Woodlake Healthcare and Rehabilitation Center
Crystal, Minnesota · CCN 245518
36 surveys since 2011. The first finding at harm level was recorded in 2015.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 112
- Surveys
- 36
- Harm or worse
- 5
- Immediate jeopardy
- 5
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 188
- Ownership
- For profit - Individual
- Chain
- Independent
- County
- Hennepin
- Medicare-certified since
- 1988
CMS ratings
- Overall
- 3
- Health inspection
- 3
- Staffing
- 4
- Quality measures
- 3
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded fewer weighted findings than most of its peer group.
Weighted by harm level, against 27 facilities with 128 or more beds in Minnesota.
Last survey on record
Dec 18, 2025
326 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 4.28 | 3.90 |
| Registered-nurse hours per resident day | 0.90 | — |
| Annual nurse turnover | 28.2% | 34.5% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D2180.8% | E415.4% | F13.8% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F7613×
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- F5502×
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- F5542×
Allow residents to self-administer drugs if determined clinically appropriate.
- F5802×
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- F6092×
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
In the surveyor’s words
From the most serious findings on record at Woodlake Healthcare and Rehabilitation Center, in the surveyor’s own words.
- Immediate jeopardy, isolatedF689Mar 9, 2022
Based on interview and document review, the facility failed to provide appropriate assistance to maintain non weight-bearing status during transfers for 1 of 2 residents (R1) who was non weight-bearing due to tibia and fibula (TIB/FIB) fracture. This resulted in actual harm as R1 sustained implant failure left distal fibula and syndesmosis (fibrous joint held together by ligaments), left distal fibula fracture, left syndesmosis injury, and subluxation of left joint (ligaments are often stretched or torn, and there may be a break in the bone.) This resulted in an immediate jeopardy (IJ) situation. The IJ began on 3/2/22, when R1 X-ray indicated R1 had a broken distal fibula plate with screws backing out. […]
- Immediate jeopardy, isolatedF760Jul 30, 2021
Based on interview, and document review, the facility failed to ensure [MEDICATION(S)] (a narcotic medication) was administered as prescribed for 1 of 3 residents (R1) reviewed for medication errors. This deficient practice resulted in an immediate jeopardy (IJ) situation for R1 who received a [MEDICATION(S)] dose 20 times greater than what was prescribed and required [MEDICATION(S)] (used to treat a narcotic overdose) administration. The IJ began on [DATE], at approximately 8:32 a.m. when R1 was administered a dose of [MEDICATION(S)] which was twenty times greater than what was prescribed by the physician. R1 subsequently became unresponsive, was hypoxic (low oxygen level), and [MEDICATION(S)] was administered to reverse a narcotic overdose. […]
- No harm, potential for more than minimal, widespreadF812Jan 26, 2024
Based on observation, interview, and record review, the facility failed to ensure food temperatures were taken in the kitchenettes to prevent foodborne illness. This had the potential to affect all 161 residents currently residing in the facility. Finding include: During an observation of temperature taking of the lunch meal on 1/26/24 at 10:30 a.m., with dining manager (DM) and the campus dining service and purchasing director (CDSPD) the cook documented the temperature of the meat on a Quality Checklist Sheet (QCS) dated 1/26/24. When asked to see the last month of temperature logs the DM produced completed lunch and dinner temperature logs. At 10:50 a.m. the DM stated she did not have any breakfast QCS logs. On 1/26/24 at 11:05 a.m. […]
- No harm, potential for more than minimal, patternF921Sep 12, 2025
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 (R1, R2, 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.R1's admission Record indicated he admitted to the facility on [DATE]. Diagnosis included Surgery of digestive system, chronic pain, and weakness. […]
- No harm, potential for more than minimal, patternF623Jan 26, 2024
Based on interview and document review, the facility failed to ensure a written notification of transfer was provided for 3 of 6 residents (R119, R126, R128) upon transfer to the hospital. In addition, the facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for 5 of 6 residents (R119, R128, R45, R50, R59), reviewed for hospitalization . This had the potential to affect all residents transferred to hospital. Findings include: R119's quarterly MDS dated [DATE], indicated R119's diagnoses included dementia with severe cognitive impairment. Progress notes indicated R119 was hospitalized from 10/20/23 through 10/24/23. R119's record lacked evidence a written notification of transfer was provided to the resident and/or resident representative. […]
Read 25 findings in full →The most serious and the most recent: 25 of 112 on record.
Every survey on record
FindingsAt actual harm or above
- Dec 18, 2025Standard3 findings
- Sep 12, 2025Complaint2 findings
- Jul 17, 2025Complaint1 finding
- Nov 26, 2024Complaint1 finding
- Oct 25, 2024Standard and complaint4 findings
- Feb 12, 2024Complaint3 findings
- Jan 26, 2024Standard8 findings
- Jan 19, 2024Complaint1 finding
Show the 28 earlier surveys
- Dec 28, 2023Complaint2 findings
- Jul 13, 2023Complaint1 finding
- Jun 30, 2023Complaint2 findings
- Apr 20, 2023Complaint1 finding
- Mar 8, 2023Complaint2 findings
- Oct 27, 2022Standard4 findings
- Mar 9, 2022Complaint1 finding · 1 harm
- Sep 30, 2021Standard1 finding
- Jul 30, 2021Complaint1 finding · 1 harm
- Mar 11, 2021Complaint1 finding
- Jan 20, 2021Complaint1 finding
- Dec 29, 2020Complaint1 finding
- Oct 12, 2020Complaint2 findings
- Sep 11, 2020Complaint1 finding
- Apr 14, 2020Complaint1 finding
- Feb 13, 2020Standard7 findings
- Dec 6, 2018Standard11 findings
- May 1, 2018Complaint1 finding · 1 harm
- Oct 5, 2017Standard6 findings
- Dec 1, 2016Standard9 findings
- Jan 7, 2016Standard and complaint1 finding
- Jul 1, 2015Complaint8 findings · 2 harm
- Mar 5, 2015Standard4 findings
- Apr 3, 2014Standard5 findings
- May 2, 2013—4 findings
- Jan 31, 2013—1 finding
- Jun 28, 2012—2 findings
- Aug 26, 2011—8 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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