Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to notify the Ombudsman of resident transfers and discharges. A cognitively intact resident with cancer, HF, renal insufficiency, and DM had multiple hospital discharges with return anticipated, but the facility’s monthly reports sent to the Ombudsman did not show the resident’s name. The DSS stated a bed hold and voluntary discharge notice were offered and that a monthly report was emailed, but could not recall whether the resident was included.
A resident who was cognitively intact and had arthritis, anxiety, and depression did not receive timely follow-up for an in-house eye provider’s recommendation for olopatadine eye drops. The resident reported itchy eyes and said she had not received the ordered drops. The chart still listed artificial tears, the new eye drop order was missing from the order summary, and staff interviews showed the facility relied on summaries and after-visit paperwork to obtain PCP orders, with the record initially missing the eye visit documentation.
Medication Storage and Access Failure: An insulin pen was observed sitting on top of a locked treatment cart while a resident and multiple staff passed by without noticing it. An LPN stated they did not know where the pen came from, then retrieved an open insulin pen for the same resident from the med cart. The RN mgr and regional DON stated open insulin pens were kept in med carts and unopened pens in the locked med refrigerator, while the facility policy required medications and biologicals to be stored in locked compartments with access limited to authorized personnel.
Surveyors found that the facility did not maintain a clean and odor-free environment, as evidenced by persistent musty and urine odors in hallways and resident rooms, stained and inadequately cleaned carpets, and improper cleaning of urine spills. Multiple residents and family members reported unpleasant smells and unclean conditions, and staff confirmed challenges with housekeeping due to staffing shortages.
Two residents were not provided with timely pain management, mobility equipment, or personal care upon admission. One resident with multiple fractures waited hours for pain medication and was left bedbound without necessary devices, while another with a new colostomy experienced significant delays in assistance and care. Staff interviews revealed delays in therapy assessments and a lack of preparedness to meet residents' immediate needs.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights was upheld.
A resident alleged sexual abuse by a nursing assistant during pericare, but the facility failed to report the incident to the state agency within the required timeframe. Despite the resident's cognitive intactness and clear communication of the incident, the nurse manager did not report it, and the director of nursing and administrator were unaware until the survey. The facility's policy requires reporting within two hours, which was not adhered to, leading to a deficiency.
A resident with moderately impaired cognition was found with unsecured and expired medications in her room, without a proper assessment or physician order for self-administration. Staff interviews revealed that a nursing assistant applied the medication, despite not being trained or authorized to do so, and the facility's policy requiring evaluation for self-administration was not followed.
A resident with dementia, requiring extensive assistance, was frequently observed in a hospital gown with uncombed hair, contrary to her preference for wearing her own clothes. Staff were unaware of her clothing preferences, and her care plan lacked this information. The DON emphasized the importance of maintaining residents' dignity through appropriate dressing and grooming, as per facility policy.
A resident with dementia in an LTC facility did not receive adequate assistance with activities of daily living (ADL), including dressing, grooming, and oral care. Despite the care plan indicating the need for extensive assistance, the resident was often observed in a hospital gown with unkempt hair and without dentures. Staff interviews revealed a lack of adherence to the care plan and the resident's preferences, leading to a deficiency in care.
A resident with dementia and a history of falls was found without access to a call light, which was lying on the floor out of reach. Despite the care plan requiring the call light to be within reach, staff interviews confirmed it was not secured properly. The DON emphasized the importance of call light accessibility for resident safety, but the facility's policy was not followed, resulting in a deficiency.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the Ombudsman of transfers and discharges for 1 of 4 residents reviewed for hospitalizations, identified as a cognitively intact resident with diagnoses of cancer, heart failure, renal insufficiency, and diabetes mellitus. The resident’s record showed multiple hospital discharges with return anticipated and subsequent entry records, including discharges on 7/8/25, 8/1/25, 8/17/25, 9/29/25, and 10/23/25. A review of the facility information sent to the Ombudsman from July 2025 through November 2025 lacked evidence that the resident’s name was included on the list of hospitalized residents. During interview, the Director of Social Services stated that when residents were discharged to the hospital, a bed hold was offered and notice of voluntary discharge was provided, and that a monthly report was pulled and sent to the Ombudsman, but he did not recall whether the resident was included on any of the reports. The Administrator stated the Director of Social Services ran a monthly report from PointClickCare for the entire facility and emailed it to the Ombudsman.
Failure to Process In-House Eye Provider Medication Recommendation
Penalty
Summary
The facility failed to ensure timely follow-up for an in-house eye provider’s recommendations for one resident who was cognitively intact and had diagnoses of arthritis, anxiety, and depression. The resident stated she had seen the eye doctor about a week earlier but had not received the ordered eye drops. The HealthDrive Eye Care Group after-visit summary documented itchy eyes, discontinuation of artificial tears ophthalmic solution, and a new order for olopatadine 0.2% eye drops, 1 drop in both eyes every morning for 90 days. The resident’s order summary sheet still listed artificial tears ophthalmic solution as needed for dry eyes and did not include the olopatadine order. The HUC initially could not locate documentation of the eye doctor visit in the resident’s record, and later uploaded the provider note. Staff interviews showed the in-house eye doctor provided summaries and after-visit summaries to facility staff, and care coordinators were expected to follow up with the PCP for medication orders because the eye doctor did not write orders. The DON stated the summary was not an order because it was not signed by the eye doctor and was unsure when the after-visit summary was received. The facility policy for medication orders did not address timeliness or processing of in-house provider orders.
Medication Storage and Access Failure
Penalty
Summary
The facility failed to ensure medications and biologicals were stored in locked compartments accessible only to authorized personnel. During constant observation on 12/16/25 from 1:27 p.m. through 1:40 p.m., an insulin pen was observed laying on top of a locked treatment cart while a resident and multiple staff passed by, and none of them noted or handled the pen. When the LPN was stopped at the cart, they stated they did not know where the pen came from or how it got there, then retrieved an open insulin pen for the same resident from the medication cart and stated they would report the incident and remove the pen from circulation. At 1:55 p.m., the RN manager stated staff were expected to keep open insulin pens in the medication carts and unopened pens in the locked medication refrigerator on the unit. On 12/18/25, the regional director of nursing stated the same process. The Medication Storage Policy dated May 2025 stated all medications must be stored in locked compartments under proper temperature control, with access limited to authorized personnel, and that during medication pass the medication must be under the observation of a licensed nurse or trained medication aide or locked in the medication storage area/cart.
Failure to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a clean and odor-free environment for three residents reviewed for environmental concerns. Observations on multiple occasions revealed musty and urine odors in hallways and outside resident rooms, with no trash or linen carts present to explain the odors. One family member reported persistent foul odors in a resident's bathroom even after cleaning. Another resident, with a history of muscle weakness, diabetes, hypertension, and falls, stated that the carpet was stained, musty, and had not been properly vacuumed, leading her to use her own fungicide to improve the smell. She also reported that a recliner brought from the basement had an unpleasant odor. A third family member described incidents where urine from a catheter was spilled onto the carpet and not properly cleaned, with staff using a paper towel to rub the urine into the carpet. A facility grievance form documented complaints about dirty floors and insufficient garbage cans. The social service designee confirmed awareness of concerns regarding urine on the carpet and the lack of a recliner, noting that these issues contributed to a negative impression of the facility's cleanliness. The environmental services director acknowledged being short-staffed, lacking a floor technician, and stated that hallway cleaning was not occurring as frequently as desired. These findings demonstrate a failure to provide a clean, odor-free, and comfortable environment for residents, staff, and visitors.
Failure to Accommodate Resident Needs and Preferences Upon Admission
Penalty
Summary
The facility failed to ensure reasonable accommodation of resident needs and preferences upon admission for two residents. One resident, admitted with multiple fractures and severe pain, did not receive prescribed pain medication for approximately seven hours after arrival, despite orders for oxycodone and documented severe pain. The resident was also left without necessary mobility devices, such as a walker or wheelchair, and was unable to transfer out of bed or access the commode due to the lack of equipment. Staff informed the resident and family that therapy assessments and equipment provision would not occur until the next day, resulting in the resident remaining bedbound and experiencing significant discomfort. The resident and family reported that staff were unprepared to assist with mobility and pain management, and that communication regarding medication availability was lacking. Another resident, admitted with a new colostomy and chronic pain, experienced delays in care and assistance. The resident was found lying in urine with the call light on and waited an hour for help on the first night. On another occasion, the resident waited two hours for assistance with a colostomy bag change, leading a family member to perform the task themselves. When a nurse eventually arrived, she was unfamiliar with how to change the colostomy bag, indicating a lack of staff preparedness and training for the resident's needs. Interviews with staff revealed that therapy assessments and equipment provision were often delayed on weekends, and that nursing staff were hesitant to provide mobility devices without therapy input. Staff also indicated that pain medication could be accessed from the emergency kit, but this was not done promptly for the resident in pain. The facility's processes and communication breakdowns resulted in residents not receiving timely pain management, mobility support, or personal care upon admission.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the state agency within the required timeframe. The incident involved a resident who claimed that a nursing assistant had assaulted him during pericare. Despite the resident's cognitive intactness, as indicated by a BIMS score of 14, and his clear articulation of the incident to the nurse manager, the allegation was not reported to the state agency as required by the facility's policy. The nurse manager, upon being informed by the resident, discussed the incident with the social services director and the director of nursing but did not report it to the state agency. The resident's care plan was updated to include 'cares in pairs' as a protective measure, but the allegation itself was not documented in the progress notes. The director of nursing and the administrator were unaware of the allegation until the day of the survey, indicating a breakdown in communication and reporting procedures within the facility. Interviews with various staff members, including the nurse manager, director of nursing, and executive director, revealed a lack of clarity and adherence to the facility's abuse reporting policy. The director of nursing stated that she would have reported the allegation immediately had she been informed. The facility's policy mandates that all alleged violations be reported to the appropriate authorities within two hours, but this protocol was not followed, resulting in a deficiency.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was comprehensively assessed for self-administration of medications. The resident, identified as having moderately impaired cognition and requiring assistance with activities of daily living, was observed with various medications unsecured in her room. These included a tube of Asper Creme, a container of petroleum jelly, and two bottles of Nystatin powder, some of which were expired. The resident indicated that a nursing assistant applied the cream for her, but there was no documented assessment or physician order for self-administration of medications in the resident's medical record. Interviews with staff revealed that the nursing assistant applied the cream at the resident's request, despite not being trained to do so. The nurse manager confirmed that the resident did not have an order for self-administration and was not supposed to have medications in her room without an order. Additionally, the director of nursing stated that only nurses, not nursing assistants, were authorized to apply creams and powders. The facility's policy required an evaluation to determine if a resident could safely self-administer medications, which was not conducted in this case.
Failure to Maintain Resident Dignity in Dressing and Grooming
Penalty
Summary
The facility failed to maintain the dignity of a resident with severely impaired cognition and a diagnosis of dementia, who required extensive assistance for dressing, grooming, and toileting. The resident was frequently observed wearing a hospital-type gown instead of her own clothes, with uncombed and matted hair, and without proper footwear. The care plan did not specify the resident's preference for wearing her own clothes or a hospital gown, and staff members were unaware of her preferences, as they relied on a care sheet that lacked this information. Interviews with staff and a family member revealed that the resident preferred to wear her own clothes and took pride in her appearance. However, she was often dressed inappropriately, with pants that were too short and without a bra, which was not in line with her usual standards. The Director of Nursing acknowledged the importance of residents feeling good about their appearance and stated that staff should assist residents in wearing clean, neat clothing and grooming their hair. The facility's policy emphasized considering the resident's former lifestyle and personal choices when providing care, but this was not reflected in the care provided to the resident.
Deficiency in ADL Assistance for Resident with Dementia
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for a resident with severely impaired cognition and a diagnosis of dementia. The resident required extensive assistance for dressing, grooming, bathing, oral care, and toileting, as indicated in their care plan. However, observations revealed that the resident was often left in a hospital gown, with messy and uncombed hair, and without dentures. Certified Nursing Assistants (CNAs) responsible for the resident's care did not consistently follow the care plan, failing to assist with hand hygiene before meals and neglecting oral and hair care. Interviews with staff and family members highlighted a lack of awareness and adherence to the resident's preferences and care needs. The resident's family member expressed that the resident preferred to wear her own clothes and took pride in her appearance, which was not respected by the staff. The Director of Nursing confirmed the resident's need for assistance and the expectation for staff to provide such care, yet the staff did not consistently meet these expectations, leading to a deficiency in the resident's ADL care.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that care plan interventions were being utilized for a resident with severely impaired cognition and a diagnosis of dementia, who required extensive assistance for daily activities. The resident's care plan, revised on September 15, 2024, indicated a risk for falls and included interventions such as ensuring the call light was within reach before staff exited the room. However, during an observation on October 25, 2024, the resident's call light was found lying on the floor, approximately two feet away from the resident and outside of her reach. There was no clip to attach the call light to the resident's bed or clothing, and no other call light was available in the room. Interviews with CNAs revealed that the resident was functionally able to use the call light to summon assistance, but the call light was not secured as required. CNA-B mentioned that the resident primarily used a specific type of call light and that it should be clipped to the blankets or wheelchair. CNA-C confirmed the call light was on the floor and stated it had been clipped to the blankets before her break. The Director of Nursing emphasized the importance of having the call light within reach for resident safety and communication. The facility's policy required staff to ensure the call light was accessible and secured, but this was not adhered to in the case of the resident, leading to a deficiency in providing adequate supervision to prevent accidents.
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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 Crystal
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Ridge Health And Rehab | 0.5 mi | ★★★★★ | 5 | 0 |
| Maranatha Care Center | 2.3 mi | ★★★★★ | 3 | 0 |
| The Terrace At Crystal Llc | 2.8 mi | — | 65 | 4 |
| Good Samaritan Society - Specialty Care Community | 3.3 mi | ★★★★★ | 26 | 0 |
| Mission Nursing Home | 3.3 mi | ★★★★★ | 11 | 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.