Woodlake Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure residents had the right to manage their finances for 1 of 3 residents (Resident #2) reviewed for personal funds in that:The facility failed to obtain consent from Resident #2's court-appointed guardian before filing to become Resident #2's representative payee, and the facility failed to prevent the Business Office Manager from signing and dating Resident #2's Medicaid application for 2025. These failures placed residents at risk of violating their right to self-manage their own financial matters.Record review of Resident #2's face sheet dated [DATE] revealed he was a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE]. His diagnoses included Down syndrome (extra full or partial copy of chromosome 21 which causes differences in physical development, learning, and developmental delay thinking), severe intellectual disabilities (significant limitations with learning, reasoning, problem solving), and speech disturbances (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to incorporate the recommendations from the PASARR Level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care services for 1 of 3 residents (Resident #1) reviewed for PASARR.-The facility failed to submit a request through the Simple LTC portal for a customized manual wheelchair for Resident #1 within the time frame set by PASARR or asked for guidance from PASARR support when form was not accepted.This failure could have affected residents who required a specialized PASARR service.Record review of Resident #1's face sheet dated 01/15/26 revealed he was a [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral palsy (group of lifelong neurological disorders that affect movement, muscle tone, and posture), dementia (decline in mental ability severe enough to interfere with activities of daily living), and speech disturbances (a condition that disrupts the ability…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the 1 of 1 kitchen. -The facility failed to ensure Dietary Staff A wore hair net and beard cover while in the kitchen. -The facility failed to ensure that the kitchen and the equipment were kept in a clean, sanitary condition. -The facility failed to ensure that prepared, leftover food items in one of two freezers, and one of one walk-in freezer were dated and labeled with an open\store date and use by date. - The facility failed to ensure that dented cans were stored away from undented cans. -The facility failed to ensure that trash can in the kitchen was covered and not exposed in food preparation area. These failures could place residents at risk for cross contamination and food-borne illnesses. Findings include: Initial kitchen observations, and interviews, on 05/27/25 from 9:00 AM to 9:20 AM revealed- - Dietary Staff A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 3 of 15 resident (Resident #14, Resident #17, and Resident #53) reviewed for accuracy of assessments. - The facility failed to accurately assess Residents #14, #17, and #53 for their lack of natural teeth in their oral cavity. These failures could place residents at risk of not receiving care and services necessary for their physical, mental, and psychosocial well-being. The findings included: Resident #14 Record review of Resident #14's face sheet dated 06/25/25 revealed a -[AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included chronic obstructive pulmonary disease, heart disease, essential (primary) hypertension (High blood), type 2 diabetes mellitus with diabetic neuropath (nerve damage that can happen with diabetes) arthritis (inflammation of the joints), panic disorder, anxiety and major depressive disorder, cognitive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the governing body failed to have a qualified Administrator reviewed for governing body. -The facility failed to ensure the Corporate Administrator was the active administrator. - The facility failed to ensure the Administrator in training (AIT) had an active Texas Administrator license. This failure could place residents at risk of being cared for by staff who were not managed by a licensed Administrator. Findings include: During the entrance conference on 5/20/24 around 9:00 am, the AIT identified herself as the Administrator/AIT and said that the Corporate Administrator would arrive at the facility shortly. Record review on 5/20/24 at 9:30 am of undated facility document titled Key Personnel revealed Corporate Administrator was listed as the facility Administrator. Interview on 5/20/24 at 2:42 pm with the Corporate Administrator, he said he was no longer the administrator at the facility and that the facility currently had no licensed Administrator. He said the AIT was the Administrator and then clarified that the AIT had no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to utilize the services of a Registered Nurse for at least 8 consecutive hours a day, seven days a week for 4th quarters of 2023 and first quarters of 2024 reviewed for RN Coverage. -The facility failed to provide evidence of a RN coverage for 8 hours a day, seven days a week for 7 days out of 92 days for quarter 4 of 2023 (07/09/, 07/22/, 07/23, 08/19, 08/20,09/02, and 09/03/23) and 9 out of 91days in Fiscal Year quarter 1 of 2024 from October 1 through December 31, 2024). (10/28, 10/29, 11/11, 11/12,11/25, 11/26,12/09, 12/10, &12/23/2024) This failure could place residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings include: Record review of the facility's Payroll Based Journal Staffing Data Report for Fiscal Year Quarter 1 2024 (October -December 31 revealed no evidence of a RN coverage on the following days 10/28/24 and 10/29/24;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to conduct a comprehensive, accurate, standardized reproducible assessment for 4 of 16 (Resident # 11, #51, #8, #66,) reviewed for accuracy of assessments. 1 Resident # 11's annual MDS assessment did not reflect her mental illness and dental care needs. 2 Resident #51 was not assessed for his race\ethnicity, His admission MDS did not reflect his use of assistive device for ambulating, his dental, vision, and hearing need, his fall history 3 Resident #8's significant change MDS did not reflect his bed rails, pressure reducing device for bed, pressure reducing device for chair, turning/repositioning program, and applications of ointments/medications. 4 Resident #66's significant change MDS did not reflect her oxygen therapy, suctioning, pressure reducing device for bed, application of nonsurgical dressings (with or without topical medications) other than to feet, applications of ointments/medications other than to feet, ability to hear (with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who had mental illness or intellectual disability for 2 of 2 residents (Residents #27 and #47) reviewed for PASARR Significant Change Notification. 1 The facility failed to notify the local mental health authority after Resident #27' significant change in mental illness diagnosis following a new PTSD diagnosis. 2 Resident #47 was identified with a significant change to their mental illness diagnoses and notification was not made to the me local mental health authority. This failure could place residents requiring PASARR services at risk of not having their special needs assessed and met by the facility. Findings include: Resident #27 Record review of Resident #27's admission record dated 3/29/2023 revealed a [AGE] year-old admitted on [DATE] with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program and to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for two of two residents (Residents #27 and #47) reviewed for PASARR assessment. The facility failed to refer Resident #27 and Resident #47 for a PASARR level II screening after a new mental disorder diagnosis was made. This failure could place residents requiring PASARR services at risk of not having their special needs assessed and met by the facility. Findings include: Resident #27 Record review of Resident #27's admission record dated 3/29/2023 revealed a [AGE] year-old admitted on [DATE] with diagnoses major depressive disorder, anxiety disorder (an intense, persistent fear of being watched and judged by others),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to review and revise the care plan after each assessment, including both the comprehensive and quarterly review assessments for 2 (#9, and #66) out of 16 residents reviewed for care plans. 1. Resident #9's code status on his care plan was not updated from full code to DNR and it did not indicate he was Spanish speaking and needed a translator. The care plan also did not mention the resident was ordered oxygen, a pressure relieving mattress, to be turned and repositioned Q 2hr, and he required feeding assistance Q 4hr PRN. 2. Resident #66's care plan did not include heel protectors, oral suctioning, a pressure relieving mattress, and bowel rest from her PEG tube. This deficient practice could place residents at risk of not receiving care and services that are needed to attain/maintain their highest practicable quality of life. 1. Record review of Resident #9's face sheet indicated he is a [AGE] year-old male, readmitted on [DATE], with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.