Cycle 1
Health 2025-01-23 · Fire 2025-01-23
13 health deficiencies
Top issue: Infection Control (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
West Saint Paul, MN
Walker Methodist Westwood Ridge Ii
1-star overall rating with 1-star inspections with $24,070 in total fines with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
61 Thompson Avenue West, West Saint Paul, MN
(651) 259-6702
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
37
Certified beds
Average residents
28
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2012-11-21
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
689
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
65.35
Composite VBP score used to determine payment impact.
Payment multiplier
1.0196
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.28
Baseline 21.98% · Performance 18.13% · Measure score 7.28 · Achievement 7.13 · Improvement 7.28
Healthcare-associated infections
10
Baseline 4.76% · Performance 4.67% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
4.41
Baseline 58.70% · Performance 45.65% · Measure score 4.41 · Achievement 4.41 · Improvement 3.35
Adjusted total nurse staffing
4.44
Baseline 4.56 hours · Performance 4.34 hours · Measure score 4.44 · Achievement 4.44 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.54% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 281 · Observed rate 8.54% · Lower 95% interval 8.34% |
| Discharge to community | 70.83% |
50.57%
20.3 pts better
|
Better than the National Rate · Eligible stays 280 · Observed rate 71.79% · Lower 95% interval 65.76% |
| Medicare spending per beneficiary | 0.69 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 92.9% |
95.27%
2.4 pts worse
|
Numerator 157 · Denominator 169 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 169 |
| Discharge self-care score | 47.52% |
53.69%
6.2 pts worse
|
Numerator 67 · Denominator 141 |
| Discharge mobility score | 23.4% |
50.94%
27.5 pts worse
|
Numerator 33 · Denominator 141 |
| Pressure ulcers or injuries, new or worsened | 0.59% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 169 · Adjusted rate 0.9% |
| Healthcare-associated infections requiring hospitalization | 4.67% |
7.12%
2.5 pts better
|
No Different than the National Rate · Eligible stays 150 · Observed rate 0.67% · Lower 95% interval 2.49% |
| Staff COVID-19 vaccination coverage | 0.65% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 155 |
| Staff flu vaccination coverage | 3.96% |
42%
38 pts worse
|
Numerator 9 · Denominator 227 |
| Discharge function score | 46.81% |
56.45%
9.6 pts worse
|
Numerator 66 · Denominator 141 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 132 · Denominator 132 |
| Resident COVID-19 vaccinations up to date | 73.42% |
25.2%
48.2 pts better
|
Numerator 58 · Denominator 79 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.9% |
88.6%
2.7 pts worse
|
81.7%
4.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.1% · Q2 85.5% · Q3 87.3% · Q4 83.5% · 4Q avg 85.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
14.0%
0.2 pts better
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 12.3% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.9%
0.4 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 0.9% · Q4 2.7% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 52.5% |
82.7%
30.2 pts worse
|
79.7%
27.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 52.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
23.1%
1.1 pts worse
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 18.0% · Expected 17.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-28 · Fire 2024-02-28
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
12 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2023-07-20 · Fire 2023-07-20
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-04
F · Potential for more than minimal harm
2025-01-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-04
F · Potential for more than minimal harm
2025-01-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-04
F · Potential for more than minimal harm
2024-02-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-23
F · Potential for more than minimal harm
2024-02-28
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-04-23
F · Potential for more than minimal harm
2024-02-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-23
F · Potential for more than minimal harm
2024-02-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-23
F · Potential for more than minimal harm
2024-02-28
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-04-23
F · Potential for more than minimal harm
2024-02-28
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-04-23
F · Potential for more than minimal harm
2024-02-28
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-02-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-02-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-02-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-02-28
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-04-23
C · Minimal harm
2024-02-28
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2024-04-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-04
F · Potential for more than minimal harm
2025-01-23
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-03-04
F · Potential for more than minimal harm
2025-01-23
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-03-04
E · Potential for more than minimal harm
2025-01-23
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-03-04
E · Potential for more than minimal harm
2025-01-23
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-23
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-03-04
D · Potential for more than minimal harm
2024-12-11
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-01-20
J · Immediate jeopardy
2024-09-12
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-10-22
D · Potential for more than minimal harm
2024-09-12
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-22
D · Potential for more than minimal harm
2024-09-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-22
D · Potential for more than minimal harm
2024-09-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-22
F · Potential for more than minimal harm
2024-02-28
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-02-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-28
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-04-05
D · Potential for more than minimal harm
2024-02-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-15
D · Potential for more than minimal harm
2023-07-20
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-07-20
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-07-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-07-20
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-07-20
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-07-20
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-08
Penalties and ownership
What sits behind the stars
$24,070
2024-09-12
Fine
Fine · fine $24,070
Fine
Ownership
Anderson, Mark
Corporate Officer · Individual
Billberg, Greg
Corporate Director · Individual
Coauette, Chad
Corporate Director · Individual
Critz, Julie
Corporate Director · Individual
Fairbairn, Scott
Contracted Managing Employee · Individual
Finn, Michael
Corporate Director · Individual
Grundhauser, Russell
Corporate Officer · Individual
Grundhauser, Russell
W-2 Managing Employee · Individual
Gugisberg, Marnie
Corporate Director · Individual
Hanson, Phillip
Corporate Director · Individual
Jodsaas, Vicki
Corporate Director · Individual
Kraft, Carol
Corporate Director · Individual
Lee, Kate
Corporate Director · Individual
Montgomery, Jeff
Corporate Director · Individual
Perry, Katie
Corporate Officer · Individual
Redden, Scott
Corporate Director · Individual
Semmer, Fred
Corporate Director · Individual
Syltie, Michael
Operational/Managerial Control · Individual
Syltie, Michael
W-2 Managing Employee · Individual
Vivie
Operational/Managerial Control · Organization
Walker Methodist
Operational/Managerial Control · Organization
Walker Senior Services Inc
Operational/Managerial Control · Organization
Wolf, David
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Southview Acres HealthCare Center
West Saint Paul, MN
3-star overall rating with 2-star inspections with $41,555 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Good Samaritan Society Inver Grove Heights
Inver Grove Heights, MN
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Cerenity Care Center on Humboldt
Saint Paul, MN
1-star overall rating with 1-star inspections with $105,767 in total fines with 18 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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