Woodbury Health Care Center: Monitoring Failures - MN
He was found unresponsive in his bed just after midnight on May 13. His oxygen saturation had dropped to 77 percent. He was admitted to the hospital at 3:30 a.m. with a temperature of 103.3 degrees.
When inspectors interviewed him a week later, he said he had just returned from the hospital the day before. He had an infection in his blood.
The inspection report, completed May 26, 2026, cited the facility for causing actual harm to the resident, identified in the report as R4.
The breakdown began at least a day earlier. On the morning of May 12, a nurse noted R4 was not feeling well, had vomited, and was weak. His temperature was 101.1 degrees. His oxygen saturation was 91 percent. The nurse offered to send him to the emergency room; he declined. He asked for Tylenol, and she gave it to him. She reported his condition to the oncoming shift.
She did not take his blood pressure. She did not take his respirations. She did not call his doctor or his family.
What followed was a day of notes that recorded events without recording the patient. At 7:46 a.m., a nurse noted that R4's condition prevented his scheduled leg treatments. The note contained no vital signs, no nursing assessment. At 11:15 a.m., R4 refused to eat. The note didn't say why, and didn't include an assessment or vital signs. At 2:14 p.m., he was given Tylenol again for pain, with a temperature still at 100.5. The note didn't say where the pain was, didn't include blood pressure or respirations.
Six minutes later, at 2:20 p.m., he received oxycodone for back pain.
At 3:27 p.m., the Tylenol was rated ineffective. His pain was a five out of ten. The oxycodone he'd received an hour earlier apparently hadn't resolved it. The note contained no call to the provider about unmanaged pain, and no mention that a second opioid dose had been given or was being considered.
At 3:28 p.m., he refused his insulin — 20 units of Novolog. The inspection report found no documentation that his provider had been notified of insulin refusals on either May 11 or May 12, and no evidence that anyone had explained to R4 the risks of refusing it.
The provider was finally contacted at 4:20 p.m. about R4's change in condition. What happened after that call, the notes don't clearly show.
By 9:49 p.m., R4 was described as "very lethargic." He refused another medication. Again, no note of a call to the provider, no documentation of education about the refusal. By 10:16 p.m., nurses noted he had been lethargic all shift, had not eaten or drunk anything, and needed help holding a cup. His brother had visited and planned to return the next day. The note contained no vital signs, no nursing assessment, no indication the provider had been updated.
Inspectors later reviewed R4's vital signs records and found something that put the entire picture in sharper focus. His blood pressure had not been recorded since May 1 — eleven days before he was found unresponsive. His pulse had not been recorded in that same span. His temperature had not been taken in the eleven days between May 1 and the morning of May 12, when the fever was first noted.
A family member, interviewed by inspectors on May 22, said R4 had a history of hospitalizations connected to his catheter and urinary tract infections. He said he was concerned about this particular hospitalization because it seemed like a deterioration — the inspection report cuts off before his full statement is recorded, but the implication is plain.
The inspection report found the progress notes lacked evidence of nursing assessments across the entire span of May 12 and into May 13: no full vital signs, no pain assessments, no documentation of changes in cognition or speech, no lung sounds, no assessment of mobility or elimination. There was no evidence that R4 or his family had been given information about the risks of refusing medications, about the delay in seeking hospital care, or about palliative care options.
When R4 was found at 12:50 a.m. on May 13, his oxygen saturation had fallen to 77 percent on five liters of supplemental oxygen. The provider was called at 12:53 a.m. and ordered him sent to the emergency room. Even that final note, inspectors found, lacked a full set of vital signs.
His brother had planned to come back that morning.
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.
He was found unresponsive in his bed just after midnight on May 13.
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.