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Woodbury Health Care Center: Pressure Ulcer Boot Failures - MN
His legs were resting directly on a disposable pad....
Latest reports, citations, and penalties from CMS data
His legs were resting directly on a disposable pad....
Her blood pressure was 144/68 that morning....
The resident, identified in inspection records only as R901, had been admitted to the facility with a broken left femur, diabetes, and hypertension....
Inspectors from the Centers for Medicare and Medicaid Services visited the facility on May 27, 2026, and reviewed care planning for two residents....
The violation was cited during a complaint inspection on May 26, 2026, at Carrier Mills Nursing & Rehab Center....
The Director of Nursing confirmed it at 7:53 a.m.: no residents, no census....
That gap, documented during a May 2026 complaint inspection, sat at the center of what federal surveyors found at the Chisago City facility....
The inspection was triggered by a complaint, not a routine survey....
It isn't always a dramatic failure, a fall with broken bones, or a resident found on the floor for hours....
She knew exactly what she was smelling and exactly why....
The first resident was standing at the nurses' station counter near the building entrance when they asked CNA A for a snack just before 10:30 in the morning....
His most recent cognitive assessment gave him a score of 7 out of 15 on the Brief Inventory of Mental Status, a threshold that indicates cognitive impairment....
He needed help with toileting, hygiene, clothing, and cleaning himself after bowel movements before he ever arrived....
Without that documentation, there was no way to confirm the treatments had happened at all....
The inspection, completed May 27, 2026, was triggered by a complaint....
Quality Life Services Westmont had been down this road before....
That was the night of May 10, 2026....
The care plan for that resident was specific....
Both the aide and the dietary manager, standing together during an immediate interview, confirmed what inspectors had just watched....
That single email was the first notification he had received about his ward's relocation, he told inspectors....