The incident occurred at Woodlake Healthcare and Rehabilitation Center during a recent stay by a resident who had undergone digestive system surgery. Federal inspectors documented the case as part of a complaint investigation completed in September.
The family member spent approximately eight hours daily at the facility during the resident's stay. On his first night there, he arrived after 7:00 p.m. to find the door locked with no one answering the phone to let him in. When he finally gained entry, the resident's call light was on and he was lying in a puddle of urine.
He waited an hour for someone to help.
The resident, identified in the report as R1, had been admitted with a new colostomy following digestive surgery. His care plan specifically directed staff to check the colostomy device each shift and assess it for appropriate fit, leakage and need for emptying. The plan also indicated he required assistance from staff for grooming, toileting and mobility.
Despite these documented care needs, the family member found himself providing care that nursing staff should have handled. On one occasion, after waiting two hours for someone to change the colostomy bag, he began the procedure himself. When a nurse finally appeared, she asked him how to change the bag.
The family member told inspectors that while the resident had received great care during previous stays at Woodlake, the current admission was different. He described struggling to find anyone to help the resident during his daily eight-hour visits.
A second resident, R3, described similar problems with staff preparedness and availability. She said the facility was not equipped to care for her when she was admitted. There was no wheelchair she could get into, and despite asking for pain medications, she did not receive them until 7:45 p.m. The nurse told her medications would not be available until later in the day while her pain "kept getting worse and worse."
R3 said staff had no knowledge of how to get her out of bed. When she asked about a walker, she was told physical therapy would bring one but not until the next day. She could not get staff to help and could not manage on her own.
She described the overnight staff as unhelpful.
The resident's admission assessment showed she was alert and oriented, walked occasionally but only for very short distances, and spent most of each shift in bed or a chair. Her care plan identified a self-care deficit requiring staff assistance for grooming, toileting, ambulation and wheelchair mobility.
Both residents' experiences occurred despite documented care plans that specifically outlined their needs and the assistance required from nursing staff. The colostomy patient's plan was dated August 21, 2025, just weeks before the family member found himself teaching a nurse how to change the device.
The inspection findings represent what federal regulators classified as minimal harm or potential for actual harm affecting few residents. However, the specific incidents documented by inspectors reveal gaps between written care plans and actual care delivery.
For the colostomy patient, the contrast was particularly stark. His care plan directed staff to monitor his colostomy device each shift, yet when it needed changing, no staff member knew how to perform the basic procedure. The family member's two-hour wait followed by his decision to do the task himself highlighted the absence of trained personnel during his relative's stay.
The facility's locked door policy also prevented family involvement in care. The family member's difficulty gaining entry after 7:00 p.m. meant the resident remained in soiled conditions with his call light on until someone finally responded an hour later.
Both residents described feeling abandoned by staff who either lacked basic skills or were unavailable when needed. The colostomy patient's family member couldn't find anyone to help during his extensive daily visits. The second resident couldn't get staff assistance with mobility and had to wait until the following day for basic equipment like a walker.
The inspection narrative ends with these unresolved care failures, documenting a facility where written care plans existed but staff either didn't know how to implement them or weren't available to provide the assistance residents required.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodlake Healthcare and Rehabilitation Center from 2025-09-12 including all violations, facility responses, and corrective action plans.
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