Waldorf Center

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure privacy and confidentiality of medical records. This was evident during 1 out of 1 dual surveyor observation of the facility's warehouse building which was conducted during the facility's recertification survey and during the review of Complaint #2714840.

Inspectors wroteBased on observation and interview it was determined that the facility failed to maintain a safe, clean, comfortable, and homelike environment. This was evident for 6 (Rooms #102, #103, #107, #118, #119, and #124) out of 17 Resident rooms and one hallway on the A Wing Unit during the facility's recertification survey.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure sanitary practices were followed and maintained and ensure food was stored in accordance with professional standards for food service safety. This was evident during the surveyor's review of the kitchen during the facility's recertification survey.

Inspectors wroteBased on record review and interviews with staff, it was determined that the facility failed to maintain medical records in accordance with accepted professional standards and practices. This was evident for 7 (Resident #2, #1, #66, #65, #5, #3, and #43) out of 45 residents reviewed during the annual survey.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure staff performance of basic infection control measures, follow appropriate infection control management of biohazard waste and storage of clean supplies and handling linens in a safe and sanitary manner. This was evident for 1 out of 1 dual surveyor observation of the facility's warehouse storage, and during an observation of the clean and soiled laundry processing rooms.

Inspectors wroteBased on observation and interview it was determined the facility failed to maintain dignity for a Resident, evident for 1 (Resident #98) out of 2 Residents reviewed for bowel and bladder; and failed to ensure residents were treated with dignity and respect, evident for 1 (Resident #4) out of 43 residents reviewed during the facility's recertification survey.

Inspectors wroteBased on interviews with residents and staff members, it was determined that the facility failed to ensure that each resident had the opportunity to exercise his or her autonomy regarding those things that are important in their life. This was evident for 1 (Resident # 11) out of 43 residents reviewed during the survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to provide the Resident and/or Resident Representative with written notification of a transfer to the hospital and written notification of the facility's bed hold policy upon transfer to the hospital with the opportunity to request to reserve the bed privately. The was evident for 2 (Resident #23 and #100) out of 3 Residents reviewed for hospitalization during the facility's recertification survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded to reflect a Resident's status. This was evident for 2 (Resident #3 and #5) out of 9 Residents reviewed for smoking during the facility's recertification survey.

Inspectors wroteBased on record review and interview it was determined the facility failed to: 1.) ensure a care plan was comprehensive and complete, evident for 1 (Resident #57) out of 1 Resident reviewed for change in condition; and 2.) ensure comprehensive person-centered care plans were developed and implemented for residents which reflect resident's goals, measurable objectives, and interventions to meet the specific goal, evident for 2 (Resident #3 and #5) out of 7 residents reviewed for accidents during the facility's recertification survey.

Inspectors wroteBased on observations, medical record review and interviews with facility staff, it was determined the facility failed to follow professional standards of practice during medication administration observation by not signing off a medication for a resident (#40) after administration, and not administering physician ordered medications to residents (#106 and #107) at their scheduled times. This was found to be evident during medication administration observation during the survey. The Findings Include:1. During the initial screening process of residents on the A Unit Wing, a Licensed Practical Nurse (LPN) #5 was observed on 1/15/26 at approximately 9:55 AM in resident #40's room. At this time resident #40 complained of an upset stomach and headache. [...]

Inspectors wroteBased on observation, record review, and interviews with staff, it was determined that the facility failed to ensure the tube feed formula container and bag of flush was labeled. This was evident for 1 (Resident #65) out of 2 Residents reviewed for tube feeding during the facility's recertification survey.

Inspectors wroteBased on observation, record review, and interview it was determined that the facility failed to ensure that Residents were properly assessed for the safe use of bedrails, obtain consent from the Resident or Resident Representative prior to use of bedrails, and obtain a physician's order for the use of bedrails. This was evident for 2 (Resident #15 and # 23) out of 8 Residents reviewed for accidents during the facility's recertification survey.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to store biologicals in accordance with guidance and ensure that medications opened and refrigerated had a date opened label on it. This was found to be evident for medications found in 1 of 2 medication rooms (B wing) observed during the facility's survey. The Findings Include: An observation was made of a B wing medication room on 1/21/26 at approximately 9:00AM with staff # 3, a Registered Nurse (RN) present. While observing the medications that were stored in the refrigerator, the following concerns were identified: 1. An opened multidose bottle of Tuberculin Purified Protein Derivative with a written date label of 1/9/25 on the bottle. 2. An opened multidose bottle of Tuberculin Purified Protein Derivative that did not have a date label on the bottle indicating when the bottle was opened. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure kitchen staff properly cleaned food preparation equipment for use and that clean pans were air dried prior to storage. These failures had the potential to increase the risk of foodborne illness and had the potential to affect 103 of 110 residents (seven residents received nutrition via tube feedings with some pleasure foods allowed) in the facility who received dietary services.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure garbage was properly disposed of and contained in one of one dumpster areas which would affect 110 census residents and staff in the facility. This failure had the potential to attract pests.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to make preplanned menus and a list of alternative foods readily available to four of four residents (Resident (R) 31, R41, R50, and R101) reviewed for choices in a total sample of 42 residents resulting in the residents not having the opportunity to choose their meal or their choice of an alternative food prior to being served. This increased the risk of residents receiving foods not to their liking and being unaware of alternative food choices available to them.

Inspectors wroteBased on interview and record review, the facility failed to act promptly to the concerns and requests of the resident council to receive meal menus and to consider their preferences for food choices. Five residents (Resident (R)11, R12, R56, R63, and R72 ) who regularly attended resident council expressed that their concerns had repeatedly been unresolved and unanswered.

Inspectors wroteBased on observations, interviews, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to follow infection control measures while caring for two of three residents (Resident (R) 31 and R1) reviewed for infection control out of a total sample of 31 residents. These failures increased the risk of COVID transmission and cross contamination during care for a resident on Enhanced Barrier Precautions.

Inspectors wroteBased on interviews and record review, the facility failed to invite one of four residents (Resident (R) 41) reviewed for care planning out of a total sample of 31 residents to care plan meetings. This failure increased the risk that the resident would not have any direct input into his/her plan of care.

Inspectors wroteBased on record review, observation of resident rooms, equipment, and interviews, it was determined the facility staff failed to 1.) provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior, this was evident on 2 of 3 nursing units observed along with the dining room; and 2.) failed to exercise reasonable care for protecting one supplemental resident's (Resident (R)169) personal property from loss or theft.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer to the resident or family/representative for one of three residents (Resident (R) 471) reviewed for hospitalizations of 31 sampled residents. This failure had the potential for the residents or their representatives to lack the knowledge of where and why they were transferred and how to appeal the transfer if desired.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate pre-admission screening and resident review (PASARR) Level II of a resident for a mental disorder (MD) or intellectual disability (ID) was utilized for one of five residents (Resident (R) 81) reviewed for PASARR. The failure to ensure R81 received a Level two PASARR evaluation for MD/ID or a related condition, could prevent the resident from attaining or maintaining his/her highest practicable level or result in a decline in the resident's physical, mental or psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide nail care to two of four residents (Resident (R) 1 and R41) reviewed for activities of daily living (ADLs) out of a total sample of 31 residents. This failure increased the risk for scratches to the skin which increased the risk of skin breakdown and infection.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to consistently apply a hand splint ordered to prevent further contractures (deformity of a joint or joints due to the shortening of muscles and/or tendons) in one of seven residents (Resident (R) 72) reviewed for positioning and mobility in a total sample of 31 residents. This failure increased the risk of further loss of mobility and increased contractures.

Inspectors wroteBased on record review, interviews, and policy review, the pharmacist failed to identify that adverse consequences and target behaviors were not identified or monitored for one of five residents (Resident (R) 107) reviewed for unnecessary medications out of a total sample of 31 residents. This failure increased the risk of residents receiving an antipsychotic medications without proper monitoring.

Inspectors wroteBased on record review, interview, observation, and policy review, the facility failed to identify and monitor potential adverse consequences and target behaviors for one of five residents (Resident (R) 107) reviewed for unnecessary medications out of a total sample of 31 residents. This failure increased the risk of residents receiving antipsychotic medication without proper monitoring.

Inspectors wroteBased on documentation review and interview it was determined the facility failed to report allegations of abuse, neglect, or an injury of unknown origin within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ) (Resident #15, #55). This was evident for 2 of 17 residents reviewed for allegations of abuse, neglect or an injury of unknown origin during an annual survey.

Inspectors wroteBased on documentation review and interview, it was determined the facility failed to thoroughly investigate an allegation of abuse for a resident (Resident #15). This was evident for 1 of 17 residents reviewed during an annual survey.

Inspectors wroteBased on interview and record review, the facility failed to have quarterly care plan meetings for residents, and to invite the resident and/or the resident representative to participate in the development of the resident's care plan and This was evident for 3 of 44 residents (Resident (R) 51, #901 & # 923) reviewed for care planning. This failure placed the residents at risk of unmet care needs and a decrease in quality of life.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to schedule a follow-up colonoscopy per physician's orders. This was evident for 1 (#906) of 40 residents reviewed for the complaint portion of the annual survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #901). This is evident for 1 of 3 residents reviewed for pressure ulcers during an annual survey.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to ensure a resident received proper foot care and treatment. This was evident for 1 of 45 residents (Resident #904) selected for review during the complaint survey process.

Inspectors wroteBased on review of a complaint, medical record review, and staff interview, it was determined the facility failed to administer respiratory inhalers as ordered for a resident who required respiratory treatment. This was evident for 1 (Resident #909) of 31 residents reviewed for complaints.

Inspectors wroteBased on a review of medical records, Controlled Medication Utilization Record sheets, Medication Administration Record (MAR), and interviews with staff, it was determined that the facility failed to consistently document the administration of an as-needed (PRN) pain medication on the electronic MAR and further monitor the resident's pain level and efficacy of the medication. This was evident during the complaint survey for Resident #903.

Inspectors wroteBased on observation, staff interview, and documentation review it was determined that facility staff failed to keep medication and treatment carts locked when unattended. This was evident on 2 of 3 nursing units observed during random observations made during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to follow up with outside resources for the care of resident (Resident #903). This was evident for 1 of 45 residents reviewed during a complaint survey.

Inspectors wroteBased on interviews and observation, it was determined the facility failed to have an effective pest control program as evidenced by numerous gnats seen throughout the facility. This was evident on 1of 3 nursing units and public areas observed during a complaint survey.

Inspectors wroteBased on review of the medical record and interview with facility staff, it was determined that the facility failed to ensure that physician progress notes from federally required physician visits reflected a review of a resident's total program of care, including medications and treatments, and were legible. This was evident for 1 (#154) of 2 residents reviewed for hospitalization.

Inspectors wroteBased on observation and review of kitchen staff documentation, the facility failed to record food temperatures for the beginning of June 2019

Inspectors wroteBased on observation of the kitchen on 6/4/19, the facility failed to label the dry storage bin or kitchenware that was not to be used, as appropriate.

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that facility staff failed to document the administration of as-needed oxygen in a resident's medication administration record. This was evident for 1 (Resident #154) of 2 residents reviewed for Hospitalization.