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Complaint Investigation

Woodlake Nursing Center

June 11, 2024 · Clute, TX · 603 E. Plantation Rd
Citations 4
CMS Rating 3/5
Beds 93
Provider ID 675234
Healthcare Facility
Woodlake Nursing Center
Clute, TX  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

WOODLAKE NURSING CENTER in CLUTE, TX — inspection on June 11, 2024.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0684

jeopardy to resident health or safety b. there is a significant change in the resident's physical, mental, or psychosocial status; c. there is a need to change the resident's room assignment;

d. a decision has been made to discharge the resident from the facility; and/or e. it is necessary to transfer the resident to a hospital/treatment center.

The administrator was notified that the IJ was removed on 06/11/24 at 07:35 pm, however the facility remained out of compliance at a scope of isolated and a level of minimal harm due to the facility's need to monitor the implementation of the plan of removal.

675234 06/11/2024

Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

jeopardy to resident health or safety Said she had not been to work since the following week and had not covered the abuse and neglect trainings yet but she would be returning to work the following day.

For the hoyer lift training, she had

position.

There should be two people present during a hoyer transfer.

When a resident fell, she would leave them there and go get the nurse.

The nurse would examine them and they would not be able to lift them up or touch them until after they has been examined after a fall.

CMA C called 4:59 p.m., 6a-6p For abuse and neglect they covered about reporting if they saw anything, like from another staff or another resident, they have to report it immediately.

The abuse coordinator was the Admin and the different types of abuse were hitting, kicking, biting and scratching.

For falls, they were supposed to get the nurse immediately and don't move them.

They left them there and asked if they were ok.

The nurse needed to check and they have to makes sure the resident was ok and have someone watching.

For hoyer training, there should always be two people with a hoyer lift.

When they use the sling, all the colors should be matching so that the resident was balanced correctly and in a sitting position.

CNA G called at 6:44 p.m., 6am- 6pm shift They covered what was abuse and neglect and the importance in making sure everybody was in communication and documenting.

The priority was to make sure residents were safe and secure.

Some examples were mental, physical, and financial. A real time example would be if a resident asked for some water or something to drink and staff ignored it and said it was not their job.

The abuse coordinator was the Admin and all abuse should be reported immediately.

When a resident fell, don't touch them and call the nurse.

Let them get viewed and don't touch them until the nurse said it was ok.

Aides do an incident report and follow up.

For the hoyer lift, staff cannot do a hoyer transfer in the hallway and it had to be 2 persons or more.

All of the colors in the straps have to match, the wheelchair must be locked, and the person must be trained to do the hoyer lift.

She explained that she was comfortable with the training and it was refresher.

She explained the Kardex was used to let you know what is happening with the resident, where their room was, what their plan of care was, and what we have to chart for. To find the Kardex she would sign in, got to the POC, go to different labels, and find the chart that said Kardex and open it up.

The Kardex showed things about the resident like meals, blood pressure, and gave some familiarity with what was going on with the resident CNA H called at 5:18 p.m., 6am-6pm shift, PRN The abuse and neglect training cove[TRUNCATED]

Review of the quizzes covering the topic of abuse and neglect reflected that al quizzes had been completed with a score of 100%.

Record review of the in-service dated 06/08/24 covering the topic of Admin, DON, ADON will notify corporate of all falls/incidents and any discrepancies displayed that it had been completed.

Record review of a termination letter from LVN Nurse A dated 06/08/24 revealed that LVN Nurse A wished to resign immediately due to an out of state family emergency.

675234

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 675234 B.

Wing 06/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

All items listed will be completed by 5:00 PM on 6/8/24 with continued follow-up for scheduled staff.

1. On 6/7/24 a hoyer lift in-service was initiated to include return demonstration with all direct care staff.

Direct care staff will not be allowed to hoyer transfer until return demonstration completed.

This in-service will include human simulation and a post test demonstration.

2. A list of all hoyer list residents was obtained for the in-service and communicated with the staff with care plan comparison.

3. On 6/7/24 pain assessments on all residents were started by nursing administration to ensure all pain needs were addressed with interventions in place.

675234

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 675234 B.

Wing 06/11/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CLUTE, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WOODLAKE NURSING CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.