Inspection Reports for
Waldon Health Care Center
2401 IDAHO STREET, KENNER, LA, 70062
Back to Facility Profile9 Reports
Inspection Report — Mar 26, 2025
Complaint Investigation CMS
Date: Mar 26, 2025
Visit Reason
The inspection was conducted to investigate complaints related to failure to implement policies to prevent abuse, neglect, and theft; insufficient staff training to meet behavioral health needs; and failure to provide timely pharmaceutical services.
Complaint Details
The investigation was complaint-driven, focusing on allegations of sexual abuse and concerns about staff training and medication availability. The complaint was substantiated by findings of improper documentation, lack of staff training, and medication delays.
Findings
The facility failed to ensure witness statements were properly signed and titled in abuse investigations, did not provide specific behavior training to staff assigned to supervise a resident with behavioral issues, and failed to have medications available for administration to a resident as ordered.
Deficiencies (3)
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.
Failed to ensure staff were provided resident specific behavior training prior to providing supervision for a resident's behaviors.
Failed to ensure medications were available for administration for one resident during medication administration.
Report Facts
Residents observed during medication administration: 7
Staff reviewed for behavior training: 4
Resident #2's Brief Interview for Mental Status score: 8
Medication dosage: 20
Medication dosage: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Documented witness statements related to sexual abuse investigation | |
| S2 Director of Nursing | Director of Nursing | Indicated lack of staff training and medication availability |
| S3 Corporate Administrator | Corporate Administrator | Interviewed regarding verbal statements in abuse investigation |
| S4 Licensed Practical Nurse | Licensed Practical Nurse | Unable to locate medications for Resident #R1 |
| S5 LPN | Licensed Practical Nurse | Provided sexual abuse allegation statement not signed by self or witness |
| S6 Social Services | Staff assigned to supervise Resident #2 without behavior training | |
| S8 Porter | Porter | Assigned 1:1 supervision of Resident #2 without behavior training |
| S9 Porter | Porter | Assigned 1:1 supervision of Resident #2 without behavior training |
| S10 Housekeeping Supervisor | Housekeeping Supervisor | Assigned 1:1 supervision of Resident #2 without behavior training |
| S12 CNA | Certified Nursing Assistant | Provided sexual abuse allegation statement not signed by self or witness |
| S13 Housekeeper | Housekeeper | Provided verbal witness statement regarding sexual abuse not signed or dated |
Inspection Report — Jan 16, 2025
Routine CMS
Date: Jan 16, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident privacy, abuse prevention, PASARR evaluations, care planning, medication management, dietary services, food safety, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy during care, failure to protect residents from abuse, failure to complete required PASARR evaluations, inadequate care planning and implementation, expired medication storage, dietary manager lacking certification, food safety violations, incomplete infection surveillance, and improper hand hygiene by staff.
Deficiencies (9)
Failed to provide privacy for a resident during incontinence care by not closing the privacy curtain.
Failed to protect a resident from resident-to-resident physical abuse which was substantiated.
Failed to ensure a resident with a new diagnosis of Schizoaffective Disorder was referred for PASARR Level II evaluation.
Failed to develop and implement a complete care plan for a resident with dialysis and failed to monitor intake and output as per care plan.
Failed to evaluate and treat a resident's blister in a timely manner.
Failed to ensure expired medication was not available for resident use.
Dietary manager had not completed an approved food safety program or passed the ServSafe exam.
Failed to maintain food safety standards including uncovered food, expired food, damaged food, improper labeling, chemical storage in food prep areas, and staff hair not fully restrained.
Failed to maintain a comprehensive infection prevention and control program including incomplete infection surveillance and failure of CNAs to perform hand hygiene during incontinence care.
Report Facts
Residents investigated for abuse: 3
Residents observed during incontinence care: 2
Containers of uncovered fruit cocktail: 83
Medication expiration date: 12
Dialysis frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S11 CNA | Certified Nursing Assistant | Did not close privacy curtain during incontinence care and failed to perform hand hygiene |
| S12 CNA | Certified Nursing Assistant | Did not close privacy curtain during incontinence care and failed to perform hand hygiene |
| S2 Director of Nursing | Director of Nursing/Infection Preventionist | Confirmed privacy and infection control deficiencies and expired medication storage |
| S1 Administrator | Administrator | Confirmed privacy, infection control, and expired medication deficiencies |
| S16 Social Services | Social Services | Confirmed resident-to-resident abuse incident |
| S3 Admissions Coordinator | Admissions Coordinator | Confirmed PASARR evaluation was not completed |
| S17 Medical Director | Medical Director | Indicated care plan interventions should have been followed |
| S19 CNA | Certified Nursing Assistant | Unaware of resident's blister and failed to report |
| S15 LPN | Licensed Practical Nurse | Unaware of resident's blister and failed to report |
| S20 LPN | Licensed Practical Nurse/Charge Nurse | Confirmed blister should have been reported |
| S22 LPN | Licensed Practical Nurse | Confirmed expired medication found in medication cart |
| S13 Dietary Manager | Dietary Manager | Had not passed ServSafe exam and confirmed food safety deficiencies |
Inspection Report — Dec 30, 2024
Complaint Investigation CMS
Date: Dec 30, 2024
Visit Reason
The inspection was conducted to investigate medication administration errors reported at the facility, specifically to ensure medication error rates were not 5 percent or greater.
Complaint Details
The visit was complaint-related, focusing on medication administration errors. The complaint was substantiated as errors were confirmed through observations, record reviews, and interviews.
Findings
The facility failed to ensure medication error rates were below 5%, with 6 errors observed out of 27 medication administration opportunities, resulting in a 22% error rate. Medication administration did not follow physician orders for Residents #R3 and #R4, including missed doses and timing errors.
Deficiencies (1)
Failed to ensure medication error rates were not 5 percent or greater, with errors observed in medication administration for Residents #R3 and #R4.
Report Facts
Medication administration opportunities: 27
Medication administration errors: 6
Medication error rate: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | S3LPN administered medication to Resident #R3 | |
| Licensed Practical Nurse (LPN) | S4LPN administered medication to Resident #R4 and admitted to errors in medication administration | |
| Director of Nursing (DON) | S2DON provided information on medication administration timing requirements | |
| Administrator | S1Administrator confirmed medication administration errors for Residents #R3 and #R4 |
Inspection Report — Sep 5, 2024
Complaint Investigation CMS
Date: Sep 5, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident supervision, medication administration, staffing sufficiency, and facility administration.
Complaint Details
The complaint investigation was triggered by concerns about resident supervision, medication administration, staffing sufficiency, and facility administration. Resident #1, identified as an elopement risk, was missing from the facility for an extended period, resulting in Immediate Jeopardy.
Findings
The facility failed to ensure adequate supervision of residents at risk for elopement, failed to follow physician orders for resident checks, falsified medication administration documentation, had insufficient licensed nursing staff on multiple days, failed to ensure proper nurse shift handoffs, failed to reconcile controlled substances properly, and lacked proper facility-wide assessments and staff training.
Deficiencies (10)
Failed to implement policies and procedures to prevent abuse, neglect, and theft, resulting in neglect of Resident #1.
Failed to deliver care per professional standards by not following physician's orders for supervisory checks every 2 hours for Resident #1 and falsifying medication administration documentation.
Failed to ensure staff provided supervision to prevent elopement for Resident #1, resulting in Immediate Jeopardy when Resident #1 was missing from the facility.
Failed to provide enough nursing staff every day to meet the needs of every resident and ensure nurses did not leave before the oncoming nurse arrived.
Failed to post daily nurse staffing information as required.
Failed to maintain a system to periodically reconcile controlled drugs for all medication carts reviewed.
Failed to administer Resident #1's medication per physician's order and falsified documentation of medication administration.
Failed to conduct and document a facility-wide assessment addressing contracts, CNA involvement, and input from residents and representatives.
Failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to certified nursing assistants.
Failed to provide ethics training to a certified nursing assistant.
Report Facts
Residents affected: 110
Deficiencies cited: 13
Time without assigned nurse: 57
Time without assigned nurse: 30
Time without assigned nurse: 45
Time without assigned nurse: 37
Time without assigned nurse: 39
Time without assigned nurse: 75
Time without assigned nurse: 184
Time without assigned nurse: 20
Time without assigned nurse: 47
Time without assigned nurse: 36
Time without assigned nurse: 105
Time without assigned nurse: 45
Time without assigned nurse: 37
Time without assigned nurse: 15
Time without assigned nurse: 91
Time without assigned nurse: 74
Time without assigned nurse: 203
Time without assigned nurse: 3
Time without assigned nurse: 79
Time without assigned nurse: 5
Time without assigned nurse: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3LPN | Licensed Practical Nurse | Named in neglect and falsification of medication administration and failure to notify administration of missing resident. |
| S4LPN | Licensed Practical Nurse | Named in neglect and falsification of medication administration and failure to follow physician orders. |
| S1Administrator | Administrator | Provided multiple interviews regarding resident elopement, staff failures, and administrative oversights. |
| S2Director of Nursing | Director of Nursing | Provided interviews regarding nursing staff responsibilities, medication administration, and administrative oversight. |
| S20Assistant Director of Nursing | Assistant Director of Nursing | Provided interview regarding nursing staff sufficiency and responsibilities. |
| S6CNA | Certified Nursing Assistant | Alerted staff to missing Resident #1 and lacked QAPI and ethics training. |
| S31CNA | Certified Nursing Assistant | Lacked QAPI training. |
| S32CNA | Certified Nursing Assistant | Lacked QAPI training. |
| S33CNA | Certified Nursing Assistant | Lacked QAPI training. |
| S34Human Resources Director | Human Resources Director | Confirmed lack of QAPI training documentation for CNAs. |
| S8Ward Clerk | Ward Clerk | Responsible for updating nurse staffing information. |
| S9Licensed Practical Nurse | Licensed Practical Nurse | Provided interview regarding medication reconciliation and nurse staffing. |
Inspection Report — Jul 31, 2024
Complaint Investigation CMS
Date: Jul 31, 2024
Visit Reason
The inspection was conducted following a complaint investigation related to a resident fall incident and personnel background check concerns.
Complaint Details
The complaint investigation involved Resident #1's fall and injury on 07/14/2024 and the background check issue of S2CNA. Resident #1 sustained bruising and an abrasion after being placed with a rolling bedside table as a fall precaution. The facility lacked documentation of final disposition for S2CNA's fugitive charge.
Findings
The facility failed to prevent injury to a resident when staff used a rolling bedside table as a fall prevention measure, resulting in bruising and an abrasion. Additionally, the facility failed to obtain a final disposition for a fugitive charge on a Certified Nursing Assistant's criminal background check.
Deficiencies (2)
Failed to ensure a resident did not sustain an injury when staff placed a rolling bedside table in front of the resident to prevent a fall.
Failed to obtain a final disposition for a fugitive charge that appeared on a Certified Nursing Assistant's criminal background check.
Report Facts
Residents reviewed for accidents: 3
Personnel records reviewed for personnel requirements: 5
Hire date: 2023
Criminal background check date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2 CNA | Certified Nursing Assistant | Personnel record reviewed for criminal background check and fugitive charge |
| S3 CNA | Certified Nursing Assistant | Placed Resident #1 in wheelchair and positioned rolling bedside table |
| S9 CNA | Certified Nursing Assistant | Observed Resident #1 after fall and noted no visible injury initially |
| S7 LPN | Licensed Practical Nurse | Assessed Resident #1 for bruising after fall |
| S8 Woundcare Treatment Nurse | Woundcare Treatment Nurse | Assisted in wheeling Resident #1 for assessment |
| S1 Administrator | Administrator | Interviewed regarding fall incident and background check findings |
Inspection Report — Apr 17, 2024
Complaint Investigation CMS
Date: Apr 17, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report an injury of unknown origin and failure to provide appropriate pain management for a nonverbal resident.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to timely report a major injury of unknown origin and failure to administer pain medication to Resident #2, resulting in actual harm.
Findings
The facility failed to report a major injury of unknown origin within two hours as required and failed to administer pain medication to a nonverbal resident showing signs of pain, resulting in actual harm. Resident #2 sustained a fracture that was not reported timely and did not receive pain medication despite documented signs of pain.
Deficiencies (2)
Failed to timely report an injury of unknown origin to the state survey agency within two hours of discovery.
Failed to provide safe, appropriate pain management for a nonverbal resident who showed signs and symptoms of pain.
Report Facts
Residents sampled: 3
Residents affected: 1
Medication dosage: 325
Medication frequency: 2
Incident discovery date: Apr 11, 2024
Incident report date: Apr 13, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Indicated failure to report Resident #2's fracture within two hours. | |
| S4 Occupational Therapist (OT) | Reported Resident #2's facial grimacing and pain on 04/09/2024. | |
| S3 Licensed Practical Nurse (LPN) | Documented Resident #2's pain and failed to administer pain medication. | |
| S5 Certified Nursing Assistant (CNA) | Reported Resident #2's pain and refusal to be touched. | |
| S2 Director of Nursing (DON) | Assessed Resident #2, notified doctor, and confirmed pain medication should have been administered. |
Inspection Report — Feb 1, 2024
CMS
Date: Feb 1, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, staff qualifications, food service, and facility maintenance at Waldon Health Care Center.
Findings
The facility was found deficient in multiple areas including failure to ensure proper PASARR Level II evaluations for residents with mental health diagnoses, inadequate communication regarding dialysis treatments, failure to verify Certified Nurse Aide registry status, serving food at unsafe temperatures, and unsanitary conditions of the dishwasher, ice machine, and water dispenser.
Deficiencies (5)
Failed to ensure residents with identified mental health diagnosis were referred for a PASARR Level II evaluation as required for 2 of 4 sampled residents.
Failed to maintain ongoing communication regarding a resident's condition prior to leaving the facility for dialysis treatments for 1 sampled resident.
Failed to ensure the Certified Nurse Aide (CNA) Registry was verified on hire and/or every 6 months for 5 personnel records reviewed.
Failed to ensure food was palatable to residents in temperature; food was served lukewarm to room temperature.
Failed to ensure dishwasher temperature gauges were maintained in proper working order and maintain the ice machine and water dispenser in a sanitary manner.
Report Facts
Residents affected: 2
Residents affected: 1
Personnel records reviewed: 5
Residents affected: 101
Dishwasher temperature: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S12 Admissions Coordinator | Responsible for obtaining and reviewing PASARRs | |
| S1 Administrator | Administrator | Acknowledged PASARR deficiencies and lack of policy |
| S13 Licensed Practical Nurse | Licensed Practical Nurse | Acknowledged failure to complete dialysis communication forms |
| S2 Director of Nursing | Director of Nursing | Confirmed dialysis communication and unsanitary conditions of ice machine and water dispenser |
| S5 Dietary Manager | Dietary Manager | Acknowledged food temperature complaints and dishwasher temperature issues |
| S11 Human Resources | Human Resources | Unaware of CNA Registry verification requirements |
| S4 Maintenance Supervisor | Maintenance Supervisor | Acknowledged dishwasher temperature gauge malfunction |
| Contracted Dishwasher Company Service Representative | Confirmed dishwasher temperature valve malfunction | |
| S10 Certified Nursing Assistant | Certified Nursing Assistant | Confirmed use of unsanitary ice machine and water dispenser |
Inspection Report — Dec 7, 2023
Annual Inspection CMS
Date: Dec 7, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with care planning requirements, specifically to determine if residents had comprehensive care plans addressing all their needs, including sexual health care.
Findings
The facility failed to ensure that Resident #1 had a comprehensive care plan addressing her sexual health care needs despite staff awareness of her sexual activity with other male residents. The administrator confirmed the lack of such a care plan and acknowledged staff were not knowledgeable about this issue.
Deficiencies (1)
Failed to develop and implement a complete care plan that meets all the resident's needs, including sexual health care for Resident #1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S3 Certified Nursing Assistant | Certified Nursing Assistant | Aware of Resident #1's sexual activity and reported it to the nurse. |
| S2 Licensed Practical Nurse | Licensed Practical Nurse | Confirmed Resident #1's sexual activity and reported it to nurse supervisor. |
| S4 Corporate MDS Nurse | Corporate MDS Nurse | Did not implement care plan addressing sexual health for Resident #1 because unaware of sexual activity. |
| S1 Administrator | Administrator | Confirmed Resident #1 did not have a care plan addressing sexual health needs and staff were not knowledgeable about the sexual activity. |
Inspection Report — Jan 13, 2023
Routine CMS
Date: Jan 13, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including staff competencies, nurse staffing postings, pharmaceutical services, medication storage and labeling, medical record accuracy, and infection prevention and control.
Findings
The facility was found deficient in ensuring annual competencies for CNAs, posting nurse staffing information daily, maintaining accurate controlled medication reconciliation records, securing medication and treatment carts, removing expired medications, documenting physician orders correctly, and enforcing hand hygiene and infection control practices.
Deficiencies (6)
Failed to ensure Certified Nursing Assistants completed annual competencies as required.
Failed to post nurse staffing information daily.
Failed to maintain accurate reconciliation records of controlled medication for medication carts.
Failed to ensure medication and treatment carts were locked when unattended, medications were properly labeled, and expired medications were removed.
Failed to safeguard resident-identifiable information and maintain accurate medical records, specifically physician orders and medication administration records.
Failed to ensure staff performed hand hygiene and used personal protective equipment appropriately during meal assistance and medication administration.
Report Facts
Residents affected: 3
Residents affected: 70
Medication carts observed: 3
Treatment carts observed: 2
Residents sampled: 26
Residents receiving medication: 14
Residents requiring meal assistance: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S1 Administrator | Administrator | Confirmed CNAs lacked annual competencies, nurse staffing not posted, medication storage and expired meds issues, and documentation deficiencies. |
| S2 Director of Nursing | Director of Nursing | Confirmed controlled substance count policy and deficiencies, medication documentation issues, and hand hygiene lapses. |
| S3 ADON | Assistant Director of Nursing | Responsible for checking expired items on treatment cart. |
| S5 LPN | Licensed Practical Nurse | Observed not performing hand hygiene during medication administration and improper handling of medication tablets. |
| S6 LPN | Licensed Practical Nurse | Reported no documentation of controlled count signature for medication cart. |
| S7 LPN | Licensed Practical Nurse | Observed leaving medication cart unlocked and unattended. |
| S11 CNA | Certified Nursing Assistant | Failed to perform hand hygiene between residents during meal assistance and lacked knowledge of hand hygiene requirements. |
| S12 CNA | Certified Nursing Assistant Supervisor | Did not complete annual competencies for CNAs due to lack of knowledge of annual requirement. |
| S13 CNA Supervisor | Certified Nursing Assistant Supervisor | Acknowledged lack of annual competency completion for CNAs. |
| S15 CNA | Certified Nursing Assistant | Observed not performing hand hygiene between residents during meal assistance. |
| S16 CNA | Certified Nursing Assistant | Observed not performing hand hygiene between residents during meal assistance. |
| S18 Unit Clerk | Unit Clerk | Confirmed failure to post daily nurse staffing hours on specified dates. |
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