Walker Methodist Westwood II

Penalties

• Sep 12, 2024 — Fine ($15,914)

Inspection findings

1. Apr 15, 2026 Health · 8 findings
   • Not serious Scope/severity D

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0628 Resident Rights Deficiencies

     Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0757 Pharmacy Service Deficiencies

     Ensure each resident’s drug regimen must be free from unnecessary drugs.

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 1, 2026 · CMS health inspection

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected May 8, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected May 8, 2026 · CMS fire safety

2. Jan 23, 2025 Health · 16 findings
   • Not serious Scope/severity D

     F0561 Resident Rights Deficiencies

     Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

     Corrected Mar 4, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0582 Resident Rights Deficiencies

     Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

     Corrected Mar 4, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Mar 4, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Mar 4, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Mar 4, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Mar 4, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Mar 4, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     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 Mar 4, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     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 Mar 4, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Mar 4, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected Mar 4, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0882 Infection Control Deficiencies

     Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

     Corrected Mar 4, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Mar 4, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Mar 4, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Mar 4, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Mar 4, 2025 · CMS fire safety

3. Dec 11, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0758 Pharmacy Service Deficiencies

     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 Jan 20, 2025 · CMS health inspection

4. Sep 26, 2024 MDH complaint investigation · 1 finding
   • Severity not stated

     H56187782C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

5. Sep 12, 2024 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Oct 22, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Oct 22, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0678 Quality of Life and Care Deficiencies

     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 Oct 22, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Oct 22, 2024 · CMS health inspection

6. Feb 28, 2024 Health · 17 findings
   • Not serious Scope/severity D

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Apr 5, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Apr 5, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Apr 5, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0882 Infection Control Deficiencies

     Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

     Corrected Apr 5, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Apr 5, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Apr 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0223 Egress Deficiencies

     Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

     Corrected Apr 23, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0226 Egress Deficiencies

     Have horizontal exits used in accordance with safety requirements.

     Corrected Apr 23, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Apr 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Apr 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Apr 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Apr 23, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Apr 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Apr 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0901 Electrical Deficiencies

     Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

     Corrected Apr 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

     Corrected Apr 23, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0926 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

     Corrected Apr 23, 2024 · CMS fire safety

7. Feb 1, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Mar 15, 2024 · CMS health inspection

8. Oct 10, 2023 MDH complaint investigation · 1 finding
   • Severity not stated

     H56185880C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

9. Jan 14, 2022 MDH complaint investigation · 1 finding
   • Severity not stated

     H5618023C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

10. Nov 16, 2021 MDH complaint investigation · 1 finding
    • Severity not stated

      H5618019C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

11. May 28, 2021 MDH complaint investigation · 3 findings
    • Severity not stated

      H5618016C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

    • Severity not stated

      H5618017C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

    • Severity not stated

      H5618018C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

Owners and managers (as published by CMS)

• ANDERSON, MARK — corporate officer, NOT APPLICABLE, since 01/01/2024
• BILLBERG, GREG — corporate director, NOT APPLICABLE, since 01/01/2024
• COAUETTE, CHAD — corporate director, NOT APPLICABLE, since 01/01/2024
• CRITZ, JULIE — corporate director, NOT APPLICABLE, since 01/01/2024
• FAIRBAIRN, SCOTT — contracted managing employee, NOT APPLICABLE, since 09/01/2019
• FINN, MICHAEL — corporate director, NOT APPLICABLE, since 07/22/2014
• GRUNDHAUSER, RUSSELL — w-2 managing employee, NOT APPLICABLE, since 12/29/2016
• GRUNDHAUSER, RUSSELL — corporate officer, NOT APPLICABLE, since 12/29/2016
• GUGISBERG, MARNIE — corporate director, NOT APPLICABLE, since 01/01/2024
• HANSON, PHILLIP — corporate director, NOT APPLICABLE, since 01/01/2017
• JODSAAS, VICKI — corporate director, NOT APPLICABLE, since 01/01/2024
• KRAFT, CAROL — corporate director, NOT APPLICABLE, since 01/01/2021
• LEE, KATE — corporate director, NOT APPLICABLE, since 01/01/2022
• MONTGOMERY, JEFF — corporate director, NOT APPLICABLE, since 01/01/2024
• PERRY, KATIE — corporate officer, NOT APPLICABLE, since 01/01/2024
• REDDEN, SCOTT — corporate director, NOT APPLICABLE, since 01/01/2022
• SEMMER, FRED — corporate director, NOT APPLICABLE, since 01/01/2022
• SYLTIE, MICHAEL — operational/managerial control, NOT APPLICABLE, since 09/25/2023
• SYLTIE, MICHAEL — w-2 managing employee, NOT APPLICABLE, since 09/25/2023
• WOLF, DAVID — corporate director, NOT APPLICABLE, since 01/01/2024
• VIVIE — operational/managerial control, NOT APPLICABLE, since 01/01/2024
• WALKER METHODIST — operational/managerial control, NOT APPLICABLE, since 09/08/2010
• WALKER SENIOR SERVICES INC — operational/managerial control, NOT APPLICABLE, since 09/08/2010