Woodlake Nursing Center

Inspectors wroteBased 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]. [...]

Inspectors wroteBased 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]. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of seven residents reviewed for quality of care. 1. The facility delayed Resident #1 a transfer to the hospital for higher level of care and delayed treatment resulting in prolonged discomfort and pain. An IJ was identified on 06/07/24. The IJ template was provided to the facility on [DATE] at 6:13 pm. While the IJ was removed on 06/11/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to monitor the implementation of the plan of removal. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for two (Resident #1 and Resident #2) of five residents reviewed for accidents hazards and supervision, in that: 1. The facility failed to make sure staff were properly trained before operating the hoyer lift. Resident #1 sustained a hip fracture during a Hoyer lift transfer by CNA A and NA B, which required surgical intervention. 2. Resident #2 was placed into his wheelchair and left unattended after a decline in his health caused him unsteady trunk balance and support. He fell out of the wheelchair, hit his face, and was transferred to the emergency room. An IJ was identified on 06/07/24. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]