Inspection Reports for
Walker Methodist – Westwood Ridge
1 Thompson Ave W, West St Paul, MN 55118, United States, MN, 55118
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
200% worse than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 13
Date: Jan 23, 2025
Visit Reason
Routine inspection of Walker Methodist Westwood Ridge II nursing home to assess compliance with regulatory requirements including resident care, infection control, medication management, and immunization practices.
Findings
The facility failed to honor resident bathing preferences, provide timely care conferences, ensure comprehensive care plans, maintain effective hospice collaboration, properly manage indwelling catheters and bowel continence, monitor psychotropic medication side effects, implement infection prevention and control programs, monitor antibiotic use, designate a qualified infection preventionist, and offer recommended pneumococcal and influenza vaccinations.
Deficiencies (13)
F 0561: The facility failed to ensure resident bathing preferences were assessed and honored for 1 of 1 residents (R5).
F 0582: The facility failed to provide required Medicaid/Medicare notices upon termination of Medicare coverage for 3 of 4 residents reviewed.
F 0583: The facility failed to keep residents' personal and medical records private and confidential, exposing information to public view affecting multiple residents.
F 0655: The facility failed to provide a copy of the resident's baseline care plan within 48 hours of admission for 1 of 2 residents reviewed.
F 0656: The facility failed to develop and implement a comprehensive care plan meeting all resident needs for 1 of 5 residents reviewed.
F 0657: The facility failed to conduct care conferences upon admission for 1 of 2 residents reviewed.
F 0684: The facility failed to ensure effective collaboration with hospice services for 1 of 1 resident reviewed, lacking hospice visit schedules and care plan documentation.
F 0690: The facility failed to reassess and justify continued use of an indwelling catheter and failed to provide appropriate bowel continence care for 2 residents reviewed.
F 0758: The facility failed to monitor side effects of psychotropic medications for 1 of 2 residents reviewed.
F 0880: The facility failed to ensure proper PPE use for 1 of 3 residents on enhanced barrier precautions and failed to maintain a comprehensive infection prevention and control program.
F 0881: The facility failed to implement an antibiotic stewardship program to monitor appropriateness of antibiotic use for all residents.
F 0882: The facility failed to ensure the acting infection preventionist had completed specialized training in infection prevention and control.
F 0883: The facility failed to ensure 5 of 6 residents reviewed were offered and/or provided pneumococcal vaccinations as recommended and 1 resident was not offered influenza vaccination.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 11
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 30
Residents affected: 5
Residents affected: 1
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 11, 2024
Visit Reason
The inspection was conducted following a complaint investigation related to the use and administration of psychotropic medication for a resident (R1) who experienced an unwitnessed fall.
Complaint Details
The investigation was triggered by a report filed on 12/07/24 after R1 had an unwitnessed fall and was found with a fracture. The complaint involved improper administration of psychotropic medication without clear parameters, leading to potential overdose and increased fall risk.
Findings
The facility failed to ensure that the as-needed antipsychotic medication order for R1 included proper parameters for use, such as dosage limits and timing. R1 received multiple doses of trazodone within a short period, contrary to the intended order, increasing the risk of adverse effects and falls.
Deficiencies (1)
F 0758: The facility failed to ensure the as-needed trazodone medication order for resident R1 included parameters for use, such as limiting administration to once in 24 hours and specifying a stop date. R1 received a second dose of trazodone four hours after the first dose, contrary to the order.
Report Facts
Dose timing: 4
Medication dose: 50
Medication dose: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)-A | Confirmed administration of trazodone on 12/06/24 and noted the second dose on 12/07/24 should have been struck out | |
| Clinical Pharmacist | Indicated trazodone should be given once every 24 hours and noted lack of parameters in the order | |
| Director of Nursing (DON) | Expected trazodone orders to have parameters to prevent overdose and acknowledged fall risk due to side effects |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 12, 2024
Visit Reason
The investigation was conducted due to a complaint regarding failure to provide timely physician notification, failure to follow provider orders for catheter reinsertion or emergency transfer, and failure to provide timely CPR to a resident who was full code and subsequently died.
Complaint Details
The complaint investigation was substantiated. The facility was found to have neglected a resident by failing to provide timely physician notification, failing to follow provider orders for catheter reinsertion or emergency transfer, and failing to provide timely CPR, resulting in the resident's death.
Findings
The facility failed to notify the physician timely after a resident pulled out their indwelling catheter, failed to follow provider orders to reinsert the catheter or send the resident to the emergency room, and failed to initiate CPR timely when the resident was found unresponsive, resulting in the resident's death. The investigation found inconsistent staff statements, inadequate assessments, delayed communication with providers, and failure to report suspected neglect timely to the state agency.
Deficiencies (4)
The facility failed to notify the physician timely for 1 resident who pulled out their indwelling catheter and had specific orders to contact the physician with change of condition.
The facility failed to immediately report to the state agency suspected neglect related to failure to provide CPR timely to 1 resident, resulting in delayed emergency response.
The facility failed to provide basic life support including timely CPR to 1 resident with full code status, resulting in immediate jeopardy to resident health and safety and the resident's death.
The facility failed to provide appropriate treatment and care according to orders and resident preferences for 1 resident recovering from bladder surgery, including failure to follow provider orders, complete assessments, and monitor for complications after catheter removal.
Report Facts
Time delay in reporting suspected neglect: 20.73
Resident hemoglobin level: 5.9
Urinary output: 350
Urinary output: 700
Urinary output: 500
Urinary output: 300
Pain medication dosage: 500
Pain scale: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-A | Registered Nurse | Named in findings related to delayed physician notification, failure to follow orders, and delayed CPR initiation |
| RN-B | Registered Nurse | Involved in verifying resident death and reporting neglect |
| NP-A | Nurse Practitioner | On-call provider who gave orders to reinsert catheter and send to emergency if resistance met |
| NP-B | Primary Nurse Practitioner | Primary provider who expected timely hospital transfer and follow-up |
| DON | Director of Nursing | Provided oversight and expectations for nursing care and communication |
| Administrator | Facility Administrator | Provided statements on expectations for nursing follow-up and care |
| MD | Medical Director | Reviewed incident and identified poor nursing decisions |
| MDU | Medical Doctor/Urologist | Provided clinical background on resident condition and care needs |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 28, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, pharmaceutical services, medication error prevention, infection preventionist qualifications, and vaccination policies at the nursing home.
Findings
The facility failed to properly assess and document residents' ability to self-administer medications, had expired medications in medication carts, did not ensure proper insulin administration technique, lacked a qualified infection preventionist with specialized training, and failed to implement current pneumococcal vaccination standards for one resident.
Deficiencies (5)
F 0554: The facility failed to assess, monitor, and document appropriate self-administration of medications for 2 residents, lacking assessments and orders for medications present at bedside.
F 0755: The facility failed to ensure 3 medication carts were free of expired stock medications, potentially affecting all 33 residents.
F 0760: The facility failed to ensure a fast-acting insulin Flexpen was primed and administered correctly for 1 resident, risking incorrect dosing.
F 0882: The facility failed to ensure the acting infection preventionist had completed specialized infection prevention and control training, affecting all 33 residents.
F 0883: The facility failed to implement current pneumococcal vaccination standards for 1 resident over [AGE] years old, lacking education and offering of recommended vaccines.
Report Facts
Residents affected: 2
Residents affected: 33
Residents affected: 1
Residents affected: 33
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-B | Licensed Practical Nurse | Observed and questioned about insulin Flexpen administration and priming |
| RN-B | Registered Nurse | Observed medication cart #2 with expired medications and verified expiration dates |
| LPN-C | Licensed Practical Nurse | Observed medication cart #3 with expired medications and verified expiration dates |
| Director of Nursing | Director of Nursing | Provided statements on medication self-administration, expired medication policies, and insulin administration |
| Infection Preventionist | Infection Preventionist | Interviewed regarding lack of specialized infection prevention training |
| Administrator | Administrator | Verified infection preventionist training status |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 1, 2024
Visit Reason
The inspection was conducted due to allegations of misappropriation of property involving narcotic medication theft by a licensed practical nurse reported by a resident.
Complaint Details
The complaint involved allegations by resident R1 that licensed practical nurse LPN-B stole narcotic medication. The allegation was substantiated by interviews and documentation. The facility delayed reporting the incident to the State Agency beyond the required 24 hours.
Findings
The facility failed to report suspected abuse and theft allegations to the State Agency within the required 24-hour timeframe. The investigation confirmed that the resident alleged medication theft by a nurse, but the report to the State Agency was delayed.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and the results of the investigation to proper authorities within 24 hours as required.
Report Facts
Residents Affected: 1
Date of Incident: Jan 27, 2024
Date Reported to State Agency: Jan 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)-B | Named as the nurse alleged to have stolen medication. | |
| Licensed Practical Nurse (LPN)-A | Charge nurse who was informed of the allegation and notified the Director of Nursing. | |
| Director of Nursing (DON) | Instructed LPN-B to stop passing medications and was responsible for filing the report with the State Agency. |
Inspection Report
Routine
Census: 116
Deficiencies: 5
Date: Aug 9, 2023
Visit Reason
The Minnesota Department of Health conducted a survey to evaluate and assess compliance with state licensing statutes for Walker Methodist Westwood I.
Findings
The licensee was found in substantial compliance but had several deficiencies including food preparation not meeting Minnesota Food Code, fire safety issues with smoke alarms and fire-rated doors, inadequate fire safety training and drills, and improper medication storage practices.
Deficiencies (5)
Food was not prepared and served according to the Minnesota Food Code.
Smoke alarms in resident units 101 and 205 were not interconnected as required.
Fire-rated doors in multiple locations failed to latch properly, compromising fire safety.
Failed to provide required employee fire safety and evacuation training and drills, and resident training.
Medications were not stored according to manufacturer's instructions; refrigerator temperature logs were incomplete.
Report Facts
Active residents: 116
Residents under Assisted Living license: 41
Temperature log completion: 29
Temperature log opportunities: 67
Night-shift fire drill records: 1
Time period for correction: 21
Time period for correction: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jonathan Hill | Supervisor, State Evaluation Team | Contact person for correction order reconsideration |
| RN-I | Registered Nurse | Managed medication storage program; interviewed regarding refrigerator temperature logs |
| LPN-J | Licensed Practical Nurse | Observed during medication refrigerator inspection; interviewed about temperature logging |
| MD-H | Maintenance Director | Accompanied survey tour and acknowledged fire safety findings |
| RMD-G | Regional Maintenance Director | Accompanied survey tour and acknowledged fire safety findings |
| LALD-A | Licensed Assisted Living Director | Interviewed regarding medication refrigerator monitoring policy |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jul 20, 2023
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to involve residents in care planning, incomplete assessments after significant changes, improper medication management including lack of non-pharmacological interventions prior to PRN medications, inadequate dental care follow-up, and failure to offer pneumococcal vaccinations per CDC guidelines.
Deficiencies (6)
F 0553: The facility failed to provide an opportunity for 1 resident to participate in the development and implementation of their person-centered care plan.
F 0637: The facility failed to complete a significant change in status Minimum Data Set assessment timely after hospice services were initiated for 1 resident.
F 0757: The facility failed to ensure non-pharmacological interventions were attempted and recorded prior to administering PRN narcotic medication for 1 resident and failed to monitor blood pressure parameters for another resident on anti-hypertensive medication.
F 0758: The facility failed to ensure non-pharmacological interventions were attempted and recorded prior to administering PRN antipsychotic medication for 1 resident.
F 0790: The facility failed to ensure assessed oral and dental abnormalities were acted upon or referred for dental care for 1 resident.
F 0883: The facility failed to offer or provide pneumococcal pneumonia vaccines according to CDC recommendations for 2 residents.
Report Facts
PRN narcotic medication administrations without prior non-pharmacological intervention: 5
PRN antipsychotic medication administrations without prior non-pharmacological intervention: 5
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-A | Registered Nurse | Interviewed regarding medication administration and non-pharmacological interventions for residents R71 and R76. |
| LPN-B | Licensed Practical Nurse | Interviewed regarding expectations for blood pressure monitoring and vaccine administration. |
| LPN-A | Licensed Practical Nurse Unit Manager | Interviewed regarding medication administration and dental care follow-up for residents. |
| RN-C | Registered Nurse | Interviewed regarding MDS completion for resident R8. |
| DON | Director of Nursing | Interviewed regarding alarm use, dental care, and overall facility expectations. |
| CP | Consulting Pharmacist | Interviewed regarding medication administration and non-pharmacological interventions. |
| LSW-A | Licensed Social Worker | Interviewed regarding resident R8's care and dental follow-up. |
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