The Woodlands, TX

The Woodlands Nursing And Rehabilitation Center

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

4650 S Panther Creek Drive, The Woodlands, TX

(281) 363-3535

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

214

Certified beds

Average residents

157

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Wellsential Health

Operator or chain grouping

Approved since

1990-04-23

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

67 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 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

0.39

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.79

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.27

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.44

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.17

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.10

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.28

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.39

CMS adjusted RN staffing hours

Adjusted total hours

3.48

CMS adjusted total nurse staffing hours

Case-mix index

1.35

Higher values indicate more complex resident acuity

RN turnover

57%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

52%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,555

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

26.34

Composite VBP score used to determine payment impact.

Payment multiplier

0.9841

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.58

Baseline 20.95% · Performance 19.77% · Measure score 3.58 · Achievement 3.58 · Improvement 2.50

Healthcare-associated infections

2.81

Baseline 8.00% · Performance 7.00% · Measure score 2.81 · Achievement 2.78 · Improvement 2.81

Total nurse turnover

2.87

Baseline 71.31% · Performance 55.64% · Measure score 2.87 · Achievement 1.97 · Improvement 2.87

Adjusted total nurse staffing

1.28

Baseline 3.23 hours · Performance 3.44 hours · Measure score 1.28 · Achievement 1.28 · Improvement 0.31

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.39%	10.72% 0.7 pts worse	No Different than the National Rate · Eligible stays 189 · Observed rate 11.64% · Lower 95% interval 8.41%
Discharge to community	53.71%	50.57% 3.1 pts better	No Different than the National Rate · Eligible stays 172 · Observed rate 47.09% · Lower 95% interval 45.64%
Medicare spending per beneficiary	0.87	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 210 · Denominator 210
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 210
Discharge self-care score	47.5%	53.69% 6.2 pts worse	Numerator 76 · Denominator 160
Discharge mobility score	61.25%	50.94% 10.3 pts better	Numerator 98 · Denominator 160
Pressure ulcers or injuries, new or worsened	3.81%	2.29% 1.5 pts worse	Numerator 8 · Denominator 210 · Adjusted rate 3.75%
Healthcare-associated infections requiring hospitalization	7%	7.12% 0.1 pts better	No Different than the National Rate · Eligible stays 121 · Observed rate 6.61% · Lower 95% interval 4.33%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 118
Staff flu vaccination coverage	47.74%	42% 5.7 pts better	Numerator 74 · Denominator 155
Discharge function score	65%	56.45% 8.5 pts better	Numerator 104 · Denominator 160
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 56 · Denominator 56
Transfer of health information to patient	98.02%	96.28% 1.7 pts better	Numerator 99 · Denominator 101
Resident COVID-19 vaccinations up to date	2.63%	25.2% 22.6 pts worse	Numerator 3 · Denominator 114

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.0	2.1 0.9 pts worse	1.9 1.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 3.6 · Expected 2.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.6	2.1 1.5 pts better	1.8 1.2 pts better	Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.7 · Expected 1.9 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	97.1% 2.5 pts better	93.4% 6.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.2% · Q4 99.2% · 4Q avg 99.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	97.9% 2.1 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.8%	3.3% 2.5 pts better	3.3% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.8% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.1%	2.7% 1.6 pts better	11.4% 10.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.8% · Q4 2.5% · 4Q avg 1.1%
Percentage of long-stay residents who lose too much weight	2.3%	3.3% 1 pts better	5.4% 3.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.8% · Q3 2.7% · Q4 2.6% · 4Q avg 2.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	14.0%	18.9% 4.9 pts better	19.6% 5.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 12.7% · Q3 15.9% · Q4 14.9% · 4Q avg 14.0%
Percentage of long-stay residents who received an antipsychotic medication	10.8%	10.8% About the same	16.7% 5.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 9.8% · Q3 11.6% · Q4 11.5% · 4Q avg 10.8% · 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	5.9%	15.4% 9.5 pts better	16.3% 10.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 7.5% · Q3 5.8% · Q4 7.0% · 4Q avg 5.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	11.8%	16.1% 4.3 pts better	14.9% 3.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 9.9% · Q3 12.7% · Q4 16.3% · 4Q avg 11.8% · 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	0.2%	0.8% 0.6 pts better	1.7% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	14.0%	15.0% 1 pts better	19.8% 5.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 15.5% · Q3 10.2% · Q4 14.7% · 4Q avg 14.0%
Percentage of long-stay residents with pressure ulcers	7.3%	4.2% 3.1 pts worse	5.1% 2.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 8.9% · Q3 6.0% · Q4 5.5% · 4Q avg 7.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	94.4%	89.7% 4.7 pts better	81.7% 12.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 97.1% · Q3 91.6% · Q4 90.3% · 4Q avg 94.4%
Percentage of short-stay residents who had an outpatient emergency department visit	7.1%	12.0% 4.9 pts better	12.0% 4.9 pts better	Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 7.4% · Expected 11.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.1%	1.5% 0.4 pts better	1.6% 0.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.9% · Q3 0.5% · Q4 1.0% · 4Q avg 1.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	92.1%	88.0% 4.1 pts better	79.7% 12.4 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 92.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	30.6%	25.9% 4.7 pts worse	23.9% 6.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 30.6% · Observed 30.9% · Expected 24.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-08-01 · Fire 2024-08-01

9 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2023-05-18 · Fire 2023-05-18

6 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

1 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 3 Health 2022-03-24 · Fire 2022-03-24

4 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-08-01

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-08-03

E · Potential for more than minimal harm 2024-08-01

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-08-03

E · Potential for more than minimal harm 2024-08-01

K929 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

Corrected 2024-08-03

C · Minimal harm 2023-05-18

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-05-22

F · Potential for more than minimal harm 2022-03-24

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2022-04-15

C · Minimal harm 2022-03-24

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2022-04-15

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-04

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-09-06

D · Potential for more than minimal harm 2025-08-19

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 2025-08-20

K · Immediate jeopardy 2025-06-17

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-06-18

E · Potential for more than minimal harm 2025-06-05

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-06-09

D · Potential for more than minimal harm 2025-04-03

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 2025-04-07

F · Potential for more than minimal harm 2024-08-01

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 2024-08-05

E · Potential for more than minimal harm 2024-08-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-08-05

D · Potential for more than minimal harm 2024-08-01

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-08-05

D · Potential for more than minimal harm 2024-08-01

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 2024-08-05

F · Potential for more than minimal harm 2023-05-18

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2023-05-27

E · Potential for more than minimal harm 2023-05-18

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 2023-05-27

E · Potential for more than minimal harm 2023-05-18

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-05-27

E · Potential for more than minimal harm 2023-05-18

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 2023-05-27

D · Potential for more than minimal harm 2023-05-18

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 2023-05-27

D · Potential for more than minimal harm 2023-05-18

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-05-27

D · Potential for more than minimal harm 2023-03-30

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 2023-04-21

E · Potential for more than minimal harm 2022-03-24

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-04-15

E · Potential for more than minimal harm 2022-03-24

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 2022-04-15

D · Potential for more than minimal harm 2022-03-24

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2022-04-15

Penalties and ownership

What sits behind the stars

$14,765 2025-06-05

Fine

Fine · fine $14,765

Fine

Ownership

Winnie-Stowell Hospital District

5% Or Greater Direct Ownership Interest · Organization

100% 75 facilities 2014-08-22

Carrasco, Gloria

W-2 Managing Employee · Individual

0% 1 facilities 2021-07-16

Murrell, Edward