C-
58/100THE WOODLANDS NURSING AND REHABILITATION CENTER Inspection Report, Violations & Safety Grade (The Woodlands, Texas)
4650 S PANTHER CREEK DR, The Woodlands, Texas 77381
Phone: 2813633535
CMS Overall:2/5
Overview & Bed Count
Certified Beds
214
Avg Residents/Day
155.7
Ownership
Government - Hospital district
Provider Type
Medicare and Medicaid
County
Montgomery
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall2/5
Health2/5
Staffing1/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | Texas Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.34 | 0.44 | -0.10 |
| Total Nurse Hours per Resident per Day | 3.45 | 3.42 | +0.04 |
| CMS Staffing Rating | 1/5 | 1.9/5 | - |
| Nursing Staff Turnover | 53.4% | 50.8% | - |
Health Citation History
30 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-06-04 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | D – Moderate Harm Potential |
| 2026-04-25 | Resident Rights Deficiencies | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | E – Moderate Harm Potential |
| 2026-04-13 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | G – Actual Harm |
| 2026-04-13 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | G – Actual Harm |
| 2026-04-13 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G – Actual Harm |
| 2026-04-13 | Environmental Deficiencies | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | E – Moderate Harm Potential |
| 2025-12-19 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | E – Moderate Harm Potential |
| 2025-12-19 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E – Moderate Harm Potential |
| 2025-12-19 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2025-12-19 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2025-12-19 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2025-12-19 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2025-12-19 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-12-19 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2025-12-19 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2025-09-04 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2025-08-19 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2025-06-17 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | K – Immediate Jeopardy |
| 2025-06-05 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2025-04-03 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2024-08-01 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2024-08-01 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2024-08-01 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2024-08-01 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D – Moderate Harm Potential |
| 2023-05-18 | Nutrition and Dietary Deficiencies | Dispose of garbage and refuse properly. | F – Moderate Harm Potential |
| 2023-05-18 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E – Moderate Harm Potential |
| 2023-05-18 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | E – Moderate Harm Potential |
| 2023-05-18 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2023-05-18 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2023-05-18 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
Fire Safety Citation History
12 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-12-19 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | F – Moderate Harm Potential |
| 2025-12-19 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-12-19 | Gas, Vacuum, and Electrical Systems Deficiencies | Have a battery powered remote alarm panel in a location accessible by operating personnel. | F – Moderate Harm Potential |
| 2025-12-19 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2025-12-19 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | E – Moderate Harm Potential |
| 2025-12-19 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2025-12-19 | Miscellaneous Deficiencies | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | D – Moderate Harm Potential |
| 2025-12-19 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | C – Minimal Harm Potential |
| 2024-08-01 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2024-08-01 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | E – Moderate Harm Potential |
| 2024-08-01 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | E – Moderate Harm Potential |
| 2023-05-18 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | C – Minimal Harm Potential |
Total Penalties & Fines
$18,944
Total Fine Amount (CMS)
2
Number of Fines
2
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2026-04-13 | Fine | $9,347 | - |
| 2025-06-05 | Fine | $9,597 | - |
Need Help Finding Safe Care?
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the The Woodlands area at no cost.
Find Safe, Vetted Facilities Near The Woodlands
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.