Waldon Health Care Center

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents who required assistance with Activities of Daily Living (ADL) was documented as provided for 3 (Resident #1, Resident #2, Resident #3) of 4 sampled residents reviewed for charting completion and accuracy.

Inspectors wroteBased on interviews and record reviews, the facility failed to:1. Ensure the Minimum Data Set (MDS) accurately reflected the diagnosis of 1(Resident #8) of 1 resident reviewed for active diagnoses;2. Ensure the MDS accurately reflected high-risk medications for 1(Resident #8) of 1 resident reviewed for medications;3. Ensure the MDS accurately reflected a Pre-admission Screening and Resident Review (PASRR) Level II for 2 (Resident #9, Resident #67) of 2 residents reviewed for PASRR Level II; and,4. Ensure the MDS accurately reflected the tobacco status of 1(Resident #67) of 1 resident reviewed for tobacco use.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the total number and the actual hours worked for licensed and unlicensed nursing personnel was posted daily during review of nurse staffing requirements.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure food stored in the facility's walk-in refrigerator was properly labelled and contained with an opened date and was unavailable for resident use.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement facility policy to ensure all witness statements received verbally were titled, and signed by both the person making the statement and the witness.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were provided resident specific behavior training prior to providing supervision for a resident's behaviors for 4 (S6Social Services, S8Porter, S9Porter, S10Housekeeping Supervisor) of 4 (S6Social Services, S8Porter, S9Porter, S10Housekeeping Supervisor) sampled staff reviewed for behavior training.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure medications were available for administration for 1 (Resident #R1) of 7 (Resident #2, Resident #3, Resident #4, Resident #R1, Resident #R2, Resident #R3, Resident #R4) sampled residents observed during medication administration.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the dietary manager had completed an approved food safety program and passed the accompanying test for 1 (S13Dietary Manager) of 1 (S13Dietary Manager) sampled dietary managers employed by the facility.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure: 1. Food items were not placed in areas in which water had accumulated on food packaging; 2. Food items were covered in the refrigerator; 3. Expired food items were discarded and not available for use; 4. Damaged food items were not stored amongst other food items; 5. Staff had all hair restrained when in the food preparation areas; 6. Chemicals were not stored in food preparation areas; 7. Food items were labeled with an opened date and labeled with the contents of the container/bag; and, 8. Staff did not store their food items with residents' food items

Inspectors wroteBased on observations, interviews, record reviews, the facility failed to ensure: 1. A facility-wide surveillance of resident's infections were maintained (Resident #7, Resident #12, Resident #27, and Resident #84); and, 2. Certified Nursing Assistants (CNAs) completed hand hygiene during incontinence care (Resident #21). This deficient practice was identified for 4 (Resident #7, Resident #12, Resident #27, and Resident #84) of 13 (Resident #1, Resident #7, Resident #12, Resident #27, Resident #39, Resident #55, Resident #56, Resident #63, Resident #73, Resident #76, Resident #79, Resident #84, and Resident #88) sampled residents reviewed for infection surveillance; and, for 1 (Resident #21) of 2 (Resident #21 and Resident #27) residents observed during incontinence care.

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to provide privacy for a resident during incontinence care for 1 (Resident #21) of 2 (Resident #21 and Resident #27) sampled residents observed during incontinence care.

Inspectors wroteBased on record reviews and interviews, the facility failed to protect a resident's right to be free from resident to resident physical abuse for 1 (Resident #84) of 3 (Resident #26, Resident #64, and Resident #84) residents investigated for abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident, with a new diagnosis of Schizoaffective Disorder, was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #63) of 3 (Resident #12, Resident #63, and Resident #84) sampled residents reviewed for PASARR.

Inspectors wroteBased on record reviews, interviews, and observations the facility failed to: 1. Develop a person-centered care plan for a resident with dialysis and, 2. Implement interventions per the resident's plan of care. This deficient practice was identified for 1 (Resident #27) of 1 (Resident #27) residents investigated for dialysis.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident's blister was evaluated and treated for 1 (Resident #79) of 2 (Resident #12 and Resident #79) residents investigated for skin conditions.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure an expired medication was not available for resident use for 1 (Medication Cart c) of 3 (Medication Cart a, Medication Cart c, and Medication Cart d) medication carts observed for expired medications.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the medication error was not greater than 5% for 2 (Resident #R3 and Resident #R4) of 10 (Resident #1, Resident #3, Resident #R1, Resident #R2, Resident #R3, Resident #R4, Resident #R5, Resident #R6, Resident #R7, and Resident #R8) sampled residents observed during medication administration.

Inspectors wroteBased on interviews and record review, the facility failed to deliver care per professional standards by failing to ensure: 1. Licensed Practical Nurses (LPNs) (S3LPN and S4LPN) followed a physician's order for supervisory checks every 2 hours for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents and/or notified the facility's administration of a missing resident (Resident #1); and, 2. LPNs (S3LPN and/or S4LPN) did not falsify documentation of administering medications per a physician's orders and/or checking the placement of a resident's wander guard per a physician's order for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This deficient practice resulted in an Immediate Jeopardy situation on 08/29/2024 at 8:55 a.m. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure staff provided supervision to prevent elopement for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents investigated for supervision. This deficient practice resulted in an Immediate Jeopardy situation on 08/29/2024 at 8:55 a.m. for Resident #1, a resident identified by the facility as an elopement risk, when Resident #1 was unable to be located in the facility by the facility's staff. Resident #1 did not return to the facility until 08/30/2024 at 3:30 p.m. and was noted to have complaints of nausea and epigastric pain. Resident #1 was then transferred to the emergency room with police escort and was placed on a Physician's Emergency Certificate. S1Administrator was notified of the Immediate Jeopardy on 08/30/2024 at 5:26 p.m. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure: 1. Licensed Practical Nurses (LPNs) (S3LPN and S4LPN) followed a physician's order for supervisory checks every 2 hours for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents and/or notified the facility's administration of a missing resident (Resident #1); 2. LPNs (S3LPN and/or S4LPN) did not falsify documentation of administering medications per a physician's orders and/or checking the placement of a resident's wander guard per a physician's order for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents; and, 3. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to: 1. Ensure the facility had a sufficient number of licensed nurses to provide direct care to residents (08/08/2024, 08/13/2024, 08/14/2024, and 08/21/2024); and, 2. Ensure a nurse assigned to a group of residents did not leave the facility before the scheduled oncoming nurse arrived at the facility to assume the responsibility of the group of residents (08/21/2024, 08/22/2024, 08/23/2024, 08/24/2024, 08/25/2024, 08/26/2024, 08/27/2024, 08/28/2024, 08/29/2024, and 08/30/2024). [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the Facility Assessment Tool: 1. Was reviewed and updated as necessary annually; 2. Addressed contracts; 3. Had involvement from the certified nursing assistants (CNAs); and 4. Used input from residents and residents' representatives.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure its Quality Assessment and Assurance Committee met at least quarterly to evaluate the activities under the Quality Assurance and Performance Improvement (QAPI) program.

Inspectors wroteBased on record reviews and interviews, the facility failed to: 1. Maintain a system to periodically reconcile controlled drugs for 4 (Medication Cart a, Medication Cart b, Medication Cart c, and Medication Cart d) of 4 (Medication Cart a, Medication Cart b, Medication Cart c, and Medication Cart d) medication carts reviewed for the reconciliation documentation of controlled substances; and 2. Administer a resident's medication per a physician's order for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.

Inspectors wroteBased on record reviews and interview the facility failed to ensure certified nursing assistants (CNAs) were provided Quality Assurance and Performance Improvement (QAPI) training for 4 (S6CNA, S31CNA, S32CNA, and S33CNA) of 5 (S6CNA, S30CNA, S31CNA, S32CNA, and S33CNA) sampled CNAs reviewed for training requirements as required.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a Certified Nursing Assistant (CNA) received ethics training for 1 (S6CNA) of 5 (S6CNA, S30CNA, S31CNA, S32CNA, and S33CNA) sampled CNAs' personnel files reviewed for training requirements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's abuse policy to protect residents from potential neglect (S3LPN and S4LPN).

Inspectors wroteBased on observations and interviews, the facility failed to ensure the daily nurse staffing information was posted daily as required.

Inspectors wroteBased on interview and record reviews, the facility failed to obtain a final disposition for a fugitive charge that appeared on a Certified Nursing Assistant's (CNA) criminal background check. This deficient practice was identified for 1 (S2CNA) of 5 (S2CNA, S3CNA, S4CNA, S5CNA, and S6CNA) personnel records reviewed for personnel requirements.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure a resident did not sustain an injury when staff placed a rolling bedside table in front of a resident to prevent a fall. This deficient practice was identified for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for accidents.

Inspectors wroteBased on interview and record review, the facility failed to administer pain medication when a nonverbal resident showed signs and symptoms of pain for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This deficient practice resulted in actual harm for Resident #2 beginning on 04/09/2024 when S4Occupational Therapist (OT) reported to S3Licensed Practical Nurse (LPN) Resident #2 had facial grimacing with movement of the right lower extremity with no intervention to manage Resident #2's pain.

Inspectors wroteBased on record review and interview, the facility failed to ensure an injury of unknown origin was reported to the state survey agency no later than 2 hours after it was discovered for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure the Certified Nurse Aide (CNA) Registry was verified on hire and/or every 6 months for 5 (S3CNA Supervisor, S6CNA, S7CNA, S8CNA, and S9CNA) of 5 (S3CNA Supervisor, S6CNA, S7CNA, S8CNA, and S9CNA) personnel records reviewed.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure dishwasher temperature gauges were maintained in proper working order and maintain the ice machine and water dispenser in a sanitary manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with identified mental health diagnosis were referred for a preadmission screening and resident review (PASARR) Level II evaluation as required for 2 (Resident #47 and Resident #54) of 4 (Resident #42, Resident #47, Resident #54, and Resident #58) sampled residents reviewed for PASARR.

Inspectors wroteBased on record reviews and interviews, the facility failed to: Maintain ongoing communication regarding a resident's condition prior to leaving the facility for dialysis treatments for 1 (Resident #21) of 1 (Resident #21) sampled residents investigated for dialysis services.

Inspectors wroteBased on interviews and observations, the facility failed to ensure food was palatable to residents in temperature. This deficient practice had the potential to affect any of the 101 residents who receive food from the facility's kitchen.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident had a comprehensive care plan that addressed her sexual health care needs for 1 (Resident #1) of 9 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9) residents reviewed in the sample for care planning.