Woodbury Health Care Center: Pressure Ulcer Boot Failures - MN
Inspectors from the Centers for Medicare and Medicaid Services visited Woodbury Health Care Center on May 20, 2026, and found the resident — identified in inspection records as R4 — with his heel protectors lying on the floor near the end of his bed. His legs were resting directly on a disposable pad. It was 11:58 in the morning.
Nine minutes later, a registered nurse came into the room to deliver a meal tray and medication. She saw the boots on the floor. She left without putting them on.
At 1:19 that afternoon, the same nurse returned with a nursing assistant to perform wound care on R4's feet. While they were in the room, R4 told them the boots were supposed to be worn most of the time and asked them to put the boots on. They finished the wound care and left the room. Neither one put the boots on.
The nurse, interviewed that afternoon, said she knew R4 was supposed to wear the boots as much as possible to help prevent pressure ulcers. She acknowledged she had not put them on before leaving. The nursing assistant said the same. He knew the boots were used to prevent openings on R4's skin.
Two days later, inspectors returned and watched again. R4 was in his room with his call light on. The protective boots were sitting in his recliner. At 1:51 p.m., a different nursing assistant answered the call light. R4 asked her to put the boots on. She said: "Right now? Your aide will be back from break soon."
R4 explained that the boots should have been put on that morning, after his daily weigh-in around 6:30 a.m.
The morning aide, interviewed separately, confirmed he was R4's assigned aide for the morning shift. He knew from his care sheet that R4 was supposed to be wearing the protective boots. He hadn't put them on because he got busy and forgot. He acknowledged that R4 could develop more wounds without them.
R4's care plan, dated April 2, 2026, listed the boots as a required intervention, initiated May 4, 2023. Three years of documentation directing staff to keep the boots on. R4's diagnoses included diabetes, diabetic foot ulcers, an unstageable pressure ulcer, lymphedema, and chronic moisture-associated skin damage. He was dependent on staff for all activities of daily living, including applying footwear. He had no sensation in his lower legs. He could not verify for himself whether the boots were on or off.
When he asked a nursing assistant what was in his recliner and was told it was only a pillow, he had no way to know otherwise.
The director of nursing, interviewed on May 26, told inspectors that R4 was supposed to always wear the protective boots when in bed, to float his heels off the mattress. A copy of the facility's policy on developing and implementing care plans was requested. It was not provided.
The inspection report classified the violation as causing minimal harm or potential for actual harm, with few residents affected. The classification does not account for what R4 already had: an unstageable pressure ulcer, meaning wound damage that had already progressed deep enough that its full extent couldn't be determined. Unstageable wounds are among the most serious pressure injuries recognized in clinical practice. The boots existed precisely because the risk of making things worse was real and documented.
R4 knew his routine. He knew the boots were supposed to go on after his morning weigh-in. He knew something was in his recliner that the aide was telling him wasn't there. He asked, more than once, across more than one day, and was told to wait for someone else.
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.
His legs were resting directly on a disposable pad.
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.