Woodlake Healthcare And Rehabilitation Center

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

asked about a walker she was told physical therapy would bring one but not until the next day. Resident 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. Resident 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. Resident R3 said the overnight staff were not helpful Resident R1's admission Record indicated he admitted to the facility on [DATE REDACTED]. Diagnosis included surgery of digestive system, chronic pain, and weakness. Resident R1's admission assessment dated [DATE REDACTED], indicated he admitted to the facility on [DATE REDACTED]. The assessment indicated Resident R1 was alert and oriented, had a colostomy and was continent of bladder. The assessment indicated Resident R1 walked occasionally but for very short distances and spent the majority of each shift in bed or chair.Resident R1's care plan dated 8/21/25, identified intact cognition and indicated Resident 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 Resident 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 Resident R1's stay. FM-A stated the first night Resident 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, Resident 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 Resident R1. FM-A said one of the nights, he waited two hours for someone to come and change Resident 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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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodlake Healthcare and Rehabilitation Center

8000 Bass Lake Road Crystal, MN 55428

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and

the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and document review the facility failed to maintain an environment that was clean and free from odors for 3 of 3 residents (Resident R1, Resident R2, Resident R3) reviewed for environmental concerns. Findings include:During observation of the two-east unit on 9/11/25 at 10:50 a.m., a musty odor was observed outside room [ROOM NUMBER]. 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.Resident R1's admission Record indicated he admitted to the facility on [DATE REDACTED]. 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. Resident 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. Resident 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., Resident R2 stated she had been at the facility for about two weeks. Resident R2 stated the facility has had the same carpet for 10 years and said, they dumped me in this shit hole. Resident R2 said the carpet is stained and musty and said the housekeepers did not vacuum, just swept the carpet. Resident 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.Resident 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 Resident R3 got to the facility, the first thing he smelled when they got to her unit was urine. FM-B said Resident 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 Resident 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, Resident 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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