Health inspection·May 23, 2024

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. 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; November 11, 12, 25; 26 and December 9;10; and 23 (9 days out of 91) Record review of the facility's Payroll Based Journal Staffing Data Report for Fiscal Year Quarter 4 2023 (July 1 - September 30the) revealed no RN coverage on July 9, 22, 23, August 19 and 20 September 2 & 3 (7 days out of 92) On 05/21/2024 at 2:30 PM, documentation of RN coverage was requested from the Business Office Manager. The Business office Manager said the report for the second quarter (January -March of 2024) was not available. She provided the schedules for January through May 19th, 2024. She said all pay roll information was handled by the cooperate office. Record review of provided schedules revealed no RN coverage for the following days of the following monthJanuary 2024- 6, 14, 20 & 21, - (4 Days in January February 2024-3, 4 (2 days in February) March 2024 -2, (1 day in March) Page 1 of 4 675234 675234 05/23/2024 Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

F 0727 April 2024-28 (1day in April) Level of Harm - Minimal harm or potential for actual harm Interview with the DON on 05/21/24 at 3:00PM, she said she was always present at the facility and the staff could call her at any time as needed. She said her job was 24 hours a day, 7 days a week. She said she cared about the residents, and she made sure that all residents were cared for. Residents Affected - Some Interview on 05/21/24 at 3:50PM, the Director of Operations said the facility worked hard to ensure that there was RN coverage daily; at least 8 hours per day. He said the DON can always be reached as needed. He said the facility cared about the residents and all residents' need were met. During a phone interview on 05/22/24 at 11:00AM, the Regional Director of Data processing said she was responsible for submitting the facility's staffing Date to CMS quarterly. She said she went by the time sheet that was submitted by the facility. Review of the facility's policy titled Staffing read in part Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation -An RN is available for coverage 8 hours a day 7 days a week. -Direct care staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter. -Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee. . 675234 Page 2 of 4 675234 05/23/2024 Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

F 0837 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. 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 active license. The Corporate Administrator said that the facility may have been out of compliance. The Corporate Administrator said he would have to check and would follow up with surveyor. Interview with the AIT on 5/20/24 on 2:53 pm, she said her direct manager and supervisor was the Corporate Administrator. The AIT said she was unsure how many days per week the Corporate Administrator was on location at the facility. Interview with AIT on 5/21/24 at 9:53 am, she said she did not have an Administrator license yet and that she was scheduled to retake her test on 5/28/24. The AIT said she took her first test in January of 2024 and bummed it, so she had to take it again. The AIT said she had been working at the facility under the Corporate Administrator's license since September of 2023. The AIT said she believed the Corporate Administrator's license was valid and in active use for the facility. The AIT said the facility was required to have a licensed Administrator and again, said she was unsure how often the Corporate Administrator was on-site at the facility weekly. In a follow up interview on 5/21/24 at 10:08 am with the Corporate Administrator, he said he was not at the facility every week. He said he averages about 16 hours per week physically at the facility and was also available to the facility virtually for extended hours. The Corporate Administrator said that he had to transfer his Administrator license to another facility in mid-April and that no one's license was on the building at that time. He went on to say he believed that the regulation was that they had a 30-day window to be without an administrator, but he believed they were currently out of compliance. He said he was working with the AIT to pass her test and that he did not have an employee file at the facility and did not have a copy of his license but would try to get it. The 675234 Page 3 of 4 675234 05/23/2024 Woodlake Nursing Center 603 E Plantation Rd Clute, TX 77531

F 0837 Corporate Administrator said there should be a licensed administrator for the facility. Level of Harm - Minimal harm or potential for actual harm Record review on 5/21/24 at 10:59 am the Corporate Administrator provided an undated document that read in part: Notification of change and was dated 3/25/2024 with facility ID number, and corporate Administrator's license number, Type of Action-Change-Administrator Effective 3/18/24 Corporate Administrator. Residents Affected - Many Record review of the facility's provided Administrator job description revealed a summary of qualifications that included: Maintains a current, valid Texas Nursing Home Administrator's License. . 675234 Page 4 of 4