Woodbury Health Care Center: Call Light Ignored 38 Minutes - MN
The resident, identified in inspection records as R4, had his call light activated. Nobody came.
The nursing assistant assigned to R4 that shift, identified as NA-D, said he told a colleague named NA-C that he was going on break and that NA-C should cover the call light. NA-D acknowledged R4 had been waiting for his protective boots, which were supposed to go on every morning, and for a blanket. He acknowledged the call light had not been answered in time. When asked what that meant for R4, NA-D said the resident would feel sad, disappointed, and not well cared for.
The registered nurse on duty, identified as RN-C, told inspectors she hadn't seen R4's call light because she couldn't see the banner displaying that it was activated. She said R4 wouldn't feel important to staff if he had to wait all morning. She also said the nursing assistant should have gone to another floor to find a blanket if one wasn't available on the unit.
The director of nursing put it plainly when inspectors interviewed her on May 26. Thirty-eight minutes waiting for a call light response was too long, she said. Staff were expected to answer as quickly as possible. "Thirty-eight minutes sitting there waiting feels like a lifetime," she told inspectors. She said R4 would feel terrible waiting for his protective boots, and that when residents asked for help, staff were expected to help.
The facility's own call light policy, dated April 2025, states that all staff who see or hear an activated call light are responsible for responding. If the staff member who responds can't provide what the resident needs, they are supposed to notify someone who can. The facility's dignity policy, updated April 1, 2026, commits the home to treating each resident with respect, recognizing individuality, and responding to requests for assistance in a timely manner.
What the policies describe and what R4 experienced that morning were not the same thing.
The breakdown followed a pattern inspectors have seen in facilities where call light responsibility is treated as shared in theory and nobody's job in practice. NA-D believed he had handed off the obligation to NA-C by saying so on his way out the door. RN-C believed she bore no responsibility because the alert banner wasn't visible to her. The result was a man sitting alone, waiting, for more than half an hour, for boots that were supposed to be on his feet every morning.
The inspection was prompted by a complaint, not a routine survey. CMS classified the harm level as minimal harm or potential for actual harm, and noted that few residents were affected. The protective boots R4 was waiting for suggest he had a condition requiring their use, though the inspection report does not specify further.
The director of nursing's own words capture what the 38 minutes meant. R4 would feel terrible, she said. When residents ask for help, staff are expected to help. On the morning in question, nobody did.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodbury Health Care Center from 2026-05-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 13, 2026 · Our methodology
WOODBURY HEALTH CARE CENTER in WOODBURY, MN was cited for violations during a health inspection on May 26, 2026.
The resident, identified in inspection records as R4, had his call light activated.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.