Woodlake Healthcare And Rehabilitation Center
WOODLAKE HEALTHCARE AND REHABILITATION CENTER in CRYSTAL, MN — inspection on September 12, 2025.
Found 2 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
asked about a walker she was told physical therapy would bring one but not until the next day. R3 said she did not think the facility was equipped to care for her when she admitted , had no wheelchair she could get into and no pain medications until 7:45 p.m., even though she had asked for them.
She said the nurse told her they would not have medications until later in the day and the pain just kept getting worse and worse.
R3 said there was a lack of preparation and said the staff had no knowledge of how to get her out of bed.
She said she could not get staff to help and could not do it herself. R3 said the overnight staff were not helpful R1's admission Record indicated he admitted to the facility on [DATE].
Diagnosis included surgery of digestive system, chronic pain, and weakness. R1's admission assessment dated [DATE], indicated he admitted to the facility on [DATE].
The assessment indicated R1 was alert and oriented, had a colostomy and was continent of bladder.
The assessment indicated R1 walked occasionally but for very short distances and spent the majority of each shift in bed or chair.R1's care plan dated 8/21/25, identified intact cognition and indicated R1 had a new colostomy and directed staff to check device each shift, and ass needed for appropriate fit, leakage and need for emptying.
The care plan identified a self-care deficit and indicated he required assistance from staff for grooming, toileting, ambulation and wheelchair mobility.During interview on 9/11/25 at 12:25 p.m., FM-A stated R1 had been at the facility in the past and had received great care but since his current admission had not received good care. FM-A said he spent approximately eight hours a day at the facility during R1's stay. FM-A stated the first night R1 was at the facility, he (FM)-A got to the facility after 7:00 p.m. and the door was locked and no one would answer the phone to let him in.
When he finally got in, R1's call light was on, and he was lying in a puddle of urine and waited an hour for someone to help him. FM-A said, it was so bad, and said he couldn't find anyone to help R1. FM-A said one of the nights, he waited two hours for someone to come and change R1's colostomy bag so he started to do it himself. FM-A said when a nurse finally came in, she asked how to change the bag.
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IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Woodlake Healthcare and Rehabilitation Center
8000 Bass Lake Road Crystal, MN 55428
SUMMARY STATEMENT OF DEFICIENCIES
During observation on the east unit on 9/12/25 at 8:23 a.m., the hallway outside of room [ROOM NUMBER] smelled of urine. No trash or linen carts were in the vicinity.R1's admission Record indicated he admitted to the facility on [DATE].
Diagnosis included Surgery of digestive system, chronic pain, and weakness.
During interview on 9/11/25 at 10:39 a.m., family member (FM)-A stated it smelled like death in his dad bathroom when he was at the facility even after they had cleaned it.
R2's admission Record indicated she admitted to the facility 9/3/25 and resided on the two- east unit of the facility.
Diagnosis included muscle weakness, DMII, hypertension and history of falls. R2's Brief interview for mental status (BIMS) dated 9/4/25, indicated her short and long terms memory was intact.During interview on 9/11/25 at 11:47 a.m., R2 stated she had been at the facility for about two weeks. R2 stated the facility has had the same carpet for 10 years and said, they dumped me in this shit hole. R2 said the carpet is stained and musty and said the housekeepers did not vacuum, just swept the carpet. R2 pulled out a bottle labeled fungicide she had ordered and said the carpet smelled better since she started using it and said she planned to spray the recliner they brought up from the basement because it stunk.R3's admission Record indicated she resided on the two- east unit of the facility.
Diagnosis included fractures of left fibula and tibia (the two bones of the lower leg), pain in left wrist and left leg, fracture of left radius (one of two bones in your forearm), unsteadiness and dependence on other enabling machines and devices.During interview on 9/11/25 at 3:12 p.m., family member (FM)-B stated when R3 got to the facility, the first thing he smelled when they got to her unit was urine. FM-B said R3 had a catheter and the first night a staff member came to empty it and did not place the cap on it and the catheter was leaking urine all over the floor. FM-B said the second time the staff member emptied the catheter bag, she spilled urine on the floor then rubbed the urine into the carpet with a brown paper towel.A facility grievance form dated 8/4/25, filed by FM-C, indicated Residents room is a mess, not enough garbage cans, floor dirty.During interview on 9/12/25 at 10:01 a.m., social service designee (SSD)-A said she was aware of the concerns reported by R3. SSD- A said the concerns included the urine on the carpet, no recliner in the room and some other things. SSD-A said because of the scenarios, R3 did not think the facility was welcoming or clean.During interview on 9/12/25 at 10:52 a.m. the environmental services director (ESD) said typically if she was made aware of a concern and spoke with the resident and/or family and said if training was needed, they would do that.
The ESD stated the facility currently did not have a floor technician and said she would like to have the hallways cleaned at least once per week but said they were currently stretched thin.
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