Woodbury Health Care Center: Catheter Death Risk Ignored - MN
The resident, identified in inspection records only as R1, was described by the facility's own medical director as "very frail, very compromised." She had melena, dark stool that signals bleeding in the upper gastrointestinal tract. Her death certificate listed sepsis and hemorrhagic shock as causes of death. The medical director told inspectors the bleeding likely killed her. The catheter, left in when it should have been taken out, was flagged as inappropriate use.
Nobody had warned her what leaving it in could do.
The inspection was triggered by a complaint and completed May 26, 2026. What inspectors found was not a documentation gap or a paperwork oversight. It was a failure of basic clinical obligation: a resident was never told that a device inserted into her body, one her own provider had ordered removed, carried a risk of sepsis. She was never given the chance to make an informed decision. And when she refused the removal, nobody came back to try again, nobody called her family, nobody wrote down why the catheter stayed in.
The nurse practitioner who reviewed the case put it plainly. If R1 had returned from the hospital with a urinary tract infection, the facility should have changed the catheter. If R1 refused the removal, staff should have come back later, tried again, involved the family, and provided education about the risks of leaving it in. The nurse practitioner said R1's infection could have gone septic because the catheter was not removed.
It did.
The medical director told inspectors the rules around indwelling urinary catheters are "clear and very limited" in terms of what diagnoses justify their use. In R1's case, the catheter was being used for comfort. That is not among the narrow clinical justifications. The medical director said it was the primary provider's responsibility to educate the resident, confirm she understood, and document it, because leaving the catheter in could cause sepsis. The facility should have attempted removal, and if that failed, written down why. None of that happened.
"Communication with the resident would have been the most vital point," the medical director said, "and the catheter use would be flagged for inappropriate use."
The director of nursing confirmed to inspectors there were no progress notes showing that any staff member or provider had educated R1 about the risks and benefits of leaving the Foley catheter in place. The director of nursing also said the catheter had not been left in for an appropriate reason, and called it the provider's decision, despite acknowledging it was inappropriate.
That framing, attributing the failure to the provider while the director of nursing stood in the same building watching it happen, is worth sitting with. R1 was frail. She had active gastrointestinal bleeding. She was in a facility that had a written policy requiring catheter removal as soon as possible unless clinical necessity justified keeping it. The policy required assessment. The policy required documentation. The facility's own incontinence policy, dated May 1, 2026, stated that residents would not be catheterized unless their clinical condition demonstrated it was necessary, and that residents who arrived with or received a catheter would be assessed for removal as soon as possible.
The assessment did not happen. The documentation did not happen. The education did not happen.
What the inspection record captures, across interviews with the nurse practitioner, the medical director, and the director of nursing, is a facility where everyone who spoke to inspectors understood exactly what should have been done and could describe it in clinical detail. The nurse practitioner knew staff should have reapproached the resident, involved the family, provided education. The medical director knew the resident needed to understand the infection risk, that infection could lead to sepsis, that documentation of the failed removal attempt was required. The director of nursing knew there were no progress notes, knew the reason for leaving the catheter was not appropriate, knew it anyway.
R1 was very frail. She was very compromised. She had a bleed in her upper gastrointestinal tract. She had a catheter in her body that her provider had ordered removed. She had low blood pressure. And at some point between the order to remove the catheter and her death, nobody sat down with her and said: there is a device inside you that can cause an infection, and that infection can kill you, and you have the right to know that before you decide whether to let us take it out.
The medical director told inspectors that with her low blood pressure, the bleeding likely caused her death. The death certificate said sepsis and hemorrhagic shock. The nurse practitioner said the infection could have gone septic because the catheter was not removed.
CMS rated the harm level as minimal harm or potential for actual harm, affecting few residents. That rating reflects the regulatory classification system, not the outcome for R1. The outcome for R1 was death.
The facility's plan of correction was not included in the inspection materials reviewed. Inspectors noted the deficiency under the regulatory tag governing catheter use and unnecessary devices, a standard that exists because indwelling urinary catheters are a known vector for infection in elderly residents, particularly those who are already medically fragile.
R1 was medically fragile. She was also a person who, according to everyone interviewed after her death, was never given the information she needed to protect herself. The nurse practitioner said family could have been contacted, could have helped reason with her. Nobody called them. The medical director said the provider should have made sure the resident understood the education and documented it. Nobody documented it. The director of nursing said there were no progress notes at all.
There is a version of events in which R1, fully informed, still refuses the catheter removal. That is her right. But that conversation never happened. She died without it.
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 immediate jeopardy violations during a health inspection on May 26, 2026.
Her death certificate listed sepsis and hemorrhagic shock as causes of death.
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.