F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to complete an accurate assessment of resident's functional
capacity for 1 (Resident #1) out of 3 residents reviewed for MDS assessment.
Residents Affected - Few
Facility failed to document stage II pressure ulcer in Resident #1's MDS dated [DATE].
This failure placed residents at risk of not receiving adequate services and/or care.
Findings included:
Record review of face sheet revealed Resident #1 was a [AGE] year old male who was admitted to the
facility on [DATE]. His diagnoses included Hemiplegia (Muscle weakness or partial paralysis on one side of
the body that can affect the arms, legs, and facial muscles), Acute posthemorrhagic anemia (a condition
which a person quickly loses a large volume of circulating blood), Dysphagia (difficulty swallowing),
Gastro-esophageal reflux disease (A chronic disease that occurs when stomach acid flows into the food
pipe and irritates the lining), Hyperlipidemia (A condition in which there are high levels of fat particles in the
blood), Traumatic subarachnoid hemorrhage (bleeding inside the brain), Hypertensive urgency (A
hypertensive urgency is a clinical situation in which blood pressure is very high with minimal or no
symptoms, and no signs or symptoms indicating acute organ damage).
Review of admission record dated 10/12/2023 revealed Resident #1 was admitted with stage 2 pressure
ulcer.
Review of care plan dated 10/17/2023 revealed Resident #1 had pressure ulcer with goal to prevent and
heal the pressure sore and skin breakdown.
Review of TAR (Treatment Administration Record) for the month of October and November 2023 revealed
documentation of pressure ulcer treatment for Resident #1.
Review of MDS dated and signed as completed on 10/17/2023, section M revealed Resident #1 had no
pressure ulcer.
On 11/09/2023 at 3:22pm in an interview with the DON, he stated the MDS record was completed by the
MDS nurse who was the one responsible for completing the MDS care assessment.
On 11/09/2023 at 3:58 pm in an interview with the MDS nurse, she stated the MDS was started on the
10/12/2023 when the resident was admitted . The MDS was signed complete on 10/17/2023 indicating the
assessment of the resident was done and completed. She stated she was not aware of the resident
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
675229
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675229
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/09/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Woodland Manor Nursing and Rehabilitation
99 Rigby Owen Rd
Conroe, TX 77304
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
having any wound or pressure ulcer at the time of the assessment. She stated she became aware of the
pressure ulcer about two weeks ago. She also stated she did not correct the MDS at that time because she
did not know how to edit or correct the MDS record because she was still in training by the Corporate MDS
Nurse. When asked why she did not ask the Director of nursing or the Corporate MDS Nurse training her
how she could fix the MDS, she stated mmm .I don't know. She said she did not ask anyone because she
did not know she had to ask someone. She stated MDS record was an important part of resident's
information, it should contain accurate information about residents, and it helped to know the area of need
that the patient was being treated for.
Record review of facility policy dated November 2019 titled 'Certifying Accuracy of the Resident
Assessment' revealed in part, The information on the assessment reflects the status of the resident during
the period for that assessment .The resident assessment coordinator is responsible for ensuring that MDS
has been completed for each resident. Each assessment is coordinated and certified as complete by the
resident assessment coordinator.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675229
If continuation sheet
Page 2 of 2
