Woodbury Health Care Center: Wound Care Failures - MN
The resident, identified in inspection records only as R4, was already carrying a serious infection load. His care plan documented chronic methicillin-resistant Staphylococcus aureus, the antibiotic-resistant bacteria known as MRSA, in his wounds. He also had an unstageable pressure ulcer, a wound so deep that inspectors and clinicians cannot determine where the damage ends, along with diabetic foot ulcers, lymphedema, and incontinence. His skin had been breaking down, in one form or another, since at least January 2022.
His wound care orders were specific. Cleanse the wound bed with a professional-grade solution. Apply a silver non-adherent dressing cut to fit. Cover with gauze. Secure with a wrap. Change every 48 hours, or sooner if the bandages became saturated or soiled.
What inspectors observed on the afternoon of May 20, 2026, did not match that picture of controlled, careful care.
At 1:10 p.m., a registered nurse identified in the report as RN-D began treating the wound on R4's right leg. She cleaned the wound, then removed her gloves and put on a fresh pair. She did not wash her hands in between. Then R4 asked her to help him put on his compression stocking on the right leg before she moved to the left.
She pulled on the compression stocking.
Then, without changing her gloves, she peeled away the soiled dressings from R4's left leg, cleaned that wound, and applied fresh bandages.
The same gloves that had handled a compression stocking, and before that had been swapped without any hand hygiene, were now touching an open wound on a man with MRSA.
Less than an hour later, inspectors interviewed RN-D. She acknowledged she was supposed to wash her hands between glove changes and was supposed to change gloves after removing soiled dressings and before applying clean ones. She said she had not done those things because she forgot.
The director of nursing, interviewed six days later on May 26, described the standard plainly: nurses should change gloves between anything dirty and anything clean, and between wounds. Hand hygiene between glove changes was expected, she said, to prevent infection from taking hold in the wounds.
When inspectors asked to see the facility's infection control policy for wound care, the facility did not provide one.
That absence matters. A policy is what gets pulled out when a nurse is being trained, when a supervisor is checking someone's technique, when a facility is trying to demonstrate that a lapse was an individual failure rather than a systemic one. Without it in the record, there is no document showing what Woodbury Health Care Center told its nurses wound care was supposed to look like.
The inspection was triggered by a complaint. It covered one resident reviewed for wound care. The harm level was classified as minimal harm or potential for actual harm, the lower end of the federal scale. But that classification reflects regulatory category, not the specific biology of what was happening in R4's wounds.
MRSA does not need many opportunities. It is resistant to the antibiotics that would ordinarily clear it. It spreads on hands and gloves. A man with open wounds on both legs, with diabetes impairing his circulation and his body's ability to fight infection, with lymphedema adding swelling and fluid to the tissue, with incontinence creating chronic moisture against fragile skin, does not have a lot of reserve capacity when something goes wrong.
The nurse said she forgot. The director of nursing said she expected better. The policy was requested and not produced.
R4 was still in that room when inspectors left.
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 14, 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 only as R4, was already carrying a serious infection load.
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.