Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodlake Nursing Center during CMS and state inspections, most recent first.
A resident with Down syndrome, severe intellectual disabilities, and documented memory problems had a court‑appointed guardian and an RP who signed admission documents authorizing the facility to manage personal funds. Despite this, a Regional Manager completed Social Security paperwork to make the facility the resident’s representative payee without consulting the guardian, stating she did not know a guardian existed and acted based on paperwork found on the DON’s desk. Separately, the Business Office Manager signed the resident’s 2025 Medicaid application by copying a prior year’s signature page and changing the date, based only on alleged verbal consent from the RP and without written authorization, witnesses, or policy support, while leadership and staff interviews revealed a lack of clear processes to prevent such unauthorized financial actions.
A resident with cerebral palsy, dementia, severe cognitive impairment, and speech disturbances was identified through PASARR Level II and an IDT care plan meeting as needing a customized manual wheelchair as a specialized service. Although therapy, PASARR staff, and the IDT agreed on this service and the resident was assessed and measured by a wheelchair vendor with physician paperwork completed, the facility failed to obtain approval through the Simple LTC portal. Multiple NFSS submissions were marked "form not accepted" due to discrepancies in the resident’s Social Security and date-of-birth information, and the facility did not inactivate and resubmit the PO1 or seek guidance from PASARR support. As a result, the resident continued to use a non-customized wheelchair, and the facility did not integrate the PASARR recommendations into the resident’s assessment, care plan, or transitions of care.
Surveyors identified multiple failures in food safety and sanitation, including dietary staff not wearing hair nets or beard restraints, unsanitary kitchen conditions with dirty floors and dead roaches, improper storage of dented cans, and unlabeled leftover food in freezers. Staff were unable to identify the source of unlabeled food items, and the trash container in the dishwashing area was uncovered and emitting a strong odor. The facility's food service policy lacked guidance on food labeling, cleanliness, and storage.
Three residents were inaccurately assessed regarding their oral and dental status, with MDS documentation not matching actual conditions such as the presence of dentures or being edentulous. These discrepancies were identified through interviews, care plan reviews, and dental records, revealing that assessments did not reflect the true oral health needs of the residents.
A resident with declining health and on hospice care experienced a fall due to the facility's failure to update his care plan. Despite being totally dependent for mobility, the resident was placed in a wheelchair without proper support, leading to a fall and emergency room transfer. Staff interviews revealed confusion about his ability to sit upright, highlighting the need for updated care protocols.
A resident with a history of contractures and hemiplegia experienced a fall during a Hoyer lift transfer, resulting in a right femur fracture and acute pain. The facility delayed transferring the resident to the hospital, prolonging her discomfort. Interviews revealed inadequate training for CNAs involved in the transfer, contributing to the deficiency.
Two residents in a LTC facility suffered injuries due to inadequate supervision and training. One resident, with hemiplegia and contractures, sustained a hip fracture during a Hoyer lift transfer by untrained staff. Another resident, on hospice care, fell from a wheelchair due to lack of supervision and improper positioning. These incidents highlight failures in staff training and adherence to safety protocols.
The facility failed to ensure a qualified and licensed Administrator was in place. The Administrator in Training (AIT) did not have an active Texas Administrator license, and the Corporate Administrator had transferred his license to another facility, leaving the facility without a licensed Administrator since mid-April. The AIT was scheduled to retake her licensing test, but until then, the facility was operating without a licensed Administrator.
The facility failed to provide RN coverage for at least 8 consecutive hours a day, seven days a week for multiple days in the 4th quarter of 2023 and the 1st quarter of 2024. This deficiency was confirmed through record reviews and interviews with staff.
Failure to Honor Resident Financial Rights and Guardian Authority
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to manage his own financial affairs through his court‑appointed guardian and responsible party (RP). The resident was an adult male with Down syndrome, severe intellectual disabilities, speech disturbances, and documented memory problems, who had been determined incapacitated and had a guardian of the person and estate per Letters of Guardianship from a Texas probate court. His face sheet and admission packet identified an RP and guardian, and the RP had signed the admission documents, including the section authorizing the facility to hold, safeguard, and manage personal funds. The resident’s MDS and care plan documented impaired cognitive function and developmental delay, with interventions to monitor changes in decision‑making ability and mental status. Despite this, the Regional Manager completed and signed Social Security form SSA‑787 to change management of the resident’s benefits to the facility, thereby filing for the facility to become the resident’s representative payee without consulting or obtaining consent from the court‑appointed guardian. In a telephone interview, the Regional Manager stated she filed for the facility to become representative payee by mistake, did not know the resident had a guardian, and acted after seeing paperwork on the DON’s table. The facility’s own policy on resident representatives stated that when a resident is determined incompetent by a court, the court‑appointed representative exercises the resident’s rights to the extent judged necessary by the court, but this was not followed in this case. The facility also failed to ensure proper authorization for the resident’s Medicaid application for 2025. The Medicaid application was signed and dated by the Business Office Manager, who later reported that the RP, while hospitalized, verbally asked her to complete and sign the form because it was about to expire. The Business Office Manager stated she copied the prior year’s signature page and changed the date, acknowledging she had no written documentation or witness to support the verbal consent and that there was no policy allowing facility staff to sign the RP’s signature. Interviews with the DON, Business Office Manager, and Interim Administrator showed that financial responsibilities were handled by the Business Office Manager, that there were no interventions in place to prevent recurrence if she was absent, and that leadership did not know what would trigger a change in representative payee or what processes existed to prevent such changes when a guardian was already in place.
Failure to Implement PASARR-Recommended Customized Wheelchair Service
Penalty
Summary
The deficiency involves the facility’s failure to incorporate PASARR Level II recommendations into a resident’s assessment, care planning, and transitions of care, specifically the provision of a customized manual wheelchair (CMWC) as a specialized service. The resident was an adult male with cerebral palsy, dementia, and speech disturbances, with a BIMS score of 03 indicating severe cognitive impairment and dependence on staff for ADLs. His care plan included requirements to complete and submit a new PL1 for any readmission or change of condition, notify the local authority and therapy department of PASARR-positive status, and hold an IDT meeting within 14 days of admission. A PASRR care plan meeting and PASRR Comprehensive Service Plan Form dated 08/06/25 documented that the IDT, including PASRR representatives, agreed the resident would receive habilitation coordination, independent living skills training, and a customized manual wheelchair as a new specialized service. Despite this agreement, the facility did not successfully submit the necessary NFSS request for the CMWC through the Simple LTC portal within the PASARR time frame. Portal records dated 08/15/25 and 11/07/25 showed the forms for the customized wheelchair were marked "form not accepted," and no NFSS was submitted. During observation, the resident was seen in a non-customized wheelchair, leaning to the left with his left hand dangling out of the chair, and attempts to interview him using a language line interpreter were unsuccessful due to unclear speech. The PTA reported that she recommended the CMWC at the PASRR meeting, the PASRR coordinator agreed, the wheelchair company assessed and measured the resident, and the physician signed the paperwork, but she was informed the NFSS was not accepted due to a discrepancy with the resident’s date of birth. Interviews with the MDS coordinator, DON, and business office manager revealed that the NFSS submission was rejected because of conflicting Social Security and date-of-birth information, and that the issue had been referred to the business office and corporate without resolution. The business office manager stated that the Social Security office had an older, incorrect date of birth that had become official and that she contacted an HHSC eligibility services clerk, who confirmed the birth date change in early August 2025. The PASRR staff reported that the facility did not reach out to PASARR support for assistance and explained that the facility should have inactivated the rejected PO1 and submitted a new one with the correct date of birth. The MDS coordinator stated that the head office changed the date on the declined PO1 but refused to cancel and resubmit it due to billing concerns, and she declined to contact PASARR support directly. The facility was unable to provide a PASRR policy when requested at entrance and exit interviews.
Deficient Food Safety and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to maintain food service operations in accordance with professional standards for food safety. Observations revealed that dietary staff did not consistently wear required hair nets or beard restraints while in the kitchen. The kitchen environment was found to be unsanitary, with greasy and dirty floors, food crumbs, dead roaches, and baked-on grease on cooking stoves. Additionally, prepared and leftover food items in both the kitchen freezer and walk-in freezer were not labeled or dated, and staff were unable to identify who left the items. Dented cans were stored together with undented cans in the dry goods storage area, and a large trash container in the dishwashing area was uncovered and emitting a strong odor, with food crumbs and dead roaches present nearby. The garbage disposal was not functioning, leading to the use of the trash can for leftover food waste. Interviews with dietary staff indicated a lack of knowledge regarding the origin of unlabeled food items and the absence of proper food storage practices. The acting administrator acknowledged that the kitchen was problematic and that all kitchen staff were new, with the dietary manager on extended leave. The registered dietitian reported limited on-site hours and noted that the facility's food preparation and service policy did not address food labeling, kitchen cleanliness, or food storage. These deficiencies were identified through direct observation, staff interviews, and review of facility policies.
Inaccurate Oral/Dental Status Documentation in Resident Assessments
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the oral and dental status of three residents. Specifically, the Minimum Data Set (MDS) assessments for these residents did not correctly document the presence or absence of natural teeth, despite evidence from care plans, dental records, and resident interviews indicating otherwise. For example, one resident was coded in the MDS as having all natural teeth intact, while her care plan and interview confirmed she had dentures and did not use her lower set due to poor fit. Another resident was also coded as having no oral/dental problems, but dental records and interviews confirmed she was edentulous and had requested new dentures due to discomfort from chewing without teeth. A third resident's MDS assessment indicated the presence of obvious or likely cavities or broken natural teeth, but during an interview, the resident stated he had no teeth and used both upper and lower dentures, which fit properly. The discrepancies between the MDS documentation and the actual oral status of the residents were identified through observation, interviews, and review of care plans and dental records. These inaccuracies in the MDS assessments were not aligned with the residents' current conditions as observed and reported. The MDS Coordinator acknowledged responsibility for ensuring the accuracy of MDS assessments and stated that assessments were completed by visiting residents, talking to them, and reviewing nursing documentation. However, the inaccuracies persisted, and the facility's policy was to follow the RAI manual for assessment accuracy. The failure to accurately assess and document the residents' oral and dental status could impact the care and services provided to them.
Failure to Update Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to review and revise the person-centered care plan for a resident who experienced a decline in health, resulting in a significant incident. The resident, an eighty-year-old man with a history of atherosclerosis, contractures, and pain, was admitted to the facility and later placed on hospice care. Despite being totally dependent for bed mobility and transfers, the resident's care plan was not updated to reflect his declining condition, which included unsteady trunk balance and support. The deficiency was highlighted when the resident was placed in a wheelchair and left unattended, leading to a fall where he hit his face and required emergency room transfer. Interviews with staff revealed confusion and lack of clarity regarding the resident's ability to sit in a wheelchair, as he had not been out of bed for some time due to his declining health. The care plan did not adequately address the resident's current needs, such as the necessity for reclining the wheelchair to prevent falls. Observations and interviews indicated that the staff were not consistently following updated care protocols, as the resident's condition had changed significantly. The care plan interventions were not revised to accommodate his increased risk of falls and lack of trunk stability, which directly contributed to the incident. The facility's failure to update the care plan in response to the resident's health decline was a critical factor in the deficiency identified by the surveyors.
Delayed Hospital Transfer and Inadequate Training Lead to Resident Injury
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice and the comprehensive person-centered care plan for a resident. The deficiency involved a delay in transferring a resident to the hospital for a higher level of care, resulting in prolonged discomfort and pain. The resident, a 65-year-old woman with a history of contractures, hemiplegia, and major depressive disorder, was involved in an incident where she fell from a wheelchair during a transfer using a Hoyer lift. The fall resulted in a right femur fracture and acute pain due to trauma. The incident occurred when two CNAs were transferring the resident from the Hoyer lift to a wheelchair. During the transfer, the resident slid off the wheelchair and landed on the ground, crying out in pain. Despite the resident's vocalizations of pain and the visible swelling on her right hip, the LVN on duty did not immediately send her to the hospital. The LVN conducted neuro checks, took vitals, and performed a skin assessment but did not perform a range of motion assessment due to the resident's contractures. The LVN believed the resident was more startled than in pain and delayed the transfer to the hospital until the family insisted upon their arrival. Interviews with staff revealed that the CNAs involved in the transfer had not received adequate training on using the Hoyer lift, and one CNA was performing a Hoyer transfer with a resident for the first time. The facility's failure to ensure proper training and immediate medical assessment and intervention after the fall contributed to the deficiency. The resident's family expressed concerns about the delay in care, and the facility's lack of timely response to the resident's condition was identified as a significant issue.
Inadequate Supervision and Training Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. This deficiency was identified in two residents. The first resident, a 65-year-old woman with a history of hemiplegia, contractures, and other medical conditions, sustained a hip fracture during a Hoyer lift transfer. The incident occurred when two nursing assistants, who were not properly trained, attempted to transfer her. During the transfer, one of the assistants let go of the wheelchair, causing the resident to slide out and fall, resulting in a fracture that required surgical intervention. The second resident, an 80-year-old man on hospice care with severe cognitive impairment and multiple physical limitations, was left unattended in a wheelchair despite his unsteady trunk balance. This resident fell out of the wheelchair, hit his face, and required emergency room care. The staff failed to monitor him adequately, and the wheelchair was not reclined as it should have been to accommodate his lack of trunk stability. This oversight led to the resident's fall and subsequent injury. Interviews and record reviews revealed that the facility did not provide adequate training for staff on the use of the Hoyer lift and failed to ensure proper supervision and safety measures for residents with significant mobility and cognitive impairments. These failures contributed to the accidents and injuries sustained by the residents, highlighting a lack of adherence to safety protocols and training requirements within the facility.
Facility Lacks Licensed Administrator
Penalty
Summary
The governing body of the facility failed to ensure that a qualified and licensed Administrator was in place to manage the facility. During the entrance conference, the Administrator in Training (AIT) identified herself as the Administrator, but it was later revealed that she did not have an active Texas Administrator license. The Corporate Administrator, who was listed as the facility Administrator in the facility's documentation, confirmed that he was no longer the active Administrator and that the facility currently had no licensed Administrator. The AIT had been working under the Corporate Administrator's license since September 2023, but the Corporate Administrator had transferred his license to another facility in mid-April, leaving the facility without a licensed Administrator since then. The Corporate Administrator admitted that the facility might be out of compliance and that he was working with the AIT to pass her licensing test. Interviews with both the AIT and the Corporate Administrator revealed that the Corporate Administrator was not physically present at the facility every week, averaging about 16 hours per week on-site and being available virtually for extended hours. The AIT was scheduled to retake her licensing test at the end of May, but until then, the facility was operating without a licensed Administrator. The facility's job description for the Administrator position clearly stated that a current, valid Texas Nursing Home Administrator's License was required, which the AIT did not possess. This failure to have a licensed Administrator in place could place residents at risk of being cared for by staff who were not properly managed by a licensed professional.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to utilize the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, seven days a week for the 4th quarter of 2023 and the 1st quarter of 2024. Specifically, there was no RN coverage for 7 days out of 92 in the 4th quarter of 2023 and 9 days out of 91 in the 1st quarter of 2024. This deficiency was identified through a review of the facility's Payroll Based Journal Staffing Data Report and confirmed by interviews with the Business Office Manager, the Director of Nursing (DON), and the Director of Operations. The DON stated that she was always present at the facility and could be reached at any time, but the records did not support continuous RN coverage as required by regulations. Further review of the facility's schedules for January through May 19, 2024, revealed additional days without RN coverage: 4 days in January, 2 days in February, 1 day in March, and 1 day in April. The Regional Director of Data Processing confirmed that staffing data was submitted to CMS quarterly based on the facility's time sheets. The facility's policy stated that an RN should be available for coverage 8 hours a day, 7 days a week, but this policy was not adhered to, as evidenced by the missing RN coverage on the specified days.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Clute
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Creekside Village | 1.3 mi | ★★★★★ | 4 | 0 |
| Brazos Healthcare Center | 1.7 mi | ★★★★★ | 4 | 0 |
| Oak Village Healthcare | 3.7 mi | ★★★★★ | 0 | 0 |
| Country Village Care | 10.6 mi | ★★★★★ | 5 | 1 |
| Cypress Woods Care Center | 10.7 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.