Woodlake Nursing Center: Hoyer Lift Hip Fracture - TX
The incident at Woodlake Nursing Center on May 24 triggered immediate jeopardy violations from federal inspectors, who found that 65-year-old Resident #1 screamed in pain when she hit the floor but wasn't sent to the hospital until her family arrived that evening and demanded action.
NA B, who had worked at the facility for just three weeks, told inspectors she had never received Hoyer lift training and "that was her first time performing a hoyer transfer with a human being and not a plastic dummy." She was assisting CNA A in moving the resident from the mechanical lift to a wheelchair when the transfer went wrong.
"While the resident was being lowered down, NA B let go of the wheelchair to straighten Resident #1," CNA A told inspectors. "Due to NA B letting go of the wheelchair so quickly, Resident #1 was described to slide out the wheelchair and land on her leg in pain."
The resident, who has left-sided paralysis from a stroke and severe contractures, cried out immediately. "When she fell, she cried out in pain instantly," CNA A said.
But LVN Nurse A, who had started working at the facility three weeks earlier, performed what he described as a limited assessment. He took vitals and checked her skin but deliberately avoided range-of-motion testing because the resident was "fully contracted and whenever he would move her limbs, she would grimace due to pain."
That decision delayed discovery of the hip fracture for hours.
The resident and her family member painted a different picture of her condition. "When she fell on [DATE], she was crying the entire time and she yelled out very loudly when she dropped because the fall hurt," the resident told inspectors. Her family member said when she arrived at 3:30 pm and tried to adjust the resident's position for an afternoon snack, "she yelled out very loudly and said Stop, Stop! It hurts!"
LVN Nurse A acknowledged the resident rated her pain as 9 out of 10 when asked, but he told the family the doctor wouldn't be available until Tuesday due to the holiday. The family refused to wait and demanded she be sent to the emergency room.
Hospital records show the resident was admitted at 4:51 pm with a right femur fracture and acute pain due to trauma. She required immediate surgery.
CNA A, who knew the resident's family personally, was visibly upset during her interview with inspectors. "She explained with tears in her eyes that this situation had really hurt her because her family and Resident #1's family were close, and she was angry that LVN Nurse A did not send her out right away."
The facility's records show a Hoyer lift training was conducted from May 29 to June 5, 2024 — after the resident's injury occurred. The Director of Nursing told inspectors she "never liked the hoyer lift and there should always be two people operating it at a time" but admitted she wasn't aware that LVN Nurse A had skipped the range-of-motion assessment.
A second resident suffered injuries from inadequate supervision just nine days before the lift incident. Resident #2, an 80-year-old hospice patient with severe cognitive impairment, fell from his wheelchair and hit his head on a bedside table after staff left him unattended.
The resident had been placed on hospice in April after his health declined significantly. Progress notes show he had been "refusing to eat, take his medication, and there had been a decline is his ADLs." Multiple staff members told inspectors he had stopped getting out of bed regularly because he no longer had the balance or trunk stability to sit safely.
But on May 15, a restorative aide asked if he wanted to get out of bed. "She walked past Resident #2's room and asked the resident if he wanted to get out of bed, in which he replied, yea baby," according to the inspection report.
With help from CNA C, she transferred him to his wheelchair and set up his bedside table. She asked if he wanted coffee, then left the room to get it. When she returned, she placed the coffee on his table and left again.
Minutes later, staff heard screaming. They found the bedside table knocked over, the resident on the floor, and "his head was laid against the leg of the table." He had a laceration above his right eye that required emergency room treatment.
The restorative aide told inspectors she hadn't reclined his wheelchair because "he was drinking coffee and she was trying to align his body." After the incident, she received training that if the resident was in a sitting position, "his wheelchair needed to be reclined back" because he couldn't recover his strength to bring his body back upright.
CNA E, who didn't work the day of the fall, was puzzled by the decision to get him up. "She was confused on why the staff got him out of bed. She explained that Resident #2 no longer had balance and he could not sit in a wheelchair."
The regional director confirmed the resident "did not have the trunk stability to bring himself back upright in a wheelchair" and made the recommendation after his fall to keep him reclined when seated.
Resident #2 died in his sleep on June 6, three weeks after his fall.
The immediate jeopardy citation was removed on June 11 after the facility implemented emergency training for all staff on incident reporting, fall assessments, and equipment operation. LVN Nurse A resigned on June 8, citing a family emergency out of state.
Federal inspectors found the facility's policies required proper training and supervision but weren't followed. The accident and incident policy required supervisors to "promptly initiate and document investigation" of incidents, while the change-in-condition policy mandated notification of physicians for accidents involving residents.
Both residents' injuries could have been prevented with proper training and supervision that the facility's own policies required but failed to ensure.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodlake Nursing Center from 2024-06-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WOODLAKE NURSING CENTER in CLUTE, TX was cited for violations during a health inspection on June 11, 2024.
"While the resident was being lowered down, NA B let go of the wheelchair to straighten Resident #1," CNA A told inspectors.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.