Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Walker Methodist Westwood Ridge Ii during CMS and state inspections, most recent first.
Lack of Psychotropic Medication Monitoring and Resident-Specific Target Behaviors: The facility failed to document resident-specific target behaviors and side effect monitoring for psychotropic medications for three residents. One resident with schizophrenia and anxiety had multiple psychotropic orders, another resident with recurrent major depressive disorder had venlafaxine ordered, and a third resident with generalized anxiety disorder had mirtazapine ordered, but the EMR, MAR/TAR, and care plans lacked the required resident-specific behavior targets and side effect monitoring. Staff stated that behavior documentation was generic and that target behaviors should have been included in the care plan and MAR/TAR.
Failure to Provide Required Discharge and Transfer Notices: The facility did not ensure written discharge notices were given as soon as practicable for one resident discharged after IV antibiotics and one resident transferred to the hospital. For the transferred resident, the notice also lacked the resident's appeal rights and the name, address, and phone number of the appeal entity. Staff interviews showed inconsistent understanding of the transfer/discharge notice process, and the DON stated the transfer notice was reviewed later rather than provided at transfer.
Baseline care plans were not in place within 48 hours for two residents. One resident was readmitted after a fall with pubic, pubis, and sacral fractures, but the care plan was not initiated until later and a prior care plan had been canceled. Another resident’s admission assessment contained a care planning section, but all intervention boxes were left blank and no baseline care plan was found in the record. Staff said the EHR upgrade affected how care plans were activated and that the admission assessment did not carry over to the baseline care plan.
A resident with a stroke history and swallowing impairment was ordered to receive a minced and moist diet with supervision during meals due to pocketing food in the oral cavity. However, the resident was observed eating lunch alone and later eating unsupervised despite prolonged chewing, delayed swallow, pocketing, and drooling. Staff interviews showed the NA and LPN interpreted supervision as only periodic checks, while therapy stated the intent was for staff to be present during meals for the resident’s safety.
Failure to monitor anticoagulant side effects: A resident receiving Eliquis for atrial fibrillation had no evidence of side effect monitoring in the EMR, including the MAR/TAR, active orders, or care plan. RN and LPN staff confirmed the monitoring was expected, and the DON stated anticoagulants are monitored for signs of bleeding or bruising.
Failure to follow contact precautions and disinfect shared equipment occurred when staff entered a resident’s room without PPE to obtain weight and vital signs, despite signage directing gown and glove use. An LPN also moved a VS tower from one resident on contact precautions directly into another resident’s room without cleaning it first. Staff stated they were unsure when PPE was required and were confused about contact precautions versus enhanced barrier precautions, while the DON confirmed the expected PPE and equipment-cleaning practices.
The facility failed to ensure proper PPE use for a resident on enhanced barrier precautions, as nursing assistants did not wear gowns during high-contact care activities. Additionally, the facility lacked a comprehensive Infection Prevention and Control Program, with no current surveillance of infections or tracking of antibiotic use. The director of nursing confirmed these deficiencies.
The facility failed to implement an effective antibiotic stewardship program, as the DON, acting as the infection preventionist, admitted to not tracking antibiotic use or conducting antibiotic time-outs. The facility's policy required detailed documentation of antibiotic regimens, but these protocols were not being followed, leading to a deficiency.
The facility's acting infection preventionist, the DON, had not completed specialized training in infection prevention and control, as required by the facility's policy. The DON confirmed she was responsible for the infection control program but was not enrolled in any training, and no other staff had the necessary specialized training.
The facility failed to protect resident information privacy by leaving care sheets and computer screens with sensitive data unattended and in public view. This included residents' names, diagnoses, and other personal details. Staff acknowledged the oversight, which violated the facility's privacy policy.
The facility failed to offer pneumococcal and influenza vaccinations to several residents as recommended by the CDC. Five residents were not offered the PCV20 or PCV21 vaccines despite eligibility, and one resident was not offered the influenza vaccine. Documentation lacked evidence of shared clinical decision-making or education regarding these vaccines. Interviews with staff confirmed that immunizations are typically offered upon admission, but records did not reflect this for the affected residents.
A resident in hospice care with intact cognition expressed a preference for showers over bed baths, but the facility failed to assess and document this preference. The care plan and other documentation lacked evidence of the resident's choice, and staff were unaware of the preference. The director of nursing confirmed that preferences should be assessed and documented, but this was not done for the resident.
The facility failed to provide timely Medicare coverage notices to three residents, resulting in delayed or missing Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) and Notices of Medicare Non-Coverage (NOMNOC). This left residents without necessary information about their coverage and potential financial liabilities, contrary to the facility's policy.
A facility failed to provide a resident with a copy of their baseline care plan upon admission, as required by policy. The resident, who was cognitively intact, confirmed not receiving the care plan and expressed a desire to have it. Interviews with staff revealed that the facility's practice was to provide the care plan only upon discharge, contrary to the policy that required providing a written summary by the completion of the comprehensive care plan.
A resident's care plan was found to be inadequate, lacking specific goals and interventions for critical areas such as communication, urinary incontinence, and falls. The plan also failed to incorporate the resident's personal preferences, such as using the bathroom over an incontinent pad and preferring showers to bed baths. Additionally, there was a lack of coordination with hospice services and no discharge planning, despite the resident's uncertain future living arrangements. Staff interviews revealed reliance on incomplete care sheets and Kardexes, leading to insufficient personalized care.
A resident admitted with multiple health conditions did not have a care conference conducted within the required timeframe. Despite the facility's usual practice of holding care conferences within a week of admission, no conference was held for this resident, who was on private pay and hospice care. Staff interviews confirmed the absence of a care conference, and the facility lacked a policy on the timing of such conferences.
A facility failed to coordinate effectively with a contracted hospice organization for a resident receiving hospice services. The resident's care plan and documentation lacked essential information about hospice visits and services, and staff interviews revealed a lack of awareness about the hospice schedule. The hospice binder was missing critical details, and a facility policy on coordination was not provided.
A facility failed to reassess and justify the continued use of an indwelling catheter for a resident with severe cognitive impairment and urine retention, despite recommendations for its removal. Additionally, a cognitively intact resident expressed a preference for using the toilet for bowel movements, but was not offered a toilet or bed pan, and had not been transferred out of bed for at least a week. The facility's policies on catheter management and incontinence were not adhered to, leading to significant deficiencies in care.
A resident with moderate cognitive impairment and multiple diagnoses was prescribed psychotropic medications but was not continuously monitored for side effects as required. Staff interviews revealed that monitoring should occur every shift without an end date, but documentation showed it ceased prematurely. A policy on monitoring was requested but not provided.
A resident with dementia and depression was prescribed trazodone for sleep without clear parameters, leading to two doses being administered within a short time frame. This oversight resulted in the resident experiencing a fall and a fracture. Interviews with staff confirmed the lack of clear medication parameters, and the DON acknowledged the need for adherence to prescribed orders to prevent overdose and reduce fall risk.
A resident with a full code status was found unresponsive and not breathing, but CPR was not initiated promptly by the nursing staff. The resident, who had a complex medical history and recent hospitalization, was discovered by an RN in a lifeless state, yet there was a delay in verifying the code status and starting resuscitation efforts. This deficiency resulted in the resident's death and highlighted inconsistencies in staff actions and statements.
A resident recovering from bladder surgery pulled out their indwelling catheter, but the facility failed to notify the physician in a timely manner. The nurse delayed contacting the on-call provider for several hours, despite the resident's history of bladder surgery and bleeding issues. The nurse received an order to reinsert the catheter but did not follow up when the resident refused the procedure. The facility's policy required timely notification of acute changes, which was not adhered to, contributing to the resident's unresponsive state and subsequent death.
A resident with a full resuscitation order experienced a delay in CPR initiation, leading to a failure to immediately report suspected neglect to the state agency. The incident involved inconsistencies in staff statements and a delayed submission of the incident report, which was filed 20 hours after the neglect was suspected.
A resident recovering from bladder surgery pulled out their catheter, and the facility failed to contact the provider timely or follow orders to replace the catheter or send the resident to the ER. The resident had a history of bladder cancer and anemia, and the facility did not conduct necessary assessments or monitoring, leading to a lack of timely intervention.
Lack of Psychotropic Medication Monitoring and Resident-Specific Target Behaviors
Penalty
Summary
The facility failed to ensure appropriate monitoring and documentation related to psychotropic medication use for 3 residents reviewed for unnecessary medications. One resident with diagnoses of schizophrenia and anxiety had orders for buspirone, risperidone, clozapine, and venlafaxine, but the care plan and MAR/TAR lacked documentation of specific target behaviors for the psychotropic medications. During interview, the DON stated nurses monitored residents for side effects and nursing assistants documented behaviors under generic tasks, but target behaviors needed to be monitored and included in the care plan and MAR/TAR. A second resident with recurrent major depressive disorder had an order for venlafaxine, but the EMR, including the MAR/TAR, orders, and care plan, lacked documented resident-specific target behaviors for psychotropic medication use. A third resident with generalized anxiety disorder had an order for mirtazapine, but the EMR, including the MAR/TAR, active orders, and care plan, lacked evidence of side effect monitoring for antidepressant medication use. Staff interviews confirmed that target behaviors were not shown on the MAR/TAR, that NAs used generic behavior tasks, and that side effect monitoring was expected but not in place for the resident receiving mirtazapine.
Failure to Provide Required Written Discharge and Transfer Notices
Penalty
Summary
The facility failed to ensure written discharge and transfer notices were provided as soon as practicable for 1 of 1 residents reviewed for hospitalization and 1 of 2 residents reviewed for discharge. For R2, the record showed intact cognition on the admission MDS, admission to the facility, and discharge after a course of IV antibiotics. The care conference note stated R2 would return to his assisted living facility and could remain in the skilled facility until the antibiotic course ended, and a progress note documented discharge with his son to an independent living facility. However, the medical record did not show that R2 received a written facility discharge notice with ombudsman contact information or information about discharge appeal rights and resources. For R35, the record showed moderately impaired cognition on the admission MDS and transfer to the hospital for a PICC replacement. The transfer notice dated after the transfer identified the hospital transfer and included contact information for staff and a separate advocacy page with multiple resources, but it did not include a statement of the resident's appeal rights or the name, address, and telephone number of the entity that receives appeal requests. Staff interviews showed nursing staff believed transfer packets and medical records were sent with residents, while social services staff stated she was not aware a written discharge notice had to be given for R2. The DON stated R35's transfer notice was verbally reviewed later rather than given at the time of transfer, and that giving a written discharge notice as soon as a discharge date was known was not part of the facility's process.
Baseline care plans were not completed within 48 hours for two residents
Penalty
Summary
The facility failed to ensure baseline care plans were in place within 48 hours of admission for 2 of 5 residents reviewed, including R25 and R50. R25 was originally admitted to the facility on 3/16/26, then discharged to the emergency room after a fall and diagnosed with a pubic bone fracture. R25 was readmitted on 3/30/26 after hospitalization for pubis and sacral bone fractures, but the resident’s entire care plan was not initiated until 4/13/26, and a completed care plan had been canceled on 4/6/26. During interview, the DON stated that because the resident returned as a return not anticipated and the facility did not hold the bed, a full new admission should have been completed upon return, including a baseline care plan. R50’s admission record included a care planning section with multiple potential concerns and interventions listed, but all boxes were left blank. The facility was unable to provide a baseline care plan that had been developed within 48 hours of admission, and the medical record did not include one with the resident’s initial goals of care, immediate safety needs, social services needs, or other baseline information. Staff interviews indicated the admission assessment was expected to trigger the baseline care plan, but the DON and clinical coordinator stated that the EHR upgrade changed how care plans were activated and that the information did not appear to have carried over for some residents.
Failure to Provide Meal Supervision for Resident with Pocketing
Penalty
Summary
The facility failed to ensure adequate supervision during meals for R42, a resident admitted with a primary diagnosis of pleural effusion and a history of stroke-related swallowing concerns. R42’s nutrition screen indicated a regular diet initially, but later orders changed the diet to minced and moist texture with supervision while eating, along with oral care after oral intake and speech therapy evaluation and treatment for swallow and cognition. The speech therapy order specifically noted supervision with meals due to food remaining in the oral cavity, and the Kardex also indicated that R42 required supervision with eating. Despite these orders and documented concerns, R42 was observed eating lunch alone in her room and was noted to have prolonged chewing, delayed swallow, pocketing of food, and drooling. On a later observation, R42 again received her lunch tray and was observed eating unsupervised. During interviews, a nursing assistant stated supervision meant checking on the resident every hour or so, and an LPN described the supervision order as periodic checks and was unable to define the frequency. The clinical coordinator confirmed awareness of the supervision order but stated the resident was not considered a choking risk despite documented pocketing, while the director of therapy stated speech therapy was recommending full supervision with meals because R42 held solids in her mouth and had cognition issues.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure implementation of medication side effect monitoring for one resident who was receiving Eliquis 2.5 mg twice daily for unspecified atrial fibrillation. The resident’s face sheet showed admission to the facility on 4/6/26, and the diagnosis record listed unspecified atrial fibrillation. The order for Eliquis identified it as a blood thinning anticoagulant medication with the most common serious side effect being bleeding, including bleeding from the gums, nose, urine, or stools. Review of the resident’s electronic medical record, including the medication and treatment administration record, active orders, and care plan, found no evidence that the resident was being monitored for side effects of anticoagulation medication. During interviews, RN-B stated that medication side effect monitoring should appear on each resident’s medication and treatment administration record and be documented every shift, LPN-A confirmed the resident did not have medication side effect monitoring in place and that it would be expected, and the DON stated that anticoagulants are monitored for signs of bleeding or bruising and that side effect monitoring is incorporated into the care plan and kardex. A facility policy on side effect monitoring was requested but not received.
Failure to Follow Contact Precautions and Disinfect Shared Equipment
Penalty
Summary
The facility failed to implement and ensure adherence to infection prevention and control practices for residents on contact precautions. R49 was admitted on 4/8/26 and was on contact precautions for a history of ESBL, and R50 was admitted on 4/9/26 and was on contact precautions for MRSA. During observation, CNA-B entered R49’s room without PPE to obtain the resident’s weight, even though the isolation signage directed staff to don gloves and a gown before room entry and to use dedicated or disposable equipment. LPN-B also entered R49’s room and obtained vital signs, including applying a blood pressure cuff, scanning the resident’s forehead for temperature, and placing an oximeter on the resident’s finger, all without PPE. During the same observation, LPN-B transported a vital signs tower from R49’s room directly into R50’s room without cleaning or disinfecting the equipment between uses. CNA-B stated she believed PPE was only required during personal care activities and not for tasks such as vital signs or weights. LPN-B stated staff were unsure when to use gowns and gloves and expressed confusion about the difference between enhanced barrier precautions and contact precautions. The DON and infection preventionist stated staff were expected to follow the isolation signage requiring gown and gloves for contact precautions and cleaning of vital sign equipment with bleach between uses, and acknowledged this had been identified during a recent mock survey. The facility policy on Transmission-Based Precautions stated that staff should wear gloves and a gown upon room entry when contact with infectious material is anticipated and dedicate equipment when able or disinfect it before use with other residents.
Failure in PPE Use and Infection Control Program
Penalty
Summary
The facility failed to ensure proper personal protective equipment (PPE) use for a resident on enhanced barrier precautions (EBP). During an observation, two nursing assistants entered the resident's room without donning gowns, despite a sign indicating the need for gowns and gloves during high-contact care activities. The resident, who was dependent on staff for bathing, toileting, and dressing, had a Foley catheter in place. The nursing assistants provided care, including a partial bed bath and brief change, without wearing gowns. Interviews with the nursing assistants and the resident's family member confirmed the lack of gown use, and the director of nursing acknowledged the importance of PPE in preventing infection spread. The facility also failed to maintain a comprehensive Infection Prevention and Control Program (IPCP). The infection control program lacked specific surveillance and analysis data, and the director of nursing, acting as the infection preventionist, confirmed the absence of current surveillance of infections, resident symptoms, or tracking of antibiotic use. There were no audits of staff adherence to PPE use or handwashing, and no tracking of antibiotic use to ensure proper follow-up. The facility's policy indicated that ongoing surveillance for healthcare-associated infections should be conducted, but this was not being implemented.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, which is crucial for preventing antibiotic resistance and the spread of infectious diseases. During an interview, the Director of Nursing (DON), who was also acting as the facility's infection preventionist, admitted that the facility was not tracking antibiotic use among residents. This included a lack of monitoring for prophylactic antibiotics and the absence of antibiotic time-outs, which are necessary to evaluate the continued need for antibiotics. The DON was unaware of any ongoing antibiotic time-outs, indicating a significant gap in the facility's infection control practices. The facility's policy on Antibiotic Stewardship, revised in January 2025, outlined the need for a designated Registered Nurse as the Infection Preventionist, who should be certified in Infection Prevention and Control. The policy also required a system to monitor antibiotic use, including detailed documentation of resident antibiotic regimens on a surveillance tracking form. This form should include information such as the resident's name, medical record number, unit and room number, date symptoms appeared, name of the antibiotic, start date, pathogen identified, site of infection, date of culture, stop date, and total days of therapy. However, these protocols were not being followed, as confirmed by the DON, leading to the deficiency noted in the report.
Infection Preventionist Lacks Specialized Training
Penalty
Summary
The facility failed to ensure that the acting infection preventionist, who is the Director of Nursing (DON), had completed specialized training in infection prevention and control. This deficiency was identified during an interview and document review, where the DON confirmed that she was responsible for overseeing the infection control program but had not completed any specialized training in this area. Furthermore, the DON was not currently enrolled in any specialized training nor had any scheduled. It was also verified that no other staff members in the facility had specialized training in infection prevention and control. The facility's policy, revised in January 2025, requires the infection preventionist to be qualified by education, training, experience, or certification and to have completed specialized training in infection prevention and control.
Failure to Protect Resident Information Privacy
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical information. During an observation, a medication cart in the 400 hallway was left unattended with a care sheet in public view. This care sheet contained sensitive information about five residents, including their full names, diagnoses, special programs, alertness, transfer and ambulation status, continence, diet, precautions, skin conditions, and other notes. Multiple residents were observed passing by the unattended cart, exposing their private information. A registered nurse acknowledged that such information should be kept out of public view. In another instance, a clipboard with a care sheet was left on the edge of a unit desk, visible to residents and family members. This sheet also contained detailed information about five residents. A registered nurse later picked up the clipboard. Additionally, a medication cart was left unattended with a computer screen displaying a resident's medication orders and a care sheet in view. A licensed practical nurse admitted to leaving the screen open and confirmed the care sheet contained resident information. The facility's policy requires maintaining the privacy and security of protected health information, which was not adhered to in these instances.
Failure to Offer Pneumococcal and Influenza Vaccinations
Penalty
Summary
The facility failed to ensure that five out of six residents reviewed for immunizations were offered or provided the pneumococcal vaccination series as recommended by the CDC. Specifically, residents were not offered the PCV20 or PCV21 vaccines despite being eligible, as it had been more than five years since their last pneumococcal dose. The records for these residents lacked evidence of shared clinical decision-making with a physician regarding these vaccines, and there was no documentation of the residents being offered or receiving the vaccines or any related education. Additionally, one resident was not offered or provided the influenza vaccination as recommended by the CDC. This resident's records also lacked evidence of being offered or receiving any pneumococcal doses or education. The facility's documentation did not reflect that the resident was provided education, offered, or received an annual influenza immunization. Interviews with facility staff, including an LPN and the DON, confirmed that immunizations are typically offered upon admission and documented in progress notes or the resident's hard chart. However, the DON verified that the records for the residents in question lacked evidence of being offered or receiving the necessary vaccinations until after the survey entrance, indicating a lapse in following the facility's policies and CDC recommendations.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor and assess a resident's bathing preferences, specifically for Resident R5, who was under hospice care. R5, who had intact cognition, expressed a preference for showers over bed baths, but this preference was not documented or honored by the facility. Since admission, R5 had only been out of bed once and had not been offered a shower, which he preferred. The care plan and other documentation, such as the Kardex and care sheets, lacked any mention of R5's preference for a shower, indicating a failure to assess and document his choices. Interviews with various staff members, including nursing assistants and registered nurses, revealed a lack of awareness and documentation regarding R5's bathing preferences. Nursing assistants relied on care sheets and Kardex for resident information, but these documents did not reflect R5's preference for showers. Staff members, including NA-C and NA-D, confirmed that R5 had not been assisted with a shower and were unaware of his preference. The registered nurse and licensed practical nurse coordinator acknowledged that resident preferences should be assessed and documented in the care plan, but this was not done for R5. The director of nursing verified that resident preferences should be assessed and included in the care plan, but this was not the case for R5. The facility's failure to assess and document R5's preference for showers over bed baths represents a deficiency in promoting and facilitating resident self-determination. Additionally, the facility was unable to provide a policy on resident choices when requested, further highlighting the lack of adherence to resident rights and preferences.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to provide necessary Medicare and Medicaid coverage notices to residents upon the termination of Medicare A coverage. Specifically, three residents did not receive the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and/or Notice of Medicare Non-Coverage (NOMNOC) in a timely manner. For one resident, the NOMNOC was received, but the SNFABN was delayed until after the private pay costs had started. Another resident received the NOMNOC but did not receive the SNFABN at all, and a third resident did not receive either notice. This lack of timely notification left residents without the necessary information regarding their coverage and potential financial liabilities. The facility's policy, revised in January 2025, mandates informing residents about available services and charges, including those not covered by Medicare/Medicaid, at admission and periodically during their stay. However, the facility did not adhere to this policy, as evidenced by the missing or delayed notices. The administrator confirmed these deficiencies and acknowledged that retraining was necessary to address the issue, as some processes were not being completed as required.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to provide a copy of the baseline care plan to a resident, identified as R26, who was admitted on 12/10/24 and was cognitively intact. The resident's Care Conference Summary, dated 12/22/24, indicated that copies of the care plan were not applicable, and during an interview on 1/22/25, the resident confirmed not receiving a copy of her care plan, expressing a desire to have one. Interviews with social services and nursing staff revealed that the facility's process was to start the baseline care plan upon admission but only provide a copy to residents or their representatives upon discharge. This practice was confirmed by the nurse coordinator and director of nursing, despite the facility's policy stating that a written summary of the baseline care plan should be provided by the completion of the comprehensive care plan.
Inadequate Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and maintain a comprehensive care plan for a resident, identified as R5, which resulted in inadequate care provision. R5's admission Minimum Data Set (MDS) indicated that the resident required maximum assistance for various activities of daily living (ADLs) and had several medical diagnoses, including acute kidney failure, diabetes, and congestive heart failure. Despite these needs, the care plan lacked specific goals and interventions for several critical areas, such as communication, urinary incontinence, falls, and psychotropic drug use. Additionally, the care plan did not address R5's cognitive abilities, behavioral symptoms, or specific needs related to mobility and safety. The care plan also failed to incorporate R5's personal preferences and specific care requirements. Interviews with nursing assistants revealed that R5 had not been offered a bed pan or the use of the bathroom, despite expressing a preference for using the bathroom over an incontinent pad. Furthermore, R5 preferred showers to bed baths, but this preference was not reflected in the care plan. The care plan also lacked coordination with hospice services, which were part of R5's care, and did not include any discharge planning, despite R5's uncertainty about future living arrangements. Staff interviews highlighted a lack of awareness and adherence to R5's care preferences and needs. Nursing assistants and registered nurses indicated that they relied on care sheets and Kardexes for resident information, but these documents did not contain the necessary details to provide comprehensive and personalized care for R5. The facility's policy required that comprehensive care plans include all necessary services to maintain the resident's well-being, but R5's care plan did not meet these standards, resulting in a deficiency in care provision.
Failure to Conduct Timely Care Conference for Resident
Penalty
Summary
The facility failed to conduct a care conference for a resident (R5) within the required timeframe following admission. R5 was admitted with multiple diagnoses, including heart failure, hypertension, diabetes, depression, obstructive sleep apnea, ischemic cardiomyopathy, and chronic kidney disease. Despite the resident's complex medical needs and the requirement to develop a complete care plan within seven days of the comprehensive assessment, there was no evidence of a care conference being conducted or planned for R5 from the time of admission on 12/31/24 to 1/23/25. Interviews with the resident and staff confirmed the absence of a care conference, and the resident expressed uncertainty about their future care plan and living arrangements. The LPN coordinator and social worker acknowledged that care conferences are typically held within a week or so after admission, involving therapy, nursing, social work, family, and the resident. However, they confirmed that no care conference had been conducted for R5, who was admitted on private pay and hospice care. The social worker indicated there was no policy mandating a specific timeframe for care conferences, and the director of nursing was unsure of any such requirement. The facility did not provide a policy on care conference timing when requested, highlighting a lack of adherence to regulatory expectations for timely care planning.
Lack of Coordination with Hospice Services
Penalty
Summary
The facility failed to ensure effective collaboration with a contracted hospice organization, affecting a resident receiving hospice services. The resident, who was cognitively intact and required maximum assistance for various activities of daily living, had multiple diagnoses including acute kidney failure, anemia, atrial fibrillation, and chronic kidney disease. Despite being under hospice care, the resident's hospice chart lacked a calendar of planned visits and a copy of the hospice care plan. Additionally, there was no coordination documented between hospice staff and facility staff, particularly from hospice nursing assistants. The resident's care plan and order summary report were missing critical information such as the hospice provider's name, contact information, services provided, and frequency of visits. The Medication Administration Record also lacked evidence of hospice provider details. Progress notes indicated some communication with hospice regarding the resident's condition, but they did not document the frequency of hospice visits or the services provided. The Kardex and care sheet also failed to reflect the resident's hospice services accurately. Interviews with facility staff, including nursing assistants and registered nurses, revealed a lack of awareness regarding the hospice schedule and services provided to the resident. The hospice binder, intended for coordination of care, was missing essential information such as a calendar of visits, notes from nursing assistants, and the hospice plan of care. The director of nursing confirmed the expectation of coordinated care between the facility and hospice, but the documentation did not support this coordination. A facility policy on coordination with providers was requested but not received.
Deficiencies in Catheter Management and Bowel Continence Care
Penalty
Summary
The facility failed to comprehensively reassess and justify the continued use of an indwelling catheter for a resident with severe cognitive impairment and urine retention due to Parkinson's Disease. Despite recommendations from a urology consult and physician progress notes to discontinue the Foley catheter and resume intermittent straight catheterization, the catheter remained in place. Interviews with facility staff revealed uncertainty about the ongoing plan for the resident's catheter, and the facility's policy indicated that residents should be assessed for catheter removal as soon as possible unless clinically necessary. Another deficiency involved a resident who was cognitively intact and expressed a preference to use the toilet for bowel movements rather than an incontinent pad. The resident's care plan indicated they were dependent on staff for toileting and encouraged the use of the toilet. However, interviews with nursing assistants revealed that the resident had not been offered the use of a toilet or bed pan and had not been transferred out of bed for at least a week. The facility's policy on incontinence emphasized the importance of implementing interventions to promote continence, but there was no evidence of a toileting program being attempted for this resident. The facility's failure to develop a comprehensive plan of care for residents with indwelling catheters and to provide services to maintain bowel continence for a resident who was continent of bowel highlights significant deficiencies in the care provided. The lack of adherence to facility policies and the absence of a clear plan for catheter management and toileting programs contributed to these deficiencies.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure proper monitoring for side effects in a resident prescribed psychotropic medications. The resident, identified as R283, had moderate cognitive impairment and was diagnosed with pneumonia, heart failure, and malnutrition, among other conditions. The resident was prescribed trazadone for insomnia and buspirone for anxiety. According to the Medication Administration Record, monitoring for psychotropic side effects was initiated but only continued until a specified date, contrary to the facility's practice of continuous monitoring. Interviews with staff, including an LPN and the Director of Nursing, revealed that the facility's protocol was to monitor residents for side effects of psychotropic medications continuously, every shift, without an end date. However, the documentation did not reflect this practice, as monitoring was not conducted beyond a certain date. Additionally, a facility policy on monitoring psychotropic side effects was requested but not provided, indicating a lack of formalized procedures or documentation to ensure compliance with monitoring requirements.
Failure to Ensure Proper Parameters for PRN Antipsychotic Medication
Penalty
Summary
The facility failed to ensure proper parameters for the administration of a PRN antipsychotic medication for a resident diagnosed with dementia with behavioral disturbance and depression. The resident, who required substantial assistance with daily activities and had fluctuating behaviors, was prescribed trazodone for sleep without clear parameters for its use. The medication order lacked documentation specifying that trazodone should only be used once in 24 hours, and there was no stop date included. This oversight led to the resident receiving two doses within a short time frame, which was not in accordance with the intended prescription. The incident was highlighted when the resident experienced an unwitnessed fall, resulting in a fracture, after receiving trazodone. Interviews with facility staff, including an LPN and the clinical pharmacist, confirmed the lack of clear parameters for the medication's administration. The Director of Nursing acknowledged that the trazodone order should have been followed as prescribed, with parameters in place to prevent overdose and reduce the risk of falls. The facility's medication management policy emphasized the need for clear medication orders and documentation, which was not adhered to in this case.
Failure to Initiate Timely CPR for Resident with Full Code Status
Penalty
Summary
The facility failed to provide basic life support, including CPR, in accordance with the resident's wishes and physician orders for full code status. This deficiency involved a resident who was found not breathing and without a pulse, yet CPR was not initiated in a timely manner. The resident, who had a full resuscitation order, was found by RN-A at 12:30 a.m. in a lifeless state, but no immediate action was taken to resuscitate her, resulting in her death. The resident had a complex medical history, including a neoplasm of the bladder, heart failure, and a history of venous thrombosis and embolism. She had recently been hospitalized for vaginal bleeding and had undergone several medical procedures, including the placement of an inferior vena cava filter. Despite these conditions, her Provider Orders for Life-Sustaining Treatment (POLST) indicated a full code status, requiring attempts at resuscitation, including CPR and advanced airway interventions. On the night of the incident, there was a significant delay in initiating CPR. RN-A, who discovered the resident unresponsive, did not immediately verify the code status or begin resuscitation efforts. Instead, there was confusion and a lack of urgency in responding to the resident's condition. The timeline of events was inconsistent, and staff statements varied, leading to an inconclusive investigation by the facility. The delay in initiating CPR and the failure to follow the resident's advance directives contributed to the immediate jeopardy situation and the resident's death.
Failure to Timely Notify Physician After Catheter Removal
Penalty
Summary
The facility failed to notify the physician in a timely manner for a resident who was recovering from bladder surgery and had pulled out their indwelling catheter. The resident had specific orders to contact the physician with any change in condition, which were not followed. The resident's medical history included a neoplasm of the bladder, acute post-hemorrhagic anemia, heart failure, and diabetes mellitus, among other conditions. The resident had a Foley catheter due to a bladder tumor diagnosis, and the care plan directed staff to monitor and report any signs of urinary tract infection or changes in condition. On the evening of the incident, the resident pulled out their indwelling catheter, causing some bleeding. The nurse on duty, RN-A, delayed contacting the on-call provider for several hours, despite the resident's history of bladder surgery and bleeding issues. When the nurse finally contacted the provider, the information provided was insufficient, and the provider was not made aware of the resident's full medical history and the duration the catheter had been out. The nurse received an order to reinsert the catheter but did not follow up with the provider when the resident refused the procedure. The facility's director of nursing and administrator both indicated that the nurse should have contacted the provider immediately and followed the orders due to the resident's medical history. The facility's policy required physicians to be notified of acute changes in a resident's condition as soon as possible, which was not adhered to in this case. The lack of timely communication and documentation contributed to the deficiency, ultimately leading to the resident's unresponsive state and subsequent death.
Delayed CPR and Reporting of Neglect
Penalty
Summary
The facility failed to immediately report to the state agency when a Provider Orders for Life-Sustaining Treatment (POLST) and cardiopulmonary resuscitation (CPR) were not initiated timely, as per the resident's wishes. The incident involved a resident with multiple medical conditions, including neoplasm of the bladder, heart failure, and diabetes mellitus. The resident's POLST indicated a full resuscitation order, but there was a delay in initiating CPR when the resident was found unresponsive. The incident occurred when nursing staff noted the resident had cessation of pulse and respirations. However, the timeline of events from nurse progress notes was inconclusive as to when CPR was initiated. A registered nurse was suspended pending further investigation, and the facility's findings were inconclusive due to inconsistencies with staff statements and the inability to establish and verify the timeline of events. The resident's primary nurse resigned immediately following the incident. The facility's incident report was submitted to the state agency 20 hours and 44 minutes after the facility suspected neglect. Interviews with staff revealed discrepancies in the timeline and actions taken, with one nurse alleging that CPR was delayed by 35 minutes. The facility's policy requires immediate reporting of suspected neglect, but the report was delayed until after staff statements were gathered and reviewed.
Failure to Provide Timely Care for Post-Surgery Resident
Penalty
Summary
The facility failed to provide necessary care and services for a resident recovering from bladder surgery. The resident, who had a history of bladder cancer, anemia, and recent surgery, pulled out their indwelling catheter, and the facility did not contact the provider in a timely manner. The provider's orders to replace the catheter or send the resident to the emergency department were not followed, and ongoing assessment and monitoring for bladder retention, bleeding, or change of condition were not completed. The resident's medical history included a neoplasm of the bladder, acute post-hemorrhagic anemia, and a recent surgery that involved partial removal of a bladder tumor. The resident was admitted to the facility with an indwelling catheter, which was crucial to prevent bladder rupture due to the thin bladder walls and history of bleeding. Despite the critical nature of the resident's condition, the facility staff delayed contacting the provider after the catheter was pulled out and failed to follow the provider's orders for re-insertion or emergency transfer. Interviews with facility staff revealed that the nurse responsible for the resident's care was overwhelmed with other tasks and did not prioritize the resident's urgent needs. The nurse did not document assessments or communicate effectively with the provider about the resident's condition, leading to a lack of timely intervention. The facility's director of nursing and administrator acknowledged the failure to follow protocol and the lack of critical thinking in addressing the resident's care needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Saint Paul
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southview Acres Healthcare Center | 1.3 mi | ★★★★★ | 12 | 0 |
| Good Samaritan Society Inver Grove Heights | 1.5 mi | ★★★★★ | 10 | 0 |
| Cerenity Care Center On Humboldt | 2.1 mi | ★★★★★ | 12 | 0 |
| Woodlyn Heights Healthcare Center | 2.6 mi | ★★★★★ | 17 | 0 |
| Shirley Chapman Sholom Home East | 2.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.