Walker Rehabilitation Center, Inc

Inspectors wroteBased on interviews, record review, review of the Administrator Job Description, and review of the facility's Abuse Policy, the facility's former Administrator, ADM #5, failed to provide oversight to ensure the facility's abuse policies were implemented and failed to conduct thorough investigations of abuse allegations to identify contributing factors and take corrective action to prevent further abuse. The Administrator's failure to ensure that the facility's abuse policies were implemented, and that allegations of abuse were thoroughly investigated to ensure the appropriate corrective actions were taken, was likely to result in further abuse and serious harm, serious injury, impairment, or death. [...]

Inspectors wroteBased on interviews, record review and review of the Director of Operations Job Description, the Governing Body failed to provide oversite to ensure the facility's Abuse Coordinators, including Administrator (ADM) #5, were provided training on how to conduct a thorough investigation, identify contributing factors, and take corrective action to prevent further abuse. The Governing Body further failed to ensure the facility developed its Abuse Policy to include the process for coordination with the QAPI program to ensure the Abuse Policy was fully implemented for all allegations of abuse and thoroughly investigated to ensure the appropriate corrective actions were taken to prevent further abuse. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on interviews, record review, and review of facility policy titled Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership the facility's QAPI committee, failed to thoroughly review all allegations of abuse that occurred on 07/08/2023, 07/09/2023, 09/06/2023, 05/10/2024 of incidents to identify all causal factors and to take appropriate action to prevent reoccurrences. These incidents are related to Resident Identifiers (RI) #5, RI #20, RI #98, and RI #99's Facility Reported Incidents (FRIs). The facility failed to ensure its Quality Assessment and Assurance (QAA) Program developed and implemented process to analyze and review all adverse events including substantiated allegations of abuse. [...]

Inspectors wroteBased on interviews, reviews of residents' medical records, review of a facility policy titled ABUSE PREVENTION, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to protect the rights of residents to be free from abuse perpetrated by employees of the facility and by other residents of the facility. Specifically: 1) On 07/08/2023 Resident Identifier (RI) #5 was verbally abused by Certified Nursing Assistant (CNA) #8 when CNA #8 yelled and cursed Damn you . at RI #5 and slammed the bathroom door with RI #5 in the bathroom. RI #5 cried while explaining to staff what happened. On 07/09/2023 RI #98 was verbally and mentally abused by CNA #8 when CNA #8 withheld and refused to provide RI #98 a lunch tray for disciplinary reasons. [...]

Inspectors wroteBased on interviews, medical record reviews, review of a facility policy titled ABUSE PREVENTION, and review of the facility investigative file, the facility failed to ensure policies and protocols were implemented to immediately intervene to protect residents and stop abuse, and immediately report the abuse. 1.) Specifically, on 07/09/2023 Certified Nursing Assistant (CNA) #9 and CNA #26 witnessed CNA #8 intentionally withholding RI #98's meal tray in the dining room for disciplinary reasons. CNA #8 told CNA #9 to not serve RI #98. The facility further failed to ensure staff who witnessed the abuse, CNA #9 and CNA #26, intervened to protect RI #98, stop the abuse, and report the abuse immediately to Administration. The abuse was not reported or acted on until 07/10/2023. [...]

Inspectors wroteBased on interviews, resident record review, review of a facility policy titled ABUSE PREVENTION, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to thoroughly investigate the occurrence of abuse of residents perpetrated by employees of the facility to include when the incident occurred, and failed to obtain statements from all those present to identify contributing factors to be able to determine appropriate interventions and actions to prevent further abuse. 1.) the facility failed to ensure a thorough investigation was conducted on 07/10/2023 after receiving reports that Certified Nursing Assistant (CNA) #8 verbally and mentally abused Resident Identifier (RI) #5 on 07/08/2023 when she yelled and cursed Damn you . [...]

Inspectors wroteBased on resident record review, interviews, review of Facility Reported Incidents (FRIs), and review of a facility policy titled ABUSE PREVENTION, the facility failed to ensure facility staff reported abuse immediately to the Administrator for allegations of abuse to be reported to the State Agency within two hours after abuse occurred when: 1. Resident Identifier (RI) #98 was verbally and mentally abused on 07/09/2023 by Certified Nursing Assistant (CNA) #8. This was witnessed by CNA #9, CNA #26, and previous Dietary Manager (DM) #15. This was not reported to Administrator until 07/10/2023. 2. RI #99 was verbally and physically abused by CNA #9 on 09/06/2023. CNA #22 witnessed the abuse and failed to report the abuse to anyone in the facility until the next day on 09/07/2023. [...]

Inspectors wroteBased on observations, interviews and facility policies titled Cleaning Dishes/Dish Machine and Resource: Taking Accurate Temperatures, the facility failed to ensure: 1) Plate domes/covers and trays were not wet nesting and; 2) The temperatures on the tray line were taken and recorded. This had the potential to affect 40 residents who received meals from the kitchen.

Inspectors wroteBased on interviews, record review, and review of the job responsibilities of the Certified Medication Aide (CMA), the facility failed to ensure subcutaneous insulin injections were not administered to residents by CMA/MAC (Medication Assistant, Certified) #10, #11, #12 and #13 from May 2023 through October 2023. This affected RI #6, #10, #18, #28, #31, #32 and #98 seven of 16 sampled residents receiving medications in the facility. This deficient practice affected four of five Med Techs who administered insulin to residents. This deficient practice was cited as a result of investigation of complaint/report number AL00046139.

Inspectors wroteBased on observations, interview, and review of a facility policy titled Posting Direct Care Daily Staffing Numbers, the facility failed to ensure the required data was on the staff posting form, to include census and the number of staff working and actual hours worked for all nursing staff on four of five days of the survey. This deficient practice had the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and facility policy titled, Homelike Environment the facility failed to ensure: 1) Screens were on the windows for Resident Identifier (RI) #8, RI #10, RI #11, RI #12, RI #19, and RI #44. 2) Holes were not in the glass windowpanes of RI #10, RI #11, and RI #44's room. 3) Paint was not peeling off of the ceiling in RI #10, RI #11, and RI #44's room. 4) The bathroom floor was not stained yellow under the sink and around the toilet in the shared bathroom for RI #8, RI #10, RI #11, RI #12, RI #19, and RI #44. 5) Wires for the call light were not intertwined with plumbing for the sink in the shared bathroom of RI #8, RI #10, RI #11, RI #12, RI #19, and RI #44. 6) Open gaps were not between the glass windowpanes and the wall in RI #10, RI #11, and RI #44's room. 7) Baseboards were not missing in RI #10, RI #11, RI #44's room.

Inspectors wroteBased on observations, record review, interviews, and a facility policy titled, POSITIONING THE RESIDENT, the facility failed to ensure Resident Identifier (RI) #25 was turned and repositioned every two hours. This affected one of two residents observed for a pressure ulcer.

Inspectors wroteBased on observation, interviews and review of POTTER AND [NAME], FUNDAMENTALS OF NURSING, NINTH EDITION, the facility failed to ensure a licensed nurse cleaned Resident Identifier (RI) #7's nasal spray container after contact with the resident's nares before recapping the container and returning it to the medication cart. Findings Include: A review of POTTER AND [NAME], FUNDAMENTALS OF NURSING, NINTH EDITION, CHAPTER 32, Medication Administration, BOX 32-16 PROCEDURAL GUIDELINES, Administering Nasal Medications, documented: 16. Administer nasal spray: .18. Wipe tip of bottle with clean, dry tissue and replace the cap, . RI #7 was readmitted to the facility on [DATE]. A diagnosis included allergic rhinitis. On 02/06/20 at 8:07 a.m., Employee Identifier (EI) #3, Licensed Practical Nurse (LPN), was observed administering RI #7's nasal spray to each nare. [...]

Inspectors wroteBased on observation, interviews, review of a facility policy titled Dietary Policy - Food Storage, the facility failed to ensure: 1. expired foods were not stored in kitchen refrigerators, 2. there was no rust present on kitchen food preparation tables and on clean dish storage shelving, and there was no chipping paint on the clean dish storage area above food serving hot bar, among other issues identified in the kitchen. This had the potential to affect 46 of 50 residents who received meals from the kitchen. Findings Include: The facility's policy titled Proper Food Storage - Refrigerated, no date, included: .13 .Leftover food is used within 3 days or discarded .14 . f . All foods should be covered, labeled, and dated. All foods will be .consumed by their safe use by dates, or frozen . or discarded . 1. [...]

Inspectors wroteBased on observations, interviews and review of a facility policy titled, Facility Environment Policy & Procedure and a facility document titled, Director of Maintenance Job Description, the facility failed to ensure Room Locators (RL)'s #1-23 were free of scuffed and chipped paint, torn veneer on doors with sharp edges, exposed commode bolts, cracked commode lid and peeling commode seat, doorframes free of rust, missing baseboards and tiles. This was observed three of three days of the survey and affected 23 rooms on all three wings of the facility. Findings Include: A review of a facility policy titled, Facility Environment Policy & Procedure, no date, revealed: . Residents are provided with a safe, clean .homelike environment . A review of a facility document titled, Director of Maintenance Job Description, no date, revealed: . C. Safety . Functions Duties: . [...]

Inspectors wroteBased on observations, interviews, and review of facility policies titled, Hand Hygiene/Glove Use Policy and Blood Glucose Testing, the facility failed to ensure: 1.) a Licensed Nurse cleaned Resident Identifier (RI) #38's personal glucometer before storing it in the medication cart and washed her hands after touching potentially contaminated objects before applying gloves to administer RI #38's insulin injection; 2.) a Licensed Nurse did not place a syringe filled with insulin for RI #39 on top of the medication cart without a barrier; 3.) a Certified Nursing Assistant (CNA) did not manipulate the paper towel dispenser with her bare hands after washing her hands and washed her hands after removing gloves during catheter care for RI #17, and 4.) a CNA removed her gloves after touching RI #15's colostomy bag during catheter care. [...]

Inspectors wroteBased on observation, interview, medical record review and review of Potter and [NAME], Fundamentals of Nursing, Ninth Edition, the facility failed to ensure physician's orders were followed for Resident Identifier (RI) #44, RI #7 and RI #251. This affected RI #44, RI #7 and RI #251, three of 15 residents whose physician's orders were reviewed. Findings Include: A review of Potter and [NAME], Fundamentals of Nursing, Ninth Edition, Chapter 23, Legal Implications in Nursing Practice, page 311, revealed: .Health Care Providers' Orders .Nurses follow health care providers' orders unless they believe that the orders are in error . 1.) RI #44 was readmitted to the facility on [DATE], with diagnoses including, Pseudobulbar Palsy, Contractures Hips, Knees, Elbows and Other Paralytic Syndromes. A review of RI #44's physician's orders revealed: [...]

Inspectors wroteBased on interview, review of Resident Identifier (RI) #44's medical record and a facility document titled, INCIDENT/ACCIDENT REPORT - RESIDENT, the facility failed to ensure Employee Identifier (EI) #8, a Certified Nursing Assistant (CNA), obtained assistance of another staff member before transferring RI #44 using a Hoyer lift, as determined by RI #44's assessment and plan of care, during a transfer on 10/06/18. During the 6:00 a.m. to 2:00 p.m. shift on 10/06/18, EI #8 failed to follow RI #44's plan of care when she transferred the resident by herself using the Hoyer lift causing RI #44's gerichair to turn over and RI #44, a resident on antiplatelet medication and at increased risk for bleeding, to sustain a raised area to the back of his/her head and skin tear to the right forearm. Resident complained of head pain and dizziness and was transferred to a local hospital after the fall. [...]