Woodbury Health Care Center
WOODBURY HEALTH CARE CENTER in WOODBURY, MN — inspection on May 26, 2026.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 5/26/26 at 3:31 p.m., the director of nursing (DON) stated waiting 38 minutes for a call light response was too long, and staff were expected to answer call lights as quickly as possible, Thirty-eight minutes sitting there waiting feels like a lifetime.
Further, the DON stated R4 would feel terrible waiting for his protective boots, and when residents asked for help, staff was expected to help meet their needs.
The Promoting/Maintaining Dignity policy dated 4/1/26 indicated it is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.
Compliance guidelines included: During interactions with residents, staff must report, document and act upon information regarding resident preferences.Respond to requests for assistance in a timely manner.
The Call Lights Accessibility and Timely Response policy dated 4/2025 indicated that all staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.
245235 05/26/2026
Woodbury Health Care Center 7012 Lake Road Woodbury, MN 55125
During an observation on 5/20/26 at 11:58 a.m., R4's heel protectors were lying on the floor near the end of R4's bed. R4's legs were resting directly on a disposable pad at the end of the bed.
During an observation on 5/20/26 at 12:07 p.m., the RN-D entered R4's room to bring R4's meal tray and medication. R4's heel protectors were left lying on the floor near the end of R4's bed when RN-D left R4's room.
During an observation on 5/20/26 at 1:19 p.m., R4's heel protectors were lying on the floor near the end of R4's bed, the RN-D and the NA-B entered the room to perform wound care for R4.
During wound care, R4 requested the RN-D and NA-B don his protective boots and stated they were to be worn most of the time.
When the wound care was completed, both the RN-D and NA-B left the room without donning R4's protective boots.
During an interview on 5/20/26 at 2:14 p.m., the RN-D stated R4 was supposed to wear his protective boots as much as possible to help prevent pressure ulcers and acknowledged she did not put them on R4 before leaving his room.
During an interview on 5/20/26 at 2:18 p.m., the NA-B acknowledged he did not put R4's protective boots on R4's feet, and stated the boots were used to prevent openings on R4's skin.
During a continuous observation on 5/22/26 starting at 1:13 p.m., R4 was in his room and had activated his call light. R4's protective boots were in his recliner. At 1:51 p.m., the NA-C answered R4's call light. R4 asked the NA-C to don his protective boots.
The NA-C responded, Right now? Your aide will be back from break soon. R4 explained to the NA-C that his protective boots should have been put on in the morning, after he was weighed.
During an interview on 5/22/26 at 1:13 p.m., R4 stated he asked a NA several times what was sitting in his recliner, and the NA had responded saying only a pillow was in the recliner. R4 stated he had poor vision and could not see what was in his chair for himself, could not feel his legs from his knees to his feet, so he did not know staff had not donned his boots. R4's routine was to have his weight checked daily around 6:30 a.m., and staff would don his boots afterwards to protect his feet and offload his heels.
During an interview on 5/22/26 at 2:25 p.m., the NA-D stated he was R4's assigned NA for the morning shift, and R4 had asked what was on his recliner.
The NA-D stated he knew from his care sheet R4 was supposed to be wearing his protective boots, but was not because the NA-D had gotten busy and forgot about them.
The NA-D acknowledged R4 could develop more wounds if he were not wearing the protective boots.
During an interview on 5/26/26 at approximately 1:30 p.m., the RN-B stated if R4's care plan and orders directed for R4 to wear the protective boots, then R4 should have been wearing them.
During an interview on 5/26/26 at 3:31 p.m., the DON stated R4 was supposed to always wear the protective boots on his feet when he was in bed to float his heels off the bed. A policy regarding developing and implementing care plans was requested but not provided.
245235 05/26/2026
Woodbury Health Care Center 7012 Lake Road Woodbury, MN 55125
During an interview on 5/20/26 at 11:58 a.m., R4 stated he had returned from the hospital the day prior for an infection in his blood.
During an interview on 5/22/26 at 9:57 a.m., the FM-E stated R4 had many hospitalizations, seemingly related to his catheter and UTIs.
The FM-E stated he was concerned about R4's recent hospitalization because it seemed like a del
245235 05/26/2026
Woodbury Health Care Center 7012 Lake Road Woodbury, MN 55125
During an interview on 5/26/26 at approximately 1:30 p.m., the RN-B stated if R4's care plan and orders indicated to wear the protective boots, then R4 should have been wearing them.
During an interview on 5/26/26 at 3:31 p.m., the DON stated R4 was supposed to always wear the protective boots on his feet when he was in bed to float his heels off the bed, and to prevent new wounds.
Without the boots, R4 was at risk for new PU.
The Skin Management Program dated 11/2017 indicated the program was utilized to promote the prevention of alterations in skin integrity, promote healing of skin alteration, and to prevent further loss of skin integrity.
All residents will be assessed for skin integrity alterations or changes in skin conditions upon preadmission screening, admission, daily within the plan of care, and weekly with a bath. A body audit will be completed weekly, preferably on bath day.
Risks for impaired skin integrity included impaired mobility, decreased functional ability, co-morbid conditions such as end stage renal disease, diabetes, obesity, cognitive impairment, exposure to moisture on the skin, resident refusal, pain, and poor sleep.
Interventions for skin integrity management included heel protection, skin observations during cares, and management of incontinence.
245235 05/26/2026
Woodbury Health Care Center 7012 Lake Road Woodbury, MN 55125
During an interview on 5/26/26 at 3:31 p.m., the director of nursing (DON) stated there were no progress notes that indicated staff or the provider educated R1 about the risks and benefits of leaving the Foley catheter inserted, it was not left for an appropriate reason, and it was the provider's decision, despite it being inappropriate.
The Incontinence Policy dated 5/1/26 indicated for residents with urinary incontinence, the facility will ensure that residents are not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary.
Residents who enter the facility with an indwelling catheter, or received one while in the facility, will be assessed for removal of the catheter as soon as possible, unless the resident's clinical condition demonstrates that catheterization was necessary.
245235 05/26/2026
Woodbury Health Care Center 7012 Lake Road Woodbury, MN 55125
During an interview on 5/22/26 at 11:54 a.m., the physical therapist (PT)-A stated R1 used compression pumps at home and another facility prior to admission to this facility. R1 was able to demonstrate how to correctly use the pumps.
The therapy department advocated for R1 to continue to use the compression pumps because R1's legs got very large with fluid, and the pumps would have helped push some of the fluid out of her legs.
The PT-A stated the facility director of nursing (DON) did not allow R1 to use the pumps initially because the nursing department was not familiar with the pumps.
Then the DON wouldn't allow R1 to use them out of fear R1 could not shut the pump off if she needed to. R1 demonstrated to the therapy department that she could turn the power off, and unzip the compression sleeves. R1 further demonstrated she understood the settings on the pumps, but was still not allowed to use them.
The PT-A stated R1's hospital orders indicated she was supposed to have PT lymphedema therapy which was available for a couple of days a week when R1 admitted to the facility, but not for the daily treatment she needed.
The PT staff who was trained to do lymphedema treatment was only on site twice a week, and having just come from the hospital, that would not have been enough to manage the lymphedema.
The PT department was trying to eliminate the barriers to using the pumps, but they were just not allowed.
During an interview on 5/22/26 at 2:54 p.m., the registered nurse (RN)-A stated the therapy department provided lymphedema care for R1, the nursing staff placed bandages and ACE wraps on R1's legs for lymphedema, and R1's husband put lymphedema pumps on R1's legs.
The nursing staff was not trained for lymphedema care.
During an interview on 5/26/26 at approximately 1:30 p.m., the RN-B stated R1 did not have a care plan for lymphedema care because nursing staff was not trained for lymphedema care.
During an interview on 5/26/26 at 3:31 p.m., the director of nursing (DON) stated R1 was admitted to the facility with orders for lymphedema wraps for her legs, which the facility therapy department provided but at some point (the DON didn't know the date), the therapy department deferred R1's lymphedema care to the nursing staff.
Instead, R1's family member was managing R1's compression wraps and pumps.
There was a six-to-seven-day delay for the therapy department to do the assessment to ensure R1 and her family member knew how to use the pumps. It should not have taken that long.
The nursing staff was not trained to use compression sleeves and pumps. It was 3/25/26 when therapy stated she could use them.
The DON stated she was unsure why the PT notes indicated on 4/22/26 R1 would benefit from using them, R1 should have been using them, with the help from her husband, but the DON was unsure if they were in use.
The DON stated the delay in care for the lymphedema pumps could have contributed to R1's legs swelling more. A policy about lymphedema care was requested but not provided.
245235 05/26/2026
Woodbury Health Care Center 7012 Lake Road Woodbury, MN 55125
During an observation on 5/20/26 at 1:10 p.m., the registered nurse (RN)-D provided wound care for R4.
The RN-D cleansed the wound on R4's right leg, doffed her gloves and then donned clean gloves without performing hand hygiene between glove changes. R4 asked the RN-D to don his compression stocking on his right leg before performing wound care on the left leg.
The RN-D donned R4's right compression stocking and then removed the dirty bandages from R4's left leg. R4 cleaned the wound and applied clean bandages over the wounds on R4's left leg without changing gloves.
During an interview on 5/20/26 at 2:14 p.m., the RN-D acknowledged she was supposed to perform hand hygiene between gloves changes, and change gloves after removing soiled dressings, before applying clean dressings to prevent infection, but had not because she forgot.
During an interview on 5/26/26 at 3:31 p.m., the director of nursing (DON) stated when performing wound care, nurses should change gloves between touching anything dirty and anything clean and between wounds.
The DON expect the nurse to perform hand hygiene in between gloves changes to prevent infection in the wounds. An infection control policy for wound care was requested but not provided.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.