Woodbury Health Care Center: Wound Care Neglect - MN
The nursing assistant, identified in the inspection report only as NA-D, told inspectors during an interview on May 22 that he knew from his care sheet the resident, referred to as R4, was supposed to be wearing the boots. He had not put them on because he had gotten busy and forgotten. He acknowledged, when asked, that R4 could develop more wounds without them.
That acknowledgment was not a small concession. R4's lower legs required bandages, black compression stockings over the bandages, and protective boots over the stockings. The layered protocol existed for a reason. The boots were designed to offload his heels entirely, keeping them suspended so that the pressure and friction that cause pressure ulcers could not reach skin that was already compromised.
The licensed practical nurse on duty, identified as LPN-D, told inspectors on May 26 that without the boots, R4's existing wounds could worsen, or he could develop entirely new ones. The registered nurse interviewed that same day said plainly that if R4's care plan and orders indicated he should be wearing the protective boots, then he should have been wearing them. The director of nursing put it in the starkest terms: R4 was supposed to always wear the protective boots when in bed, to float his heels off the mattress and prevent new pressure ulcers. Without them, she said, he was at risk.
The word "always" is doing significant work in that statement. This was not a judgment call left to individual aides on individual shifts. It was a standing order, documented in R4's care plan, specific enough to describe the sequence of dressing his legs from bandage to stocking to boot. The morning shift nursing assistant knew it was there. He read the care sheet. He simply did not follow it.
Woodbury Health Care Center's own Skin Management Program, in place since November 2017, lists the exact population of residents it is designed to protect: those with impaired mobility, decreased functional ability, conditions like end-stage renal disease and diabetes, cognitive impairment, exposure to moisture on the skin. The program calls for heel protection as an explicit intervention, alongside skin observations during cares and management of incontinence. R4, a resident with wounds serious enough to require a multi-layer protective system on both legs, was precisely the kind of patient that program was written for.
The inspection, conducted on May 26, 2026, was triggered by a complaint. CMS classified the harm level as minimal harm or potential for actual harm, and noted that few residents were affected. Those classifications reflect the regulatory framework's language, not a reassurance that nothing serious was at stake. A resident with open wounds sitting in a recliner without his prescribed heel protection, in a facility whose own skin management policy identifies impaired mobility as a primary risk factor for pressure ulcer development, was not in a safe situation. He was in the situation the entire care plan existed to prevent.
What the inspection report does not say is how long R4. sat without the boots before he looked over at his recliner and asked about them. It does not say whether anyone had checked on him before that moment, or what condition his existing wounds were in when the oversight was discovered. It records what the nursing assistant said when asked, what the nurses said when asked, what the director of nursing said when asked. It records the protocol that existed and was not followed.
R4 found his own boots sitting on the chair beside him and asked what they were doing there. That question started the chain of interviews that ended with the director of nursing confirming he was supposed to be wearing them at all times.
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 neglect violations during a health inspection on May 26, 2026.
He had not put them on because he had gotten busy and forgotten.
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.