Waldron Rehabilitation and Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to treat residents with dignity and respect for 3 of 6 resident's reviewed for dignity (Residents F, H, and L).

Inspectors wroteBased on interview and record review, the facility failed to ensure staff timely reported allegation of abuse to the Executive Director for 1 of 4 residents reviewed for abuse (Resident F).

Inspectors wroteBased on interview and record review the facility failed to assess pain level prior to administering as needed pain medications and to implement non-pharmacological pain interventions for 1 of 1 resident reviewed for pain ( Resident F).

Inspectors wroteBased on interview and record review, the facility failed to completely and accurately reconcile admission orders and failed to timely input and initiate physician orders for a resident with a change of condition for 1 of 6 residents reviewed for medication management and 1 of 1 resident reviewed for hospitalization (Resident 18 and 5).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was assessed accurately to determine if the resident was able to participate in a smoking activity for 1 of 9 residents reviewed for smoking. (Resident 3)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper hand hygiene was utilized during medication administrations for 4 of 6 residents observed during medication administration. (Resident 1, Resident 7, Resident 19 and Resident 22)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received mail on Saturdays. This had a potential to affect 46 of 46 residents that resided in the facility.

Inspectors wroteBased on interview and record review, the facility failed to properly ensure treatment of a urinary tract infection was completed for 1 of 3 residents reviewed for identification and treatments of urinary tract infections. (Resident D)

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation was complete and accurate, related to care-planned arguing between 2 of 6 residents reviewed for possible abuse allegations and for 1 of 5 residents reviewed for activities programming. (Resident C, Resident D, and Resident H)

Inspectors wroteBased on interview and record review, the facility failed to have a Registered Nurse (RN) 8 hours a day, 7 days a week, for 5 of 5 months of RN coverage reviewed. This had the potential to affect all 47 residents that resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a chemical dishwasher was tested/monitored three times daily per their expectations and to maintain documentation of such monitoring. This had the potential of affect all 47 residents who resided in the facility. Based on observation, interview, and record review, the facility failed to maintain holding temperatures for pureed foods for 5 of 5 residents receiving pureed foods. (Resident 18, 26, 34, 39, and 40)

Inspectors wroteBased on observation, interview, and record review, the facility failed to have knowledgeable dietary staff regarding a chemical dishwasher for 6 of 6 dietary employees reviewed for kitchen. (Dietary Manager, [NAME] 4, [NAME] 5, Dietary Aid 6, Dietary Aid 7, and Dietary Aid 8) A tour of the kitchen was conducted with [NAME] 4 on 10/3/24 at 11:15 a.m. [NAME] 4 indicated she was not sure what the dishwasher strip testing should read. It was observed [NAME] 4 was using the wrong testing strips to test the chemical dishwasher. She also was unsure of proper temperatures that should be recorded. [NAME] 4 did not know what the temperatures or readings should be for chemical sanitization parts per million (ppm). During an observation of the chemical dishwasher with the Dietary Manager (DM) on 10/3/24 at 12:00 p.m., she was using the wrong chemical testing strips to test the chemical dishwasher. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote residents' dignity by ensuring privacy for a resident during toileting and providing incontinent care in a timely manner for 2 of 2 residents reviewed for dignity. (Resident 23 and Confidential Resident)

Inspectors wroteBased on interview and record review, the facility failed to hold quarterly care plan meetings for 1 of 3 residents reviewed for care plans. (Resident 8) The clinical record for Resident 8 was reviewed on 10/7/24 at 10:35 a.m. The diagnoses included, but were not limited to, chronic kidney disease, heart failure, and generalized anxiety disorder. During an interview with Resident 8 on 10/4/24 at 11:00 a.m., they indicated they did not have regular care plan meetings. A Quarterly Minimum Data Set (MDS) assessment, dated 8/1/24, indicated Resident 8 was cognitively intact for daily decision making. The electronic health record (EHR) indicated Resident 8 had a quarterly care plan meeting, on 8/4/23, a quarterly care plan meeting, on 2/5/24, and another quarterly care plan meeting, on 7/9/24; indicating no care plan meetings were done for six months, then not again for another five months. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize an assistive device of a gait belt during a transfer resulting in a fall for 1 of 2 residents reviewed for accidents. (Resident 23)

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 2 residents reviewed for misappropriation of property were not subjected to missing narcotic medications. (Residents B and C) The deficient practice was corrected on 4-4-24, prior to the start of the survey, and was therefore past noncompliance. The facility had immediately began an investigation upon learning of the missing narcotic medication and associated paperwork and begin staff education regarding the correct means to conduct controlled substance counts. Based on resident assessments and interviews, there was not a negative impact to the comfort level of either resident identified as being affected by this deficient practice.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures related to misappropriation of resident property for 2 of 2 residents reviewed for misappropriation of property related to drug diversion. (Residents B and C) The deficient practice was corrected on 4-4-24, prior to the start of the survey, and was therefore past noncompliance. The facility had immediately began an investigation upon learning of the missing narcotic medication and associated paperwork and begin staff education regarding the correct means to conduct controlled substance counts. Based on resident assessments and interviews, there was not a negative impact to the comfort level of either resident identified as being affected by this deficient practice.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe, clean, sanitary and comfortable environment for a resident shower room and a resident's recliner was observed with a dried brown substance present. These deficient practices have the ability to adversely affect any residents who utilize the shower room and Resident F. (Resident F)

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure resident specific fall interventions of antiroll back brakes and bright color tape were applied to wheelchair brakes 1 of 3 residents reviewed for falls. (Resident G)

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 residents reviewed for nutrition had an admission weight obtained in less than 14 days from time of admission. (Resident B)

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to properly prevent and/or contain COVID-19 for 4 of 40 residents observed during a random observation. (Residents 14, 31, 35, and 29).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's money was secure and accounted for while it was being stored by a staff person for 1 of 3 residents reviewed for misappropriation of a resident's property. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to timely report an allegation of misappropriation to the IDOH (Indiana Department of Health) per policy for 1 of 4 residents reviewed for misappropriation. (Resident E)

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough investigation was conducted for 1 of 3 residents reviewed for misappropriation of a resident's property. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to timely obtain a urinalysis as ordered and to ensure post fall occurrence follow-up assessments were completed at least once per shift for 72 hours following a fall for 2 of 3 residents reviewed for falls. (Resident C and F)

Inspectors wroteBased on observation, interview and record review the facility failed to provide fresh water and failed to keep water within reach for 10 of 10 residents reviewed for hydration (Resident 21, Resident 39, Resident 48, Resident 14, Resident 41, Resident 51, Resident 7, Resident 8, Resident 50 and Resident 26).

Inspectors wroteBased on observation, interview and record review the facility failed to provide an ongoing activity program for the memory care unit for 4 of 4 residents reviewed for activities (Resident 48, Resident 42, Resident 51 and Resident 157).

Inspectors wroteBased on observation, interview and record review the facility failed to implement fall interventions and failed to keep walk ways free of clutter for 4 of 7 residents reviewed for falls (Resident 51, Resident 50, Resident 19 and Resident 20).

Inspectors wroteBased on observation, interview and record review the facility failed to have adequate staffing on the memory care unit to provide care, monitor, intervene and provide services in a safe manner for 4 of 4 random resident observations. (Resident 151, Resident 52, Resident 48 and Resident 21).

Inspectors wroteBased on observation, interview and record review the facility failed to implement an specialized memory care unit activity program and failed to implement individualized interventions for residents with dementia for 5 of 5 residents reviewed for dementia (Resident 48, Resident 42, Resident 51, Resident 157 and Resident 21).

Inspectors wroteBased on observation, interview, and record review, the facility failed to cover a foley catheter drainage bag, to provide dignity for a resident with a foley catheter for 1 of 4 residents reviewed for catheters. (Resident 8)

Inspectors wroteBased on interview and record review, the facility failed to have documentation that a Notice of Medicare Non-Coverage (NOMNOC) or Advanced Beneficiary Notice (ABN) was provided to Resident 50 for 1 of 3 residents reviewed for beneficiary notices.

Inspectors wroteBased on interview, observation, and record review, the facility failed to promote a clean homelike environment for 1 of 4 residents reviewed for room cleanliness. (Resident 210)

Inspectors wroteBased on interview, observation, and record review, the facility failed to timely complete a grievance for missing items reported verbally to a staff member for 1 of 2 residents reviewed for missing items. (Resident 46)

Inspectors wroteBased on observation, interview and record review the facility failed to assist dependent residents with Activities of Daily living (ADL) for 3 of 6 residents reviewed for ADL assistance (Resident 21, Resident 51 and Resident 27)

Inspectors wroteBased on observation and record review, the facility failed to ensure the urinary catheter drainage bag was free of contact with the floor for 1 of 3 residents reviewed for urinary catheter. (Resident 50)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen tubing was dated for 2 of 3 residents reviewed for oxygen therapy. (Resident 210 and Resident 20)

Inspectors wroteBased on observation, interview and record review the facility failed to assess a new onset of pain, treat a new onset of pain and failed to notify the physician of a resident experiencing an new onset of pain for 1 of 4 resident's reviewed for pain (Resident 42)

Inspectors wroteBased on interview and record review, the facility failed to provide eight hours of RN coverage for 2 of 6 days triggered reviewed in Quarter 2 of Fiscal Year 2023 and 1 of 1 days randomly selected for Quarter 2 of Fiscal Year 2023.

Inspectors wroteBased on interview and record review, the facility failed to complete an inventory sheet and failed to have staff or resident/resident's representative sign the inventory sheet upon discharge.

Inspectors wroteBased on interview and record review, the facility failed to accurately report the RN coverage hours for 4 of 6 days triggered on a Payroll Based Journal Report for Fiscal Year 2023 Quarter 2.