The Broadmoor at Creekside Park
5665 Creekside Forest Drive, The Woodlands, TX 77389 · CCN 676357
Ratings
- Overall
- ★★★☆☆ 3
- Health inspection
- ★★★☆☆ 3
- Quality measures
- ★★★★☆ 4
- Staffing
- ★★☆☆☆ 2
Facility
- Ownership type
- For profit - Corporation
- Certified beds
- 112
- Avg residents/day
- 95.9
- Phone
- 2812558180
Inspection history vs Texas & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Texas avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2024-12-17 | 9 | 9.1 | 9.5 | -0.1 better |
| 2 | 2023-10-02 | 13 | 9.4 | 9.8 | +3.6 worse |
| 3 | 2022-08-05 | 9 | 8.1 | 9.3 | +0.9 worse |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 4 |
| Resident assessment and care planning | 1 |
| Pharmacy service | 1 |
| Environmental | 1 |
| Administration | 1 |
| Infection control | 1 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 3.54 | 66.7% |
| RN staffing (reported) | 0.58 | 61.1% |
| Total nurse staffing (adjusted) | 3.66 | — |
Fines & penalties
- Total fines
- $36,472
- Number of fines
- 1
- Number of penalties
- 1
- Payment denials
- 0
Chain
- Chain
- CANTEX CONTINUING CARE
- Facilities in chain
- 38
- Chain avg overall
- 3.10 / 5
Inspection citations (31)2 immediate jeopardy1 actual harm
- EF0921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.2025-12-12 · Health · corrected 2025-12-13
Potential for more than minimal harm
- DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-11-20 · Health
Potential for more than minimal harm
- EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-12-17 · Health · corrected 2024-12-18
Potential for more than minimal harm
- DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2024-12-17 · Health · corrected 2024-12-18
Potential for more than minimal harm
- DF0691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.2024-12-17 · Health · corrected 2024-12-18
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-12-17 · Health · corrected 2024-12-18
Potential for more than minimal harm
- EF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-12-17 · Health · corrected 2024-12-18
Potential for more than minimal harm
- DF0849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.2024-12-17 · Health · corrected 2024-12-18
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2024-12-17 · Health · corrected 2024-12-18
Potential for more than minimal harm
- DF0602Protect each resident from the wrongful use of the resident's belongings or money.2024-12-12 · Health · corrected 2024-12-17
Potential for more than minimal harm
- EF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-12-12 · Health · corrected 2024-11-11
Potential for more than minimal harm
- EF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2024-12-12 · Health · corrected 2024-11-18
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2024-12-12 · Health · corrected 2024-12-18
Potential for more than minimal harm
- GF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-04-19 · Health · corrected 2024-05-09
Actual harm
- DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2023-10-02 · Health · corrected 2023-10-03
Potential for more than minimal harm
- DF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2023-10-02 · Health · corrected 2023-10-03
Potential for more than minimal harm
- EF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-10-02 · Health · corrected 2023-10-03
Potential for more than minimal harm
- JF0697Provide safe, appropriate pain management for a resident who requires such services.2023-10-02 · Health · corrected 2023-10-03
Immediate jeopardy
- JF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2023-10-02 · Health · corrected 2023-10-03
Immediate jeopardy
- EF0759Ensure medication error rates are not 5 percent or greater.2023-10-02 · Health · corrected 2023-10-03
Potential for more than minimal harm
- EF0761Ensure 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.2023-10-02 · Health · corrected 2023-10-03
Potential for more than minimal harm
- DF0880Provide and implement an infection prevention and control program.2023-10-02 · Health · corrected 2023-10-03
Potential for more than minimal harm
- DF0572Give residents a notice of rights, rules, services and charges.2023-06-21 · Health · corrected 2023-07-20
Potential for more than minimal harm
- DF0578Honor 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.2023-06-21 · Health · corrected 2023-07-20
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2023-05-24 · Health · corrected 2023-06-17
Potential for more than minimal harm
- DF0607Develop and implement policies and procedures to prevent abuse, neglect, and theft.2022-08-05 · Health · corrected 2022-08-06
Potential for more than minimal harm
- DF0645PASARR screening for Mental disorders or Intellectual Disabilities2022-08-05 · Health · corrected 2022-08-06
Potential for more than minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2022-08-05 · Health · corrected 2022-08-06
Potential for more than minimal harm
- DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2022-08-05 · Health · corrected 2022-08-06
Potential for more than minimal harm
- FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2022-08-05 · Health · corrected 2022-08-06
Potential for more than minimal harm
- EF0813Have a policy regarding use and storage of foods brought to residents by family and other visitors.2022-08-05 · Health · corrected 2022-08-06
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| SWEENY HOSPITAL DISTRICT | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2024-12-01 |
| MCARTHUR, ANGELA | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2024-12-01 |
| PARK, KELLY | Individual | CORPORATE OFFICER | — | 2019-08-01 |
Other facilities in The Woodlands
| Name | Overall | Beds |
|---|---|---|
| THE WOODLANDS NURSING AND REHABILITATION CENTER | ★★★☆☆ | 214 |
| Ridgewood at the Woodlands | ★☆☆☆☆ | 126 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.