Cycle 1
Health 2024-12-17 · Fire 2024-12-17
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
The Woodlands, TX
The Broadmoor at Creekside Park
3-star overall rating with 3-star inspections with $36,472 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
5665 Creekside Forest Drive, The Woodlands, TX
(281) 255-8180
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
96
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cantex Continuing Care
Operator or chain grouping
Approved since
2014-04-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
38 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.54
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
3.66
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
61%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,577
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
3.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.03% · Performance 23.20% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.21% · Performance 9.27% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 72.17% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.41
Baseline 3.44 hours · Performance 3.48 hours · Measure score 1.41 · Achievement 1.41 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.38% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 164 · Observed rate 15.24% · Lower 95% interval 9.18% |
| Discharge to community | 52.07% |
50.57%
1.5 pts better
|
No Different than the National Rate · Eligible stays 167 · Observed rate 44.91% · Lower 95% interval 46.28% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 87.91% |
95.27%
7.4 pts worse
|
Numerator 80 · Denominator 91 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 91 |
| Discharge self-care score | 31.88% |
53.69%
21.8 pts worse
|
Numerator 22 · Denominator 69 |
| Discharge mobility score | 43.48% |
50.94%
7.5 pts worse
|
Numerator 30 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 1.1% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 91 · Adjusted rate 1.07% |
| Healthcare-associated infections requiring hospitalization | 9.27% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 12.37% · Lower 95% interval 5.76% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 117 |
| Staff flu vaccination coverage | 1.63% |
42%
40.4 pts worse
|
Numerator 3 · Denominator 184 |
| Discharge function score | 28.99% |
56.45%
27.5 pts worse
|
Numerator 20 · Denominator 69 |
| Transfer of health information to provider | 95.45% |
95.95%
0.5 pts worse
|
Numerator 21 · Denominator 22 |
| Transfer of health information to patient | 98.28% |
96.28%
2 pts better
|
Numerator 57 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
97.9%
0.6 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.3%
1.1 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.6% · Q3 2.8% · Q4 1.4% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
2.7%
1.6 pts worse
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 5.0% · Q3 3.0% · Q4 6.2% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
3.3%
1.5 pts worse
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 11.7% · Q3 3.2% · Q4 3.1% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.4% |
18.9%
4.5 pts better
|
19.6%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 11.7% · Q3 11.1% · Q4 14.1% · 4Q avg 14.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.9% |
10.8%
3.9 pts better
|
16.7%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 9.4% · Q3 5.7% · Q4 7.1% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.5% |
15.4%
6.9 pts better
|
16.3%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 8.6% · Q3 9.7% · Q4 9.3% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.9% |
16.1%
6.2 pts better
|
14.9%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 6.7% · Q3 9.5% · Q4 18.6% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
0.8%
0.3 pts worse
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.4% · Q4 1.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.5% |
15.0%
3.5 pts better
|
19.8%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 14.6% · Q3 18.5% · Q4 9.0% · 4Q avg 11.5% |
| Percentage of long-stay residents with pressure ulcers | 8.6% |
4.2%
4.4 pts worse
|
5.1%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 12.1% · Q3 5.1% · Q4 4.9% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
89.7%
7.6 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 97.4% · Q3 99.6% · Q4 98.0% · 4Q avg 97.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
12.0%
4.5 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 8.2% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.7% · Q3 0.7% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.9% |
88.0%
6.9 pts better
|
79.7%
15.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.5% |
25.9%
0.4 pts better
|
23.9%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.5% · Observed 28.2% · Expected 26.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-02 · Fire 2023-10-02
13 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-08-05 · Fire 2022-08-05
9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-12-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-12-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-18
F · Potential for more than minimal harm
2023-10-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-10-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-03
F · Potential for more than minimal harm
2022-08-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-05
E · Potential for more than minimal harm
2022-08-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-08-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-12
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-12-13
D · Potential for more than minimal harm
2025-11-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
E · Potential for more than minimal harm
2024-12-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-12-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-12-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-12-17
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-12-17
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-12-17
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-12-18
D · Potential for more than minimal harm
2024-12-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-18
E · Potential for more than minimal harm
2024-12-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-12-12
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-12-12
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-12-17
D · Potential for more than minimal harm
2024-12-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-18
G · Actual harm
2024-04-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-09
J · Immediate jeopardy
2023-10-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-03
J · Immediate jeopardy
2023-10-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-10-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-10-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-10-02
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-10-02
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-10-02
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-10-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-06-21
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-21
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-05-24
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-06-17
F · Potential for more than minimal harm
2022-08-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-06
E · Potential for more than minimal harm
2022-08-05
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-08-06
D · Potential for more than minimal harm
2022-08-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-08-06
D · Potential for more than minimal harm
2022-08-05
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-08-06
D · Potential for more than minimal harm
2022-08-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-08-06
D · Potential for more than minimal harm
2022-08-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-08-06
Penalties and ownership
What sits behind the stars
$36,472
2023-10-02
Fine
Fine · fine $36,472
Fine
Ownership
Sweeny Hospital District
5% Or Greater Direct Ownership Interest · Organization
Mcarthur, Angela
Operational/Managerial Control · Individual
Park, Kelly
Corporate Officer · Individual
Nearby options
Other facilities in reach
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The Woodlands Nursing And Rehabilitation Center
The Woodlands, TX
3-star overall rating with 2-star inspections with $14,765 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Ridgewood at the Woodlands
The Woodlands, TX
1-star overall rating with 2-star inspections with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
The Village At Gleannloch Farms
Spring, TX
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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