, and staffing stability that affect resident experience and perceived safety.
Dining, housekeeping, and facility upkeep are similarly mixed. Common areas and hallways are often described as clean and odor-free, and individual rooms are sometimes praised for comfort and natural light. However, multiple accounts note inconsistent meal quality, under-portioned or poorly prepared meals, and delays in meal service. Housekeeping and laundry services have occasional backlogs or inconsistencies, and a few reviews mention odor concerns or maintenance issues such as broken blinds.
Safety, security, and property controls are notable areas of concern. Reviews reference missing personal items and perceived security gaps, leading to suggestions for improved lockable storage and property safeguards. A small number of reviews also raise concerns about suspected impaired staff behavior and serious clinical incidents; these warrant investigation by facility leadership and oversight bodies to assess policy adherence and staff monitoring.
Management and communication responses are variable. Several families praised administrative assistance with admissions and placement and named social-services staff who were helpful. Other reviewers found management unresponsive when addressing clinical incidents, documentation requests, and family communications. Recurrent mentions of inconsistent charting and difficulty obtaining records point to opportunities to strengthen documentation practices and family-facing communication protocols.
Overall, Woodlands appears to offer strong rehabilitation resources and has individual staff members who deliver high-quality, compassionate care. At the same time, recurring operational weaknesses — most notably inconsistent staffing, variable clinical responsiveness, gaps in wound-care and infection-control practices, and security/documentation issues — produce markedly different experiences for different residents. Prospective residents and families should weigh the facility’s rehabilitation strengths against these operational concerns, ask specific questions about staffing ratios, incident protocols, wound-care processes, property-security measures, and documentation access, and consider visiting during different shifts to gauge consistency before making placement decisions.
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Medicare Ratings
2·/ 5
Overall
Health Inspection
Staffing
Quality Measures
Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov
Location
Woodlands Rehabilitation and Healthcare Center is located at 102 Woodchase Park Dr, Clinton, MS, 39056.
About Woodlands Rehabilitation and Healthcare Center
Woodlands Rehabilitation and Healthcare Center, also known as Nexion Woodlands Rehab and Healthcare, sits over on 102 Woodchase Park Dr in Clinton, Mississippi, operated by Nexion Health, and offers a mix of skilled nursing, long-term care, assisted living, and specialized Alzheimer's/memory care programs all under one roof, so people with different care needs can feel safe and supported in one place instead of having to move around, and the center's got beds for up to 145 residents, with room types including studios and semi-private or share/companion rooms, and you'll find that the atmosphere is meant to be warm and inviting, with comfortable living spaces and access to outdoor areas which helps folks feel more at home, and it's a place where pets are allowed too, which a lot of folks appreciate since it makes things feel friendlier and less lonely.
You'll find the team's made up of nursing, therapy, and interdisciplinary care professionals, and they work round-the-clock to provide skilled nursing care, handle medication, and assist with activities of daily living like bathing, dressing, or eating, plus they've got specialists who focus on dementia and Alzheimer's care and create tailored wellness and care plans based on each resident's needs, and the care staff also manage wound care for folks with chronic or complex wounds. There's a strong focus on rehabilitation too, with therapy services like physical, occupational, and speech therapy on site-including special swallowing assessments with the Modified Barium Swallow Study to help those who need it eat and drink safely-and for anyone needing a short stay, say after surgery or an illness, the center also offers short-term rehab with the help of telemedicine for remote consultations and quick care decisions, and they're able to admit new residents at any hour of the day or night.
Woodlands has a range of community activities and programs to help keep residents engaged, and you'll find the place strives to create a supportive, compassionate environment where people can feel comfortable and maintain their dignity, and being the second-highest rated community out of four in Clinton with an average score of 8.6 out of 10 shows many folks feel positively about their care, and being federally approved for Medicare and Medicaid helps residents stay without extra worries about payment, and the skilled nursing home care level, with 24-hour nurse staffing and physician oversight, meets the needs of folks looking for both ongoing support and specialized programs in a Fair Housing & Equal Opportunity Provider facility.
People often ask...
Woodlands Rehabilitation and Healthcare Center offers assisted living, memory care, and skilled nursing.
There are 26 photos of Woodlands Rehabilitation and Healthcare Center on Mirador.
The full address for this community is 102 Woodchase Park Dr, Clinton, MS 39056.
No, Woodlands Rehabilitation and Healthcare Center does not offer respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
Safety & Compliance
In Mississippi, the State Department of Health licenses care facilities and publishes the survey, complaint, and infection-control reports from its inspections.
License number
nh-255148
Facility type
Nursing Home
Special certification
Medicaid/Medicare – Dually certified
Inspection Reports
111
Reports
2
Type A Citations
1
Type B Citations
73
Complaints
8
Years
01 Jun 2026Revisit
01 Jun 2026Revisit
Determined the facility was back in compliance with minimum standards after a desk review of a complaint, following the prior survey findings.
01 Jun 2026Revisit
01 Jun 2026Revisit
Verified that corrective actions were implemented to address the deficiency and sustain compliance. The agency recommended restoring compliance effective 2026-05-29.
01 Apr 2026Complaint
01 Apr 2026Complaint
Investigated complaints found violations of residents' rights and care practices, including privacy during care, call-light placement, and incontinent care procedures.
45.17.2Residents' Rights
45.21.4Urinary incontinence
01 Apr 2026Complaint
01 Apr 2026Complaint
Investigated a complaint and found violations related to resident rights, privacy during care, call light accessibility, and incontinence care.
42 CFR 483.10(a)(1)(2)(b)(1)(2); 42 CFR 483.10(b)(1)-(2)Resident Rights/Exercise of Rights
42 CFR 483.25(e)Bowel/Bladder Incontinence, Catheter, UTI
01 Mar 2026Complaint
01 Mar 2026Complaint
Investigated a complaint about a resident waiting four hours for nurse care and found no violations cited.
01 Mar 2026Complaint
01 Mar 2026Complaint
Investigated a complaint alleging a resident waited four hours for nurse care and found no deficiencies.
01 Nov 2025Complaint
01 Nov 2025Complaint
Investigated a complaint about accommodation of needs and found no deficiencies.
01 Nov 2025Complaint
01 Nov 2025Complaint
Investigated a complaint about accommodation of needs and found no deficiencies.
01 Sept 2025Complaint
01 Sept 2025Complaint
Confirmed compliance after a follow-up visit; no deficiencies cited.
01 Sept 2025Complaint
01 Sept 2025Complaint
Investigated misappropriation and abuse/neglect complaints; found no deficiencies cited in this review, but remained out of compliance due to deficiencies cited on a prior survey.
01 Sept 2025Complaint
01 Sept 2025Complaint
Verified compliance with Medicare and Medicaid participation after a follow-up visit; placed back in compliance.
01 Sept 2025Complaint
01 Sept 2025Complaint
Investigated complaints related to misappropriation and abuse; found no deficiencies during this survey. Remained out of compliance due to deficiencies cited in an earlier survey.
01 Aug 2025Inspection
01 Aug 2025Inspection
Investigated; found failures in informing residents about advance directives, supervising bathing to prevent accidents, proper medication labeling/storage, and infection control practices.
M0500 - Residents' RightsResidents' Rights
M0640 - AccidentsAccidents
M0715 - Labeling of drugsLabeling of drugs
M1570 - Infection ControlInfection Control
01 Aug 2025Complaint
01 Aug 2025Complaint
Investigated multiple resident care and safety issues, including advance directives, care planning, fall and infection prevention, dialysis transport, medication management, and recordkeeping, resulting in several deficiencies identified.
§483.10(c)(6); §483.10(c)(8); §483.10(g)(12)Advance directives information/Resident rights
§483.21(b)(1); §483.21(b)(3)Develop/Implement Comprehensive Care Plan
§483.25(d)(1); §483.25(d)(2)Free of Accident Hazards/Supervision/Devices
§483.25(l)Dialysis
§483.45(f)Free of Medication Error Rates
§483.45(g); §483.45(h)(1)-(2)Labeling/Storage of Drugs and Biologicals
§483.20(f)(5); §483.70(h)(1)-(5)Resident Records - Identifiable Information
§483.80(a)(1); §483.80(a)(2); §483.80(a)(4); §483.80(e); §483.80(f)Infection Prevention & Control
01 Aug 2025Complaint
01 Aug 2025Complaint
Investigated identified multiple deficiencies: residents were not informed about advance directives or offered assistance to form one; an individual’s bathing care lacked needed supervision; a medication was left unsecured; and infection control practices, including hand hygiene and enhanced barrier precautions, were not consistently followed.
General Residents' Rights (Mississippi licensure regulation)Residents' Rights
45.21.8Accidents
Labeling of drugs (Mississippi Board of Pharmacy)Labeling of drugs
48.58.1Infection Control
01 Aug 2025Inspection
01 Aug 2025Inspection
Identified multiple deficiencies across resident rights, care planning, safety, transportation for dialysis, medication management, infection control, and medical records.
CFR §483.10(c)(6)-(8), §483.10(g)(12)Advance directives rights and information
CFR §483.21(b)(1)-(3)Develop/Implement Comprehensive Care Plan
CFR §483.25(d)(1)-(2)Free of Accident Hazards/Supervision/Devices - Accidents
CFR §483.25(l)Dialysis
CFR §483.45(f)Free of Medication Error Rates 5 Percent or More
CFR §483.45(g)-(h), §483.70(h)Label/Store Drugs and Biologicals
CFR §483.20(f)(5), §483.70(h)(1)-(5)Resident Records - Identifiable Information
CFR §483.75Quality Assurance and Performance Improvement (QAPI)
CFR §483.80(a)-(f)Infection Prevention & Control
01 Aug 2025Inspection
01 Aug 2025Inspection
Found no deficiencies. Emergency preparedness requirements were met.
01 Mar 2025Complaint
01 Mar 2025Complaint
Investigated elopement incident; found inadequate supervision allowed a vulnerable resident to leave the premises unsupervised, but corrective actions were implemented and compliance with standards documented.
45.21.8Accidents
01 Mar 2025Complaint
01 Mar 2025Complaint
Investigated a resident elopement and found inadequate supervision, resulting in the resident leaving the premises unsupervised with initial jeopardy, later resolved after corrective actions.
42 CFR 483.25(d)(1)(2)Free of Accident Hazards/Supervision/Devices
01 Feb 2025Complaint
01 Feb 2025Complaint
Investigated a case of staff-initiated physical and emotional abuse toward a resident and found a violation of residents' rights.
45.17.2Residents' Rights
01 Feb 2025Complaint
01 Feb 2025Complaint
Investigated an abuse incident and a delay in reporting; found violations of abuse prevention and mandated reporting requirements.
Type A42 CFR 483.12Freedom from Abuse, Neglect, and Exploitation
c42 CFR 483.12Reporting of Alleged Violations
01 Oct 2024Revisit
01 Oct 2024Revisit
Concluded that the facility was back in compliance after reviewing the complaint information. No deficiencies were cited.
01 Oct 2024Revisit
01 Oct 2024Revisit
Concluded that compliance was restored. The agency recommended placing the provider back in compliance.
01 Sept 2024Complaint
01 Sept 2024Complaint
Investigated a complaint and found deficiencies in daily living activities, equipment maintenance, and resident room environments.
45.21.2Activities of daily living
45.31.9Equipment and Utensil Construction
45.35.3Resident Bedrooms
01 Sept 2024Complaint
01 Sept 2024Complaint
Investigations found deficiencies in maintaining a safe, clean, and homelike environment, implementing care plans, providing timely incontinence care, and ensuring equipment was safe to use.
Investigation found failures to notify the physician about severe pain and to provide timely pain medication for a resident after admission.
483.10(g)(14) (Notification of Changes); 483.10(g)(15) (Admission to a composite distinct part).Notify of Changes
483.25(k)Pain Management
01 Jun 2024Revisit
01 Jun 2024Revisit
Verified compliance after a follow-up visit; adherence to Medicare/Medicaid participation requirements was confirmed.
01 Jun 2024Revisit
01 Jun 2024Revisit
Determined that corrective actions placed the facility back in compliance with the applicable standards, but deficiencies from a prior survey remained.
01 Jun 2024Complaint
01 Jun 2024Complaint
Investigated a complaint alleging quality-of-care concerns related to a resident left wet for extended periods and neglect, and found no deficiencies.
01 Jun 2024Revisit
01 Jun 2024Revisit
Verified compliance was achieved as of 06/19/2024. However, it remained out of compliance due to deficiencies cited on 06/06/2024 survey.
01 Jun 2024Revisit
01 Jun 2024Revisit
Confirmed compliance with Medicare/Medicaid participation after a follow-up review. Compliance was restored.
01 Apr 2024Complaint
01 Apr 2024Complaint
Determined noncompliance with state licensure standards during the recertification review and a deficiency was cited.
—Minimum Standards for Institutions for the Aged or Infirm (state licensure requirement)
01 Apr 2024Inspection
01 Apr 2024Inspection
Identified an infection control lapse in transporting soiled laundry, potentially spreading infection. The finding was documented as a Level II deficiency.
48.58.1Infection Control
01 Apr 2024Inspection
01 Apr 2024Inspection
Investigated multiple deficiencies in resident assessments, PASARR coordination, care planning, medication administration, infection control, and handling of soiled laundry.
CFR 483.20(g)Accuracy of Assessments
CFR 483.20(e)(1)-(2)Coordination of PASARR and Assessments
CFR 483.21(b)(2)Care Plan Timing and Revision
CFR 483.45(f)(1)Medication Errors
CFR 483.80(a)-(f)Infection Prevention & Control
01 Apr 2024Complaint
01 Apr 2024Complaint
Investigated care plan updates and AV shunt dressing management; found failures to update care plans timely and to follow dialysis aftercare orders.
42 CFR 483.21(b)(2)Care Plan Timing and Revision
42 CFR 483.25(l)Dialysis
01 Apr 2024Inspection
01 Apr 2024Inspection
Found no deficiencies related to emergency preparedness following the survey.
01 Apr 2024Inspection
01 Apr 2024Inspection
Found no deficiencies. The survey concluded compliance with applicable life safety code requirements.
01 Mar 2024Complaint
01 Mar 2024Complaint
Investigated the wrongful discharge allegation and found no deficiencies.
01 Mar 2024Complaint
01 Mar 2024Complaint
Found no deficiencies related to the wrongful discharge allegation.
01 Mar 2024Complaint
01 Mar 2024Complaint
Investigated a complaint alleging failure to take a resident to scheduled therapy appointments and honor resident choices; found no deficiencies.
01 Mar 2024Complaint
01 Mar 2024Complaint
Investigated a complaint about failing to take a resident to scheduled therapy appointments and honoring resident choices; found no deficiencies.
01 Dec 2023Complaint
01 Dec 2023Complaint
Investigated three complaints and found no deficiencies cited.
01 Dec 2023Complaint
01 Dec 2023Complaint
Concluded that the establishment was in compliance with the standards and no deficiencies were cited.
01 Aug 2023Revisit
01 Aug 2023Revisit
Determined no deficiencies were cited after reviewing information related to a complaint, and placed back in compliance.
01 Aug 2023Revisit
01 Aug 2023Revisit
Determined substantial compliance with Medicare/Medicaid participation requirements; no deficiencies cited.
01 Jun 2023Complaint
01 Jun 2023Complaint
Found that a resident with limited range of motion did not receive prescribed restorative care to maintain ROM, including the resting hand splints not being applied as ordered.
45.21.5Range of motion
01 Jun 2023Complaint
01 Jun 2023Complaint
Investigated complaints found failures to implement a comprehensive, resident-centered care plan and to maintain mobility for a resident with limited range of motion.
483.21(b)(1)-(3)Comprehensive Care Plans
483.25(c)(1)-(3)Mobility
01 May 2023Complaint
01 May 2023Complaint
Investigated a complaint and found no deficiencies.
01 May 2023Complaint
01 May 2023Complaint
Investigated a complaint and found no deficiencies.
01 Sept 2022Complaint
01 Sept 2022Complaint
Investigated a complaint and did not substantiate the discharge and notification allegation. Found no deficiencies in this investigation, but noted ongoing noncompliance from the 7/14/2022 survey.
01 Sept 2022Revisit
01 Sept 2022Revisit
Concluded that the facility was back in compliance after review.
01 Sept 2022Revisit
01 Sept 2022Revisit
Concluded that the facility was in compliance with the minimum standards after review; recommended placing back in compliance effective 08/15/22.
01 Sept 2022Revisit
01 Sept 2022Revisit
Recommended placing back in compliance after a desk review.
01 Sept 2022Revisit
01 Sept 2022Revisit
Found no deficiencies cited in the emergency preparedness review.
01 Sept 2022Revisit
01 Sept 2022Revisit
Verified compliance and recommended restoring compliance after a follow-up visit.
01 Sept 2022Complaint
01 Sept 2022Complaint
Investigated a complaint and found it not substantiated with no deficiencies cited in this investigation; however, ongoing Medicare/Medicaid participation noncompliance remained due to deficiencies cited on a prior survey conducted on 7/14/2022.
01 Sept 2022Revisit
01 Sept 2022Revisit
Concluded that the provider was placed back in compliance with participation requirements after corrective actions.
01 Sept 2022Revisit
01 Sept 2022Revisit
Concluded that the provider should be placed back in compliance following a desk review. No deficiencies were identified in this document.
01 Sept 2022Revisit
01 Sept 2022Revisit
Determined the provider was back in compliance after a desk review of information related to a prior survey; no deficiencies were cited.
01 Jul 2022Inspection
01 Jul 2022Inspection
Found that a complete manual fire alarm system was not maintained.
NFPA 101, Life Safety Code 9.6; NFPA 72, Fire Alarm Code Chapter 10Date of Construction & Life Safety Code Compliance
01 Jul 2022Complaint
01 Jul 2022Complaint
Investigated an abuse allegation; found failures to report to authorities within required timeframes and to conduct a thorough investigation.
CFR 483.12(c)(1)-(4)Reporting of Alleged Violations
Identified deficiencies in fire safety and electrical testing, including an inoperative fire alarm notification device, incomplete alarm system status, missing fire drill documentation, and incomplete generator testing records.
Concluded the facility was in compliance with regulatory requirements after a complaint investigation.
01 Jun 2022Complaint
01 Jun 2022Complaint
Found no deficiencies identified following complaint investigations.
01 May 2022Complaint
01 May 2022Complaint
Investigated a complaint and found no evidence to support the stated allegations of resident grooming, falls, rights, dietary, nursing, or medications issues; nevertheless, noncompliance with Medicare/Medicaid participation remained due to deficiencies cited on 03/03/2022.
—
01 May 2022Complaint
01 May 2022Complaint
Investigated a complaint and found no support for the allegations about grooming, falls, resident rights, dietary services, nursing services, and medications; however, deficiencies from an earlier survey left the operation out of compliance.
01 May 2022Complaint
01 May 2022Complaint
Found deficiencies cited on the 3/3/2022 survey; the discharge allegation was unsubstantiated.
01 May 2022Complaint
01 May 2022Complaint
Investigated a complaint about resident discharge; found no substantiation for that allegation, but noted ongoing deficiencies from a prior survey.
01 Apr 2022Complaint
01 Apr 2022Complaint
Investigated the complaint and found no substantiated abuse; however, compliance with licensure standards remained out of compliance due to previously cited deficiencies.
01 Apr 2022Complaint
01 Apr 2022Complaint
Investigated a complaint of abuse; found no evidence to support the allegation; nonetheless, prior deficiencies left participation out of compliance.
01 Mar 2022Complaint
01 Mar 2022Complaint
Investigated complaints identified mismanagement of resident funds, misappropriation of funds, infection control weaknesses, and improper wound care hand hygiene.
CFR 483.10(f)(10)(iii)Accounting and Records
CFR 483.12Free from Misappropriation/Exploitation
CFR 483.80Infection Prevention & Control
01 Mar 2022Complaint
01 Mar 2022Complaint
Investigated found misappropriation of resident funds and inadequate infection control practices during wound care, with multiple deficiencies identified.
45.17.2Residents' Rights
45.21.3Pressure sores
01 Mar 2022Complaint
01 Mar 2022Complaint
Investigated a complaint. Found no substantiation for substandard quality of care or neglect, but noted ongoing noncompliance from deficiencies cited earlier.
01 Mar 2022Complaint
01 Mar 2022Complaint
Investigated a complaint; found no deficiencies identified in this review. Prior deficiencies cited on 03/03/2022 left participation in Medicare and Medicaid programs out of compliance.
01 Jul 2021Complaint
01 Jul 2021Complaint
Investigated a complaint alleging resident negligence; concluded no deficiencies were found.
01 Jun 2021Complaint
01 Jun 2021Complaint
Investigated six complaints and found no deficiencies.
01 Jun 2021Complaint
01 Jun 2021Complaint
Concluded compliance with the applicable standards; no deficiencies were cited.
01 Mar 2021Revisit
01 Mar 2021Revisit
Found no deficiencies and determined substantial compliance as of 2021-02-28.
01 Mar 2021Revisit
01 Mar 2021Revisit
Found no deficiencies. Substantial compliance was confirmed after a desk review, with status as of 2021-02-28.
01 Mar 2021Revisit
01 Mar 2021Revisit
Concluded substantial compliance. Found no deficiencies.
01 Mar 2021Revisit
01 Mar 2021Revisit
Determined substantial compliance after a desk review.
01 Mar 2021Revisit
01 Mar 2021Revisit
Determined substantial compliance after a desk review conducted in March 2021.
01 Mar 2021Revisit
01 Mar 2021Revisit
Determined substantial compliance as of 2021-02-28 after a desk review conducted on 2021-03-11.
01 Feb 2021Complaint
01 Feb 2021Complaint
Identified lapses in infection control related to lift sling reprocessing, risking cross-contamination between residents.
Investigated CNA documentation gaps for bed mobility and turning/repositioning across four residents and found incomplete medical records and no policy for record maintenance.
42 CFR §483.70(i)Medical Records
01 Jan 2021Complaint
01 Jan 2021Complaint
Found that bed mobility and turning documentation for four residents was not consistently maintained, indicating medical records were not accurately documented.
Type B§483.20(f)(5); §483.70(i)(1)-(5)Resident Records - Identifiable Information
01 Jan 2021Infection Control
01 Jan 2021Infection Control
Investigated for medical records management; found missing and incomplete documentation for bed mobility and turning/repositioning across multiple residents, indicating failures to maintain accurate medical records.
Type A45.25.1Medical Records Management
01 Jan 2021Complaint
01 Jan 2021Complaint
Found deficiencies in medical records management due to missing documentation of bed mobility and turning/repositioning for four residents.
45.25.1Medical Records Management
01 Jan 2021Infection Control
01 Jan 2021Infection Control
Found no deficiencies during a COVID-19 focused emergency preparedness survey.
01 Jan 2021Complaint
01 Jan 2021Complaint
Investigated a focused COVID-19 emergency preparedness survey and found compliance with the applicable federal requirement.
01 Dec 2020Infection Control
01 Dec 2020Infection Control
Found no deficiencies related to infection control; COVID-19 precautions recommended by CMS and CDC were in place.
01 Dec 2020Infection Control
01 Dec 2020Infection Control
Confirmed no deficiencies were found related to emergency preparedness during a COVID-19 focused survey.
01 Dec 2020Infection Control
01 Dec 2020Infection Control
Found in compliance with emergency preparedness requirements during a COVID-19 focused survey.
01 Dec 2020Infection Control
01 Dec 2020Infection Control
Verified compliance with infection control requirements during a focused COVID-19 survey.
01 Dec 2020Infection Control
01 Dec 2020Infection Control
Found no deficiencies; infection control measures complied with CMS and CDC guidance.
01 Nov 2020Infection Control
01 Nov 2020Infection Control
Verified no deficiencies were identified related to infection control during the focus survey.
01 Nov 2020Infection Control
01 Nov 2020Infection Control
Found no deficiencies related to emergency preparedness during a COVID-19 focused survey.
01 Sept 2020Complaint
01 Sept 2020Complaint
Determined the complaint was unsubstantiated and no deficiencies were cited.
01 Aug 2020Infection Control
01 Aug 2020Infection Control
Found no deficiencies. The focused infection control review confirmed compliance with infection control regulations and CDC/CMS recommendations.
01 Aug 2020Infection Control
01 Aug 2020Infection Control
Verified compliance with COVID-19 infection control requirements. No deficiencies were identified.
01 Jul 2020Complaint
01 Jul 2020Complaint
Found no deficiencies. Determined compliance with Medicare and Medicaid participation.
01 Jun 2020Infection Control
01 Jun 2020Infection Control
Found no deficiencies related to infection control during the COVID-19 focused assessment.
01 Jun 2020Infection Control
01 Jun 2020Infection Control
Found no deficiencies. Confirmed compliance with infection control requirements during a Covid-19 focused review.
01 Mar 2020Complaint
01 Mar 2020Complaint
Concluded no deficiencies were found and confirmed compliance with Medicare and Medicaid requirements.
01 May 2019Complaint
01 May 2019Complaint
Investigated a complaint alleging concerns and found no deficiencies.
01 Apr 2019Inspection
01 Apr 2019Inspection
An inspection identified multiple deficiencies related to resident rights, care planning, transfers, and activity and diet administration, indicating numerous failures to meet required standards.
CFR 483.10(f) and 483.10(f)(1)-(3)(8)Self-Determination
CFR 483.10(g)(14)-(15)Notify of Changes (Injury/Decline/Room, etc.)
S483.15(c)(3)-(8)Notice Requirements Before Transfer/Discharge
S483.15(c)(3)-(8)Notice Requirements Before Transfer/Discharge
CFR 483.21(a)(1)-(3)Baseline Care Plans
CFR 483.21(b)(1)-(4)Develop/Implement Comprehensive Care Plan
CFR 483.21(b)(2)(i)-(iii)Care Plan Timing and Revision
CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
CFR 483.24(c)(1)Activities Meet Interests/Needs
CFR 483.25(c)(1)-(3)Increase/Prevent Decrease in ROM/Mobility
Investigated a complaint and found deficiencies in residents' rights, daily living activities, and recreational programs. Specifically, a resident did not receive a preferred shower, nails were not cared for in a timely manner, a knee splint was not applied as ordered, and activities were not adequately provided or documented.
M500.45.17.2Residents' Rights
M610.45.21.2Activities of Daily Living
M625.45.21.5Range of Motion
M780.45.27.2Activity Program
01 Apr 2019Complaint
01 Apr 2019Complaint
Investigated the complaint and found no deficiencies.
01 May 2018Complaint
01 May 2018Complaint
Found no deficiencies.
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Mirador Living is not affiliated with the owner or operator(s) of Woodlands Rehabilitation and Healthcare Center. The information above has not been verified or approved by the owner or operator. For exact information, please contact Woodlands Rehabilitation and Healthcare Center directly. There is no cost for this service. We are compensated by the community you select.
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