Walker Methodist Westwood Ridge II: Choking Risk - MN
Resident 42 was admitted to Walker Methodist Westwood Ridge II on April 6 with pleural effusion. Within days, staff documented that she retained food in her mouth at 7:22 p.m. and required help eating because she spilled food on the floor.
On April 13, her diet was changed to minced and moist texture with explicit orders for supervision while eating. The speech therapy orders specified the supervision was "due to food remaining in oral cavity."
The facility's own care instructions, printed April 14, indicated the resident required supervision with eating.
Yet federal inspectors found her eating alone.
During observation on April 13 at 12:21 p.m., the resident was eating lunch alone in her room. Inspectors documented "prolonged chewing with delayed swallow" and noted she held food in her mouth. Drooling was observed throughout the meal.
The next day, inspectors watched again from 12:21 p.m. to 12:31 p.m. The resident received her lunch tray and ate unsupervised.
When confronted, staff revealed a fundamental misunderstanding of what supervision meant.
Nursing assistant A acknowledged that care instructions required supervision due to food pocketing. However, the aide described supervision as "checking on the resident every hour or so."
Clinical coordinator and licensed practical nurse A confirmed awareness of the supervision order but described it as "periodic checks" and was unable to define the frequency. The nurse stated the resident was not considered a choking risk despite documented pocketing.
The director of therapy said nursing staff "may need more education on what supervision with meals meant and why it was implemented."
Speech therapist A, who wrote the supervision order, clarified her intent during an interview on April 15. She stated the order was "intended to ensure staff were present during meals for the resident's safety due to pocketing of foods."
The speech therapist said she would clarify the order to ensure the resident received adequate supervision.
The resident's initial nutrition screening on April 8 indicated she could not use a straw because of her past stroke and would self-select soft foods. Her original diet was regular texture with thin liquids.
After staff observed food remaining in her mouth, orders were changed to minced and moist texture. The speech therapy evaluation recommended full supervision because the resident held solids in her mouth "at all times."
The speech therapist told inspectors the resident had "not only swallowing issues but cognition issues as well."
During the two days of observation, inspectors documented the resident's dangerous eating patterns. She demonstrated prolonged chewing with delayed swallowing and consistently held food in her oral cavity. Drooling occurred throughout meals.
The facility's Kardex system contained the supervision requirement, but staff interpreted it as occasional check-ins rather than continuous presence during meals.
The speech therapist's orders also directed staff to perform oral care after the resident's oral intake, indicating the severity of her swallowing difficulties.
Despite physician orders dated April 13 requiring supervision, and despite the facility's own care instructions printed April 14 confirming the supervision requirement, the resident ate alone on both April 13 and April 14.
The clinical coordinator's statement that the resident was not considered a choking risk contradicted both the physician orders and the speech therapist's assessment. The speech therapist specifically cited safety concerns due to food pocketing as the reason for requiring supervision.
Staff had access to the care information but failed to follow the explicit supervision orders, leaving a stroke patient with documented swallowing impairments to eat alone while holding food in her mouth.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Walker Methodist Westwood Ridge II from 2026-04-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WALKER METHODIST WESTWOOD RIDGE II in WEST SAINT PAUL, MN was cited for violations during a health inspection on April 15, 2026.
Resident 42 was admitted to Walker Methodist Westwood Ridge II on April 6 with pleural effusion.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.