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Woodbury Health Care Center

7012 Lake Road, Woodbury, MN 55125 · Washington County · (651) 735-6000

155 certified beds, about 111 residents a day · Non profit - Corporation · Medicare and Medicaid since 1981

Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
1 of 5
CMS note: The accuracy of the staffing data for this measure could not be validated by CMS.
Quality measures
4 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 245235 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on July 16, 2026, inspectors cited 11 health deficiencies (the Minnesota average is 7.1, the national average 9.2).

Of 46 health citations since September 2023, 4 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).

CMS lists 2 fines totaling $185,461 in the last three years; the largest was $167,862, and the latest is dated December 2, 2025.

24.4% of nursing staff left within the year CMS measured (Minnesota average 42.2%).

CMS links it to Lifespark, an affiliated group of 4 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 46 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
33D
4E
3F
Potential for minimal harm
0A
2B
0C
July 16, 2026Standard inspection, Complaint inspection · 11 citations
  1. F
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) August 6, 2026
    Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was served in a timely manner and at palatable temperatures for 1 of 1 residents (R102) who expressed concerns about food temperatures and palatability.
  2. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) August 6, 2026
    Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food items were labeled, dated when opened, and stored at the proper temperatures to prevent foodborne illness. In addition, the facility failed to ensure dishware was cleaned and sanitized and failed to ensure cups and pans were dry prior to stacking and storage. This had the potential to affect all residents who consumed food from the main production kitchen. Furthermore, the facility failed to ensure nursing and dietary staff followed appropriate infection control practices while handling plate covers during 1 of 1 meal service. This had the potential to affect residents residing on the second floor who received room tray.
  3. F
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    F847 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) August 6, 2026
    Inspectors wroteBased on interview and document review, the facility failed to ensure binding arbitration agreements for 3 of 3 residents (R63, R5, R120) were clearly explained in a form and manner that they understood prior to entering into the binding arbitration agreements.
  4. D
    Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
    F559 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 6, 2026
    Inspectors wroteBased on interview and document review, the facility failed to provide in writing a transfer of room notice. This effected 2 of 2 residents (R1, R102) reviewed for room change. Findings Include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact. Diagnoses included heart failure, post-traumatic stress disorder (PTSD), depression, and anxiety disorder. R1 was admitted on [DATE], to a transitional care unit (TCU) bed. R1's census report undated indicated R1 move to a long-term care (LTC), semiprivate bed on 5/5/26. R1's Transfer, Discharge, Bed Hold Notification form dated 5/5/26 at 3:38 p.m., indicated R1 was transferred from TCU to LTC on 5/5/26, because TCU was for rehabilitation and R1 was staying long term. The form lacked a signature or indication R1 refused to sign. [...]
  5. D
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    F605 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 6, 2026
    Inspectors wroteBased on interview and document review, the facility failed to ensure residents had the appropriate indications for use for 1 of 1 resident (R11) who was receiving antipsychotic medications.
  6. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 6, 2026
    Inspectors wroteBased on interview and document review the facility failed to report an allegation of physical abuse to the state agency (SA) for 1 of 1 residents (R1) reviewed for abuse. Findings IncludeR1's admission Minimum Data Set, dated [DATE], indicated R1 was cognitively intact. Diagnoses included heart failure, post-traumatic stress disorder (PTSD), depression, and anxiety disorder. R1's care plan dated 4/20/26, indicated R1 was a vulnerable adult and interventions included investigating any suspicions of abuse and report as necessary. R1's care plan dated 5/14/26, also indicated R1 had a history of experienced trauma and PTSD.R1's Trauma Informed Care Screening dated 6/6/26, indicated R1 had a history or experienced trauma with a goal to feel secure in the environment. In email correspondence received 7/15/26 at 1:04 p.m. [...]
  7. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 6, 2026
    Inspectors wroteBased on interview and document review the facility failed to thoroughly investigate an allegation of abuse for 1 of 1 residents (R1) reviewed for physical and mental abuse. Findings IncludeR1's admission Minimum Data Set, dated [DATE], indicated R1 was cognitively intact. Diagnoses included heart failure, post-traumatic stress disorder (PTSD), depression, and anxiety disorder. R1's care plan dated 4/20/26, indicated R1 was a vulnerable adult and interventions included investigating any suspicions of abuse and report as necessary. R1's care plan dated 5/14/26, also indicated R1 had a history of experienced trauma and PTSD.R1's Trauma Informed Care Screening dated 6/6/26, indicated R1 had a history or experienced trauma with a goal to feel secure in the environment. In email correspondence received 7/15/26 at 1:04 p.m. [...]
  8. D
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    F628 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 6, 2026
    Inspectors wroteBased on interview and document review, the facility failed to ensure written bed hold/transfer notices were give upon transfer to the hospital for 2 of 2 residents (R32, R9) reviewed for hospitalization.
  9. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 6, 2026
    Inspectors wroteBased on observation, interview, and document review the facility failed to ensure pressure ulcer interventions were implemented for 1 of 1 resident (R16) reviewed for pressure ulcers. R16's quarterly Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition and diagnoses of chronic kidney disease, congestive heart failure (CHF), and diabetes. It further indicated R16 was dependent on staff for most activities of daily living (ADL) and mobility, was at risk for and had (1) unstageable facility acquired pressure ulcer and moisture associated skin damage (MASD). R16's physicians orders dated 6/10/26, indicated R16 required pressure reducing boots on at all times, every shift for deep tissue injury (DTI) to left heel. [...]
  10. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 6, 2026
    Inspectors wroteBased on observation, interview, and document review the facility failed to ensure perimeter mattress were assessed for safety for 2 of 2 residents (R11, R16) reviewed for falls.
  11. D
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    F770 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 6, 2026
    Inspectors wroteBased on interview and document review, the facility failed to ensure orders were carried out for a urinary analysis and urine culture (UA/UC) in a timely manner for 1 of 1 resident (R76) reviewed for urinary tract infection (UTI).
May 26, 2026Complaint inspection · 7 citations
  1. G
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 25, 2026
    Inspectors wroteBased on interview and document review the facility failed to assess and monitor a change in condition for 3 of 4 residents (R1, R2, R4) reviewed for wound care. The lack of assessment and monitoring for R1 resulted in harm for R1 when R1 appeared to be sleeping in bed but instead had a change in responsiveness and mentation, was not assessed timely for the change, and was hospitalized . The lack of thorough assessment and monitoring for R2 resulted in delay in treatment for wounds related to moisture associated skin damage (MASD). Wound care staff identified wounds on 4/28/26, but were not evaluated until 5/11/26. The wounds were open and R2 reported pain associated with the wounds. [...]
  2. E
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) July 25, 2026
    Inspectors wroteBased on interviews and document review, the facility failed to develop a comprehensive care plan for 1 of 4 resident (R1) reviewed for compressive care plan. Additionally, based on interviews, observations, and document review, the facility failed to implement care planned interventions for 2 of 4 residents (R2, R4) reviewed for care plan implementation.
  3. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 3, 2026
    Inspectors wroteBased on interview, observation, and document review the facility failed to promote dignity for 1 of 4 residents (R4) when his call light was not answered timely, staff did not honor a request to don R4's protective heel boots, and did not provide a blanket to cover his body.
  4. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 3, 2026
    Inspectors wroteBased on interview, observation, and document review, the facility failed to ensure pressure ulcer (PU) preventative measures indicated on the care plan were implemented for 2 of 4 residents (R2, R4) reviewed for wounds.
  5. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 3, 2026
    Inspectors wroteBased on interviews and document review the facility failed to follow orders for catheter removal and failed to ensure catheter was in place for a valid medical reason for 1 of 3 residents (R1) reviewed for catheter care.
  6. D
    Provide or get specialized rehabilitative services as required for a resident.
    F825 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 3, 2026
    Inspectors wroteBased on interview and document review, the facility failed to ensure lymphedema (swelling caused by an accumulation of protein-rich fluid in the body's tissues) care was provided as ordered for 1 of 4 residents (R1) reviewed for wound care.
  7. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 3, 2026
    Inspectors wroteBased on observations, interviews, and document review, the facility failed to maintain an effective infection prevention and control program by ensuring staff utilized proper hand hygiene and appropriate glove use during wound care treatments for 1 of 1 resident (R4) reviewed for wound care.
December 2, 2025Complaint inspection · 1 citation
  1. J
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 5, 2026
    Inspectors wroteBased on interview and document review the facility failed to accurately transcribe a medication order correctly for Bumex (diuretic medication used to remove fluid) for 1 of 1 resident (R1) which resulted in an 18-pound (lb.) weight loss in 12 days, critical labs, vomiting and a hospitalization. In addition, the facility had two additional medication errors and failed to implement appropriate corrective actions to prevent the significant medication error for R1. The facility failure resulted in an immediate jeopardy (IJ) for R1. The IJ began on 11/07/25, when R1 was ordered Bumex (diuretic) 2 milligrams (mg) by mouth (po) QD (daily) x three days. The order was transcribed as Bumex 2 mg po TID (three times daily) with no stop date indicated. As a result, R1 received (36) 2 mg doses from 11/7/25 to 11/18/25 versus the 3 doses he should have been administered. [...]
July 24, 2025Standard inspection, Complaint inspection · 8 citations
  1. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) October 1, 2025
    Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food items were disposed of when needed and were properly stored, labeled, and dated. This had potential to affect all residents, staff, and visitors who consumed food from the main kitchen,and dining refrigerators.
  2. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) October 1, 2025
    Inspectors wroteBased on observation, interview, and document review, the facility failed to implement transmission-based precautions (TBP) and infection surveillance for 1 of 1 resident (R111) who had an active order to collect a stool sample for Clostridioides difficile (C. diff).
  3. D
    Allow residents to self-administer drugs if determined clinically appropriate.
    F554 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 1, 2025
    Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self administration of medications (SAM) was completed to allow residents to safely administer their own medications for 1 of 1 resident (R68) observed with a medication at the bedside. R68's Medical Diagnosis form indicated the following diagnoses: acute and chronic respiratory failure with hypoxia, severe persistent asthma, chronic obstructive pulmonary disease with acute exacerbation, and emphysema. R68's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, and had shortness of breath with exertion when sitting at rest, and when lying flat. R68's care plan dated 4/3/25 indicated R68 could not self-administer medications and nebulizers, and the facility was to administer medications as resident was not safe to independently administer medications at this time. [...]
  4. D
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    F578 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 1, 2025
    Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a resident's wishes for resuscitation were accurately documented in all areas the medical record for 1 of 22 residents (R87) reviewed for advanced directives. R87's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and diagnoses of [NAME]-Danlos Syndrome, signs and symptoms involving cognitive function and awareness, and Chronic Obstructive Pulmonary Disease (COPD). It further indicated R87 required supervision with activities of daily living (ADL) and was independent with mobility. R87's face sheet/banner in Point Click Care (computer system for documentation) indicated Do Not Resuscitate (DNR). R87's physician's orders indicated DNR. R87's Physician's Order for Life Sustaining Treatment (POLST) dated [DATE], indicated Cardiopulmonary Resuscitation (CPR) and DNR. [...]
  5. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 1, 2025
    Inspectors wroteBased on interview and document review, the facility failed to provide routine care conferences to allow for resident/ family participation and interdisciplinary review, and update, if necessary, of the care plan for 1 of 1 resident (R50) reviewed for care conferences.
  6. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 1, 2025
    Inspectors wroteBased on interview, observation, and document review, the facility failed to ensure symptoms of constipation were acted upon and assessed to determine what, if any interventions were needed to promote appropriate bowel management for 1 of 1 resident (R4).
  7. D
    Provide care or services that was trauma informed and/or culturally competent.
    F699 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 1, 2025
    Inspectors wroteBased on interview and record review the facility failed to assess trauma history and identify potential triggers for 1 of 1 residents (R8) with post-traumatic stress disorder (PTSD).
  8. D
    Provide medically-related social services to help each resident achieve the highest possible quality of life.
    F745 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 1, 2025
    Inspectors wroteNumber of residents sampled:2Number of residents cited:2Findings include:R11's quarterly Minimum Data Set (MDS) dated [DATE], indicated R11 was cognitively intact and had diagnoses of anxiety and depression. R11's care plan revised 12/15/24, indicated R11 had a psychosocial well-being problem related to depression and anxiety. Interventions included to encourage R11 to verbalize feelings, perceptions and fears and help identify precipitating factors of stressors. R11's medical record lacked indication follow up was completed after a behavioral outburst by R105. R105's admission MDS dated [DATE], indicated R105 was cognitively intact and had diagnoses of adjustment disorder with mixed disturbances and conduct and heart failure. R105's nursing progress note dated 6/17/25 at 8:48 p.m., indicated R105 had loud and disruptive behaviors for over 4 hours. [...]
April 30, 2025Complaint inspection · 2 citations
  1. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 4, 2025
    Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure call lights were within reach and accessible for 1 of 3 residents (R1), who was dependent on staff for care.
  2. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 4, 2025
    Inspectors wroteBased on observation, interview and document review the facility failed to ensure Enhanced Barrier Precautions (EBP)- (an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities,) were implemented or followed for management of a non-pressure skin wound to reduce the risk of infection to others for 1 of 1 resident (R1). Further the facility failed to implement hand hygiene for 1 of 1 resident (R1) observed during incontinence care and transfer.
March 7, 2025Complaint inspection · 1 citation
  1. J
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on interview and document review, the facility failed to accurately assess and implement interventions to prevent hypoglycemia (low blood sugar) for 1 of 1 resident who was diabetic, had a blood sugar of 30 mg/dl (milligrams per deciliter; normal range is 80-130 mg/dl) and was unresponsive at dialysis. This resulted in an immediate jeopardy for R1 who was hospitalized with hypogylcemia. The IJ began on 3/1/25 at 5:00 p.m. when R1 was admitted to the facility with orders for insulin but lacked orders to check blood sugars. The facility did not implement standing orders or request orders to monitor R1's blood glucose levels, resulting in a severe drop in R1's blood sugar level and hospitalization. The administrator, director of nursing (DON), and regional nurse were notified of the IJ on 3/7/25 at 11:50 a.m. [...]
June 27, 2024Standard inspection, Complaint inspection · 15 citations
  1. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on observation, interview and document review, the facility failed to implement care plan interventions, including providing required supervision, which resulted in a fall for 1 of 1 residents (R68) reviewed for accidents. This resulted in actual harm when R68 required hospitalization for pain control and sustained a fractured left tibia and fibula (lower leg bones). The facility had implemented and completed corrective action prior to the start of the survey, and the deficient practice is being issued at past non-compliance.
  2. E
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 14, 2024
    Inspectors wroteBased on observation, interview, and document review, the facility failed to promote dignity for 6 of 6 residents (R1, R23, R28, R31, R47, R58) reviewed for resident rights when name labels were observed on the outside of clothing. Additionally, the facility failed to ensure a dignified home-like environment was provided during dining services in 1 of 2 dining rooms reviewed.
  3. D
    Allow residents to self-administer drugs if determined clinically appropriate.
    F554 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 14, 2024
    Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure self-administration of medications was comprehensively assessed for 1 of 1 residents (R75) with medication found at the bedside.
  4. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 14, 2024
    Inspectors wroteBased on interview and document review, the facility failed to ensure a comprehensive, person-centered care plan was developed and readily available to promote continuity of care for 2 of 3 residents (R61, R199) reviewed for care planning.
  5. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 14, 2024
    Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure bathing care was consistently provided or recorded for 1 of 2 residents (R61) reviewed for activities of daily living (ADLs) and who was dependent on staff assistance for bathing.
  6. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 14, 2024
    Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess and, if needed, develope interventions to promote a proactive bowel management program to promote comfort and reduce the risk of complication (i.e., impaction, constipation) for 1 of 1 residents (R61); and failed to comprehensively assess and, if needed, develop or implement interventions to promote good posture and positioning while in bed for 1 of 1 resident (R26) observed who leaned significant to the side while in bed.
  7. D
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    F688 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 14, 2024
    Inspectors wroteBased on observation, interview and document review, the facility failed to provide passive range of motion and palm protector to prevent possible contracture for one of one residents (R38) reviewed for range of motion (ROM) who had limited functional movement of their hands.
  8. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 14, 2024
    Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure urology orders for catheterization were clarified; and failed to ensure the use of an in-dwelling Foley catheter was comprehensively assessed or care-planned to promote continuity of care for 1 of 1 resident (R20) reviewed for catheter use.
  9. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 14, 2024
    Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper cleaning of a non-invasive ventilation machine to reduce the risk of complications (i.e., respiratory infection) for 1 of 1 residents (R40) observed for non-invasive ventilation machine use.
  10. D
    Provide care or services that was trauma informed and/or culturally competent.
    F699 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 14, 2024
    Inspectors wroteBased on observation, interview, and document review the facility failed to comprehensively assess past trauma and develop a comprehensive person-centered care plan with goals and interventions utilizing a trauma-informed approach including monitoring of PTSD (post-traumatic stress disorder) for 1 of 1 (R39) residents reviewed for trauma-informed care.
  11. D
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 14, 2024
    Inspectors wroteBased on interview and document review, the facility failed to ensure consultant pharmacist recommendations were acted upon timely, and an appropriate rationale was recorded for not implementing recommendations for 1 of 5 residents (R38) reviewed for unnecessary medication use.
  12. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 14, 2024
    Inspectors wroteBased on interview and document review, the facility failed to ensure a scheduled antifungal medication without an end date was evaluated for the appropriateness of its continued use for 1 of 5 residents (R40) reviewed for unnecessary medications.
  13. D
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 14, 2024
    Inspectors wroteBased on interview and document review the facility failed to care plan and document resident specific target behaviors for 1 of 5 residents (R38) who was prescribed scheduled antipsychotic medication. Further, the facility failed to ensure that as-needed (PRN) psychotropic medications were limited to 14 days of use or the practitioner documented both a specific order duration and the rationale for extending the PRN psychotropic order, to ensure the medications continued necessity and reduce the risk of complication for 1 of 5 residents (R69) reviewed for unnecessary medication use.
  14. B
    Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
    F568 · Resident Rights · No actual harm, potential for minimal harm, pattern · Corrected (the home has a date of correction) August 14, 2024
    Inspectors wroteBased on interview and document review, the facility failed to ensure quarterly statements of resident' trust fund balances were provided for 2 of 2 residents (R13, R75) who voiced they had not received one; and for an additional 32 of 32 residents identified to have trust accounts managed by the care center.
  15. B
    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
    F569 · Resident Rights · No actual harm, potential for minimal harm, pattern · Corrected (the home has a date of correction) August 14, 2024
    Inspectors wroteBased on interview and document review, the facility failed to ensure resident' trust account balances above the state-required supplemental security income (SSI) threshold (i.e., $3,000) were identified and notice provided to the resident for 3 of 3 residents (R26, R5, R45) whose balance was over the amount. This had potential to affect a total of 6 of 6 residents with excessive balances with the potential to impact their medical assistance coverage.
September 15, 2023Complaint inspection · 1 citation
  1. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 13, 2023
    Inspectors wroteBased on interview and document review, the facility failed to report to the state agency immediately, within 2 hours, an allegations of verbal abuse for one of one (R1) residents reviewed. R1's hospital discharge paperwork dated 8/28/23, indicated R1 was discharged to the facility for supportive care following a coronary artery bypass graft (CABG) surgery. A handwritten complaint from R1 written 8/31/23 indicated a facility employee had entered her room unannounced and when R1 attempted to speak with the employee, he had told her to shut up. MDS admission assessment dated [DATE] indicated R1's diagnoses included non-ST elevation myocardial infarction, coronary artery disease, and the presence of bypass grafts. R1's Brief Interview for Mental Status (BIMS) was 12 out of 15, and indicated she was moderately cognitively impaired. [...]

Fire safety inspections

30 fire safety citations on file: 4 on July 16, 2026, 14 on July 24, 2025, 12 on June 27, 2024.

Every fire safety citation30 citations
  1. F
    Provide properly protected cooking facilities.
    K 324 · July 16, 2026 · Corrected (the home has a date of correction)
  2. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · July 16, 2026 · Corrected (the home has a date of correction)
  3. D
    Have an enclosure around a vertical opening shaft.
    K 311 · July 16, 2026 · Corrected (the home has a date of correction)
  4. D
    Have proper medical gas storage and administration areas.
    K 923 · July 16, 2026 · Corrected (the home has a date of correction)
  5. F
    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
    K 223 · July 24, 2025 · Corrected (the home has a date of correction)
  6. F
    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
    K 372 · July 24, 2025 · Corrected (the home has a date of correction)
  7. F
    To conduct inspection, testing and maintenance of fire doors by qualified individuals.
    K 761 · July 24, 2025 · Corrected (the home has a date of correction)
  8. F
    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
    K 914 · July 24, 2025 · Corrected (the home has a date of correction)
  9. E
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · July 24, 2025 · Corrected (the home has a date of correction)
  10. D
    Have a combustible roofing system that meets safety standards.
    K 162 · July 24, 2025 · Corrected (the home has a date of correction)
  11. D
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · July 24, 2025 · Corrected (the home has a date of correction)
  12. D
    Provide properly protected cooking facilities.
    K 324 · July 24, 2025 · Corrected (the home has a date of correction)
  13. D
    Follow proper procedures when the fire alarm was out of service for more than 4 hours.
    K 346 · July 24, 2025 · Corrected (the home has a date of correction)
  14. D
    Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
    K 354 · July 24, 2025 · Corrected (the home has a date of correction)
  15. D
    Properly select, install, inspect, or maintain portable fire extinguishes.
    K 355 · July 24, 2025 · Corrected (the home has a date of correction)
  16. D
    Install properly constructed and protected linen or trash chutes.
    K 541 · July 24, 2025 · Corrected (the home has a date of correction)
  17. D
    Have simulated fire drills held at unexpected times.
    K 712 · July 24, 2025 · Corrected (the home has a date of correction)
  18. D
    Ensure proper usage of power strips and extension cords.
    K 920 · July 24, 2025 · Corrected (the home has a date of correction)
  19. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · June 27, 2024 · Corrected (the home has a date of correction)
  20. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · June 27, 2024 · Corrected (the home has a date of correction)
  21. F
    Install smoke barrier doors that can resist smoke for at least 20 minutes.
    K 374 · June 27, 2024 · Corrected (the home has a date of correction)
  22. F
    Install properly constructed and protected linen or trash chutes.
    K 541 · June 27, 2024 · Corrected (the home has a date of correction)
  23. F
    Have simulated fire drills held at unexpected times.
    K 712 · June 27, 2024 · Corrected (the home has a date of correction)
  24. F
    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
    K 914 · June 27, 2024 · Corrected (the home has a date of correction)
  25. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · June 27, 2024 · Corrected (the home has a date of correction)
  26. F
    Ensure proper usage of power strips and extension cords.
    K 920 · June 27, 2024 · Corrected (the home has a date of correction)
  27. F
    Have proper medical gas storage and administration areas.
    K 923 · June 27, 2024 · Corrected (the home has a date of correction)
  28. F
    Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
    K 926 · June 27, 2024 · Corrected (the home has a date of correction)
  29. F
    Ensure proper storage of liquid oxygen.
    K 930 · June 27, 2024 · Corrected (the home has a date of correction)
  30. C
    Properly select, install, inspect, or maintain portable fire extinguishes.
    K 355 · June 27, 2024 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
December 2, 2025Fine $167,862
March 7, 2025Fine $17,599

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeMinnesotaUnited States
All nursing staff (RN, LPN and aides)not reported4.193.86
Registered nursesnot reported1.060.69
All nursing staff on weekendsnot reported3.713.42
Nurse aidesnot reported
Licensed practical nursesnot reported
Nursing staff turnover (share who left in a year)24.4%42.2%45.8%
Registered nurse turnover32.0%38.6%42.9%
Administrators who leftnot reported

CMS note on this home's staffing data: The accuracy of the staffing data for this measure could not be validated by CMS.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.10 on weekdays and 3.52 on weekends, 14% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.37 in April to June 2025 to 3.93 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.930.944.103.52 0.0%0 of 90111
Oct to Dec 20254.261.094.503.64 0.0%0 of 92102
Jul to Sep 20253.500.813.722.96 21.1%0 of 9299
Apr to Jun 20253.370.893.582.82 0.4%0 of 91108
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Minnesota, Jan to Mar 20264.191.054.383.735.2%0.8% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.

Official wage estimates for Minnesota

JobMedianMiddle halfEmployed
Minnesota, all employers
CNAs (nursing assistants)$22.44$19.39 to $23.7229,120
LPNs and LVNs$30.65$28.83 to $34.2612,840
Registered nurses$48.80$42.76 to $55.1770,110
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeMinnesotaUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
12.418.213.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.31.90.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
1.32.61.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
0.34.03.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
0.71.91.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
18.220.514.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
5.05.24.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
19.217.115.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
31.023.523.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
7.314.812.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
2.61.61.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
0.81.91.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Woodbury Health Care Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (62.1% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

62.1% this home

Better than the national rate

US median of homes 51.5% · Minnesota: 66 better, 14 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 231 eligible stays.

Potentially preventable readmissions

9.4% this home

No different from the national rate

US median of homes 10.7% · Minnesota: 0 better, 0 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 218 eligible stays.

Infections that led to a hospital stay

9.6% this home

No different from the national rate

US median of homes 7.1% · Minnesota: 2 better, 0 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 135 eligible stays.

Self-care and mobility at discharge

48.8% this home

Median of homes: Minnesota57.8% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 82 residents counted.

Falls with major injury

2.7% this home

Median of homes: Minnesota0.0% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 111 residents counted.

New or worsened pressure ulcers

4.2% this home

Median of homes: Minnesota2.0% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 111 residents counted.

Medication list given at discharge

96.9% this home

Median of homes: Minnesota98.5% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 32 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: SENIOR CARE WOODBURY, LLC. CMS links this home to Lifespark, a group of 4 nursing homes averaging 1.2 stars overall.

NameRoleTypeShareSince
Senior Care CommunitiesDirect ownership interestOrganization03/01/2007
Marshall, SusanManaging control - governing bodyIndividual03/01/2007
Marshall, SusanCorporate directorIndividual03/01/2007
Toulouse, MollyCorporate directorIndividual08/01/2021
King, RyanCorporate officerIndividual04/01/2025
Lifespark Management ServicesOperational/managerial controlOrganization06/30/2020
Twsl. LLCOperational/managerial controlOrganization07/01/2007
Karel, MikeOperational/managerial controlIndividual02/01/2016
King, RyanOperational/managerial controlIndividual04/01/2025
Parmar, MonaOperational/managerial controlIndividual05/01/2022
Sounthala, NicoleOperational/managerial controlIndividual10/31/2024
Martin, RichardIndividual is an owner, partner or trustee of any ADP of the SNFIndividual07/08/2025
Senior Care CommunitiesTrustee of the SNFOrganization03/01/2007
Aegis Therapies, Inc.Adp of the SNFOrganization01/01/2009
Grape Tree Medical Staffing LLCAdp of the SNFOrganization12/01/2023
Lifespark Management ServicesAdp of the SNFOrganization07/07/2025
Senior Care CommunitiesAdp of the SNFOrganization03/01/2007
Shiftster LLCAdp of the SNFOrganization12/01/2023
Twsl. LLCAdp of the SNFOrganization05/19/2025
Karel, MikeAdp of the SNFIndividual02/01/2016
King, RyanAdp of the SNFIndividual04/01/2025
Parmar, MonaAdp of the SNFIndividual05/01/2022

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 17 problems in this area, most recently on July 16, 2026: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 10 problems in this area, most recently on July 16, 2026: "Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made."
  3. How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 4 problems in this area, most recently on July 16, 2026: "Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function."
  4. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 4 problems in this area, most recently on December 2, 2025: "Ensure that residents are free from significant medication errors."

Other nursing homes nearby

Minnesota contacts for a concern about a nursing home

These are the official offices in Minnesota. NursingHomeClear cannot take or act on complaints.

Common questions

What is Woodbury Health Care Center's Medicare star rating?
CMS rates Woodbury Health Care Center 1 out of 5 stars overall, with 1 for health inspections, 1 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Woodbury Health Care Center get at its last inspection?
11 health deficiencies at the standard inspection on July 16, 2026. The Minnesota average is 7.1.
Has Woodbury Health Care Center been fined?
Yes. CMS lists 2 fines totaling $185,461 in the last three years.
Does Woodbury Health Care Center accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Woodbury Health Care Center?
CMS lists 22 owners and managers, and links the home to Lifespark. Legal business name: SENIOR CARE WOODBURY, LLC.

Sources

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