Inspection Reports for Waldron Rehabilitation and Healthcare Center
505 N MAIN ST, IN, 46182
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 30, 2025, found the facility in compliance with complaint investigation requirements and no deficiencies were cited. Earlier inspections showed a pattern of some deficiencies related mainly to documentation accuracy, resident care planning, medication management, and safety measures such as fall prevention and environmental cleanliness. Several complaint investigations substantiated issues with misappropriation of medications and resident funds, as well as incomplete care planning and safety interventions, but enforcement actions such as fines or license suspensions were not listed in the available reports. Most complaint investigations were unsubstantiated, and the facility corrected cited deficiencies when found. The trend suggests improvement over time, with recent inspections showing fewer or no deficiencies compared to earlier reports.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
233% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
47 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 30, 2025
Visit Reason
Paper compliance review related to the Investigation of Complaints IN00459777 and IN00459780 completed on May 28, 2025.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the Complaint Survey. Both complaints IN00459777 and IN00459780 were corrected.
Complaint Details
Complaint IN00459777 and Complaint IN00459780 were investigated and found to be corrected.
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Jun 9, 2025
Visit Reason
This visit was conducted to investigate Complaint IN00460800 at Waldron Rehabilitation and Healthcare Center.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00460800 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 47
Medicare residents: 2
Medicaid residents: 37
Other payor residents: 8
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
May 28, 2025
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00458155, IN00458168, IN00458641, IN00459777, and IN00459780) regarding the facility.
Findings
The facility was found deficient in ensuring complete and accurate documentation related to care-planned arguing between residents and activities programming. Specifically, unclear documentation of resident interactions and incomplete activity documentation were noted.
Complaint Details
Complaints IN00459777 and IN00459780 were substantiated with Federal/State deficiencies cited at F842. Complaints IN00458155, IN00458168, and IN00458641 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure documentation was complete and accurate related to care-planned arguing between residents and activities programming. | SS=D |
Report Facts
Census: 49
Medicaid residents: 40
Other payor residents: 9
Deficiency count: 1
Days without documented activities: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Cherry | Executive Director | Named in relation to the Plan of Correction and correspondence |
| Suzanne Williams | Director of Division Long Term Care | Named as contact for the complaint survey |
| RN 3 | Registered Nurse | Named in relation to documentation deficiencies and language barrier |
| Director of Nursing | Director of Nursing | Interviewed regarding documentation and care plans |
| Activities Director | Activities Director | Interviewed regarding activities programming and documentation |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 49
Deficiencies: 0
Apr 15, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457249.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00457249 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 49
Total Capacity: 49
Medicare Residents: 4
Medicaid Residents: 36
Other Payor Residents: 9
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 0
Mar 6, 2025
Visit Reason
This visit was conducted for the investigation of Complaints IN00450959 and IN00452866.
Findings
No deficiencies related to the allegations in Complaints IN00450959 and IN00452866 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00450959 - No deficiencies related to the allegations are cited. Complaint IN00452866 - No deficiencies related to the allegations are cited.
Report Facts
Census SNF/NF beds: 51
Census total residents: 51
Census Medicare residents: 9
Census Medicaid residents: 38
Census other payor residents: 4
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 0
Jan 2, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00449358.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00449358 found no deficiencies related to the allegations.
Report Facts
Census: 46
Total Capacity: 46
Medicare Census: 7
Medicaid Census: 33
Other Payor Census: 6
Inspection Report
Re-Inspection
Census: 46
Capacity: 71
Deficiencies: 0
Dec 17, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/31/24 was performed to verify compliance with life safety and licensure requirements.
Findings
At this PSR survey, Waldron Rehabilitation and Healthcare Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinkled except for a detached wooden garage and wooden shed which were not sprinkled.
Report Facts
Facility capacity: 71
Census: 46
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 0
Dec 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448650.
Findings
No deficiencies related to the allegations in Complaint IN00448650 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00448650 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 4
Medicaid residents: 37
Other payor residents: 7
Inspection Report
Life Safety
Census: 45
Capacity: 71
Deficiencies: 4
Oct 31, 2024
Visit Reason
The Indiana Department of Health conducted an Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey on 10/31/2024 to assess compliance with federal and state regulations including 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code requirements. Deficiencies included an exit door with an incorrect code posted, lack of a lockable shutoff switch for a cooktop in the Therapy Room, corridor doors that did not close and latch properly, and improper use of extension cords and power strips in patient care areas.
Severity Breakdown
SS=E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure the means of egress through 1 of 8 exits was readily accessible; incorrect code posted at back gate exit discharge. | SS=E |
| Failed to ensure staff had access to a lockable shutoff switch for 1 of 1 cook tops in the Therapy Room. | SS=E |
| Failed to ensure 3 of over 50 corridor doors had no impediment to closing and latching into the door frame, resisting passage of smoke. | SS=E |
| Failed to ensure 2 of 2 extension cords including power strips were not used as a substitute for fixed wiring in patient care vicinity. | SS=E |
Report Facts
Certified beds: 71
Census: 45
Deficiencies cited: 4
Residents potentially affected: 10
Residents potentially affected: 5
Residents potentially affected: 20
Residents potentially affected: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Cherry | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Senior Maintenance Director | Interviewed and involved in observations related to deficiencies | |
| Executive Director | Interviewed and involved in observations related to deficiencies |
Inspection Report
Annual Inspection
Census: 47
Capacity: 47
Deficiencies: 7
Oct 9, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on October 3, 4, 7, 8, and 9, 2024.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy during toileting, failure to hold quarterly care plan meetings, failure to use assistive devices during transfers resulting in a fall, lack of RN coverage for required hours, and deficiencies in dietary staff knowledge and food safety practices.
Severity Breakdown
SS=D: 3
SS=E: 1
SS=F: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to promote residents' dignity by ensuring privacy during toileting and timely incontinent care for 2 residents. | SS=D |
| Failed to hold quarterly care plan meetings for 1 resident reviewed. | SS=D |
| Failed to utilize a gait belt during transfer resulting in a fall for 1 resident. | SS=D |
| Failed to have a Registered Nurse (RN) 8 hours a day, 7 days a week for 5 of 5 months reviewed. | SS=F |
| Failed to have knowledgeable dietary staff regarding chemical dishwasher for 6 dietary employees. | SS=E |
| Failed to ensure chemical dishwasher was tested/monitored three times daily and maintain documentation. | SS=F |
| Failed to maintain holding temperatures for pureed foods for 5 residents receiving pureed foods. | SS=F |
Report Facts
Census SNF/NF: 47
Total Capacity: 47
Medicaid Census: 35
Other Payor Census: 12
RN coverage days without RN: 7
RN coverage days without RN: 7
RN coverage days without RN: 4
RN coverage days without RN: 6
RN coverage days without RN: 2
Deficiency completion date: Oct 28, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Clapp | Executive Director | Signed Plan of Correction letter |
| Nicole Cherry | Laboratory Director or Provider/Supplier Representative | Signed inspection report |
| Brenda Buroker | Director of Division Long Term Care | Recipient of Recertification and State Licensure Survey letter |
| Director of Nursing | Interviewed regarding privacy curtain and toileting issues, fall incident, and staffing | |
| Therapy Manager | Interviewed regarding gait belt use during transfers | |
| Dietary Manager | Interviewed regarding chemical dishwasher knowledge and monitoring | |
| Cook 4 | Observed and interviewed regarding dishwasher testing and food holding temperatures | |
| Social Service Director | Interviewed regarding care plan meetings |
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 9, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Waldron Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 0
Jun 25, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00435745 and IN00437353.
Findings
No deficiencies related to the allegations were cited for either complaint. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00435745 and Complaint IN00437353 were investigated with no deficiencies found related to the allegations.
Report Facts
Census Bed Type: 51
Medicare Census: 2
Medicaid Census: 38
Other Payor Census: 11
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 2
May 22, 2024
Visit Reason
Investigation of complaints IN00429563, IN00433363, and IN00434334 related to misappropriation of narcotic medications at the facility.
Findings
The facility failed to ensure 2 residents were free from misappropriation of narcotic medications. An investigation revealed missing narcotics and inconsistent documentation. Staff education and audits were implemented. No negative impact on resident comfort was found. The facility had policies for controlled medication storage and accountability but failed to fully implement them related to the incidents.
Complaint Details
Complaints IN00433363 and IN00434334 were substantiated with deficiencies cited at F602 and F607. Complaint IN00429563 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure residents were free from misappropriation of narcotic medications (Residents B and C). | SS=D |
| Failed to develop and implement policies and procedures related to abuse, neglect, and misappropriation of resident property. | SS=D |
Report Facts
Census: 54
Total Capacity: 54
Percocet administrations for Resident B: 9
Percocet administrations for Resident B: 5
Percocet administrations for Resident B: 5
Hydrocodone administrations for Resident C: 16
Hydrocodone administrations for Resident C: 6
Total tablets received for Resident B: 210
Total tablets received for Resident C: 180
Tablets destroyed for Resident C: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Licensed Practical Nurse | Identified as possible suspect in narcotic diversion; resigned after situation |
| RN 4 | Registered Nurse | Identified as possible suspect in narcotic diversion; resigned after situation; observed on video suspiciously handling medication |
| QMA 5 | Qualified Medication Aide | Identified as possible suspect in narcotic diversion; remains employed |
| LPN 6 | Licensed Practical Nurse | Reported missing narcotics and medication paperwork on 3-27-24 |
| RN 7 | Registered Nurse | Observed on video destroying medication with RN 4 |
| Executive Director | Executive Director | Provided interviews and timeline of narcotic diversion investigation |
| Director of Nursing | Director of Nursing | Notified of missing medications; conducted audits and staff education |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 14, 2024
Visit Reason
Paper compliance review of the Investigation of Complaints IN00424182, IN00424732, IN00425127, and IN00425169 completed on January 18, 2024.
Findings
Waldron Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review Complaint Investigation Survey.
Complaint Details
The visit was a paper compliance review of multiple complaint investigations, with findings indicating compliance.
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 3
Jan 16, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00424182, IN00424732, IN00425127, IN00425169, and IN00425984) regarding alleged deficiencies at Waldron Rehabilitation and Healthcare Center.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, ensuring fall prevention interventions, and timely obtaining admission weights for residents. Specific issues included stained shower tiles, unclean resident recliner, missing antiroll back brakes on a wheelchair, and failure to obtain an admission weight within 14 days for one resident.
Complaint Details
The complaint investigation involved multiple complaints (IN00424182, IN00424732, IN00425127, IN00425169, and IN00425984). Deficiencies related to allegations were cited at F584, F689, and F692. Complaint IN00425984 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to maintain a safe, clean, sanitary, and comfortable environment for a resident shower room and a resident's recliner with dried brown substance present. | SS=D |
| Failed to ensure resident-specific fall interventions of antiroll back brakes and bright color tape were applied to wheelchair brakes for 1 of 3 residents reviewed for falls. | SS=D |
| Failed to ensure 1 of 5 residents reviewed for nutrition had an admission weight obtained in less than 14 days from time of admission. | SS=D |
Report Facts
Census: 51
Total Capacity: 51
Medicare Census: 6
Medicaid Census: 37
Survey Dates: 2024-01-16 to 2024-01-18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Clapp | Executive Director | Signed the report and plan of correction; mentioned in relation to facility management and plan of correction |
| Brenda Buroker | Director of Division Long Term Care | Recipient of the complaint survey report |
| LPN 3 | Provided observations about shower room condition | |
| Resident F | Resident affected by unclean recliner and shower room | |
| Resident G | Resident affected by missing fall prevention interventions | |
| Resident B | Resident affected by missing admission weight | |
| Director of Nursing | Director of Nursing | Interviewed regarding fall prevention and admission weight issues |
| CNA 2 | Confirmed missing fall prevention interventions for Resident G | |
| Corporate Nurse | Provided information about shower tile replacement schedule |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 4, 2024
Visit Reason
The visit was a paper compliance review related to the investigation of complaints IN00422935 and IN00421548, as well as an unrelated citation.
Findings
Waldron Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review Complaint Investigation Survey.
Complaint Details
The survey was conducted as a paper compliance review of complaints IN00422935 and IN00421548. The facility was found to be in compliance.
Inspection Report
Complaint Investigation
Census: 49
Capacity: 49
Deficiencies: 1
Dec 7, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00422935 and IN00421548. No deficiencies related to the allegations of these complaints were cited, but an unrelated deficiency was identified.
Findings
The facility failed to properly prevent and/or contain COVID-19 for 4 of 40 residents observed during a random observation. Deficiencies included staff not properly donning eye protection when entering isolation rooms and improper handling of PPE and meal trays, potentially risking infection transmission.
Complaint Details
Complaint IN00422935 and Complaint IN00421548 were investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly prevent and/or contain COVID-19 for 4 of 40 residents observed, including improper use of PPE such as not donning eye protection when entering isolation rooms and improper handling of contaminated meal trays. | SS=E |
Report Facts
Residents observed: 40
Residents affected: 4
Census: 49
Total capacity: 49
Medicare residents: 8
Medicaid residents: 32
Other payor residents: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Clapp | Laboratory Director or Provider/Supplier Representative | Signed the report |
| CNA 2 | Certified Nursing Assistant | Observed failing to don eye protection and improperly handling PPE and meal trays in isolation rooms |
| CNA 3 | Certified Nursing Assistant | Observed failing to don eye protection and improperly handling PPE and meal trays in isolation rooms |
| ED | Executive Director | Interviewed regarding COVID-19 positive residents and PPE usage |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 24, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00418875, IN00419976, and IN00419986.
Findings
Waldron Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review complaint investigation survey.
Complaint Details
The visit was complaint-related involving complaints IN00418875, IN00419976, and IN00419986. The facility was found to be in compliance.
Inspection Report
Complaint Investigation
Census: 53
Capacity: 53
Deficiencies: 4
Oct 23, 2023
Visit Reason
Investigation of multiple complaints alleging misappropriation of resident property and other concerns at the facility.
Findings
The facility was found to have failed to ensure the security and accounting of a resident's funds held by staff, failed to timely report an allegation of misappropriation, failed to conduct thorough investigations, and failed to timely obtain ordered urinalysis and complete post-fall assessments for residents.
Complaint Details
This visit was triggered by complaints IN00418875, IN00419976, IN00419986, IN00420158, and IN00417033. Deficiencies related to misappropriation of funds and reporting were substantiated in complaints IN00418875, IN00419976, and IN00419986. Complaints IN00420158 and IN00417033 had no deficiencies cited.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure a resident's money was secure and accounted for while stored by a staff person. | SS=D |
| Failed to timely report an allegation of misappropriation to the Indiana Department of Health. | SS=D |
| Failed to thoroughly investigate allegations of misappropriation of resident property. | SS=D |
| 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. | SS=D |
Report Facts
Resident census: 53
Total licensed capacity: 53
Amount withdrawn: 9975
Amount recovered: 6404
Amount missing: 3571
Amount spent by resident: 400
Amount given to friend: 100
Amount missing from Resident E: 500
Fall follow-up assessments: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Clapp | Executive Director | Named in relation to investigation and corrective actions for misappropriation and reporting. |
| MDS Coordinator | Staff member involved in misappropriation of Resident C's funds and subject of investigation. | |
| Director of Nursing | DON | Involved in investigation and reporting of misappropriation allegations. |
| Police Officer 4 | Involved in investigation of misappropriation allegation. | |
| Resident C's Power of Attorney | Provided allegations and information regarding Resident C's funds. | |
| Human Resources | Participated in interview of MDS Coordinator regarding misappropriation. | |
| Medical Records/Scheduler | Reported missing funds for Resident E. | |
| Receptionist 5 | Assisted in investigation of missing funds for Resident E. |
Inspection Report
Follow-Up
Census: 49
Capacity: 79
Deficiencies: 0
Oct 6, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 08/08/23.
Findings
At this PSR Emergency Preparedness survey and Life Safety Code survey, Waldron Rehabilitation and Healthcare Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Re-Inspection
Census: 48
Capacity: 48
Deficiencies: 0
Oct 4, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2023-07-17.
Findings
Waldron Rehabilitation and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census: 48
Total Capacity: 48
Payor Type Census: 4
Payor Type Census: 35
Payor Type Census: 9
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 16, 2023
Visit Reason
The visit was conducted as a paper compliance review related to the Investigation of Complaint IN00410146 completed on June 15, 2023.
Findings
Waldron Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper review Complaint Investigation Survey.
Complaint Details
Investigation of Complaint IN00410146 completed on June 15, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 0
Aug 9, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00414271.
Findings
No deficiencies related to the allegations in Complaint IN00414271 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaint IN00414271 found no deficiencies related to the allegations.
Report Facts
Medicare census: 3
Medicaid census: 41
Other payor census: 10
Inspection Report
Life Safety
Census: 53
Capacity: 79
Deficiencies: 3
Aug 8, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with federal and state regulations including emergency preparedness requirements and fire safety codes.
Findings
The facility was found not in compliance with emergency preparedness communication plan requirements, emergency preparedness training requirements, and life safety corridor door requirements. Specifically, the emergency preparedness communication plan lacked specific contact information for the State Long Term Care Ombudsman, annual emergency preparedness training was not conducted or documented, and one corridor door failed to close and latch properly.
Severity Breakdown
SS=C: 1
SS=F: 1
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Emergency preparedness communication plan did not include specific contact information for the State Long Term Care Ombudsman. | SS=C |
| Failed to conduct and document annual emergency preparedness training and demonstrate staff knowledge of emergency procedures. | SS=F |
| One corridor door to the Therapy Area failed to close and latch positively into the door frame, impeding smoke resistance. | SS=E |
Report Facts
Facility capacity: 79
Census: 53
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Clapp | Administrator | Interviewed regarding emergency preparedness communication plan and training deficiencies |
| Maintenance Director | Interviewed regarding emergency preparedness communication plan, training deficiencies, and corridor door issue |
Inspection Report
Annual Inspection
Census: 59
Capacity: 59
Deficiencies: 14
Jul 17, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from July 10 to July 17, 2023.
Findings
The facility was found deficient in multiple areas including respect and dignity related to catheter care, hydration needs, Medicaid/Medicare coverage notices, safe and clean environment, grievance handling, ADL care, activity programming especially for memory care residents, fall prevention, respiratory care, pain management, staffing adequacy, and resident record keeping.
Deficiencies (14)
| Description |
|---|
| Failed to cover a foley catheter drainage bag to provide dignity for a resident with a foley catheter. |
| Failed to provide fresh water and keep water within reach for 10 of 10 residents reviewed for hydration. |
| Failed to provide Notice of Medicare Non-Coverage or Advanced Beneficiary Notice for 1 of 3 residents reviewed. |
| Failed to promote a clean homelike environment; bedside commode was found with dried feces. |
| Failed to timely complete a grievance for missing items reported verbally for 1 of 2 residents reviewed for grievances. |
| Failed to assist dependent residents with activities of daily living for 3 of 6 residents reviewed. |
| Failed to provide an ongoing activity program and individualized interventions for residents with dementia on the memory care unit. |
| Failed to ensure resident environment free of accident hazards and adequate supervision for 4 of 7 residents reviewed for falls. |
| Failed to ensure urinary catheter drainage bag was free of contact with the floor for 1 of 3 residents reviewed for urinary catheter. |
| Failed to ensure oxygen tubing was dated for 2 of 3 residents reviewed for oxygen therapy. |
| Failed to assess, treat, and notify physician of new onset pain for 1 of 4 residents reviewed for pain. |
| Failed to complete and have signed inventory sheet upon discharge for 1 resident reviewed. |
| Failed to accurately report RN coverage hours for multiple days in Payroll Based Journal report. |
| Failed to have sufficient nursing staff on the memory care unit to provide care, monitor, intervene and provide services safely. |
Report Facts
Census: 59
Total Capacity: 59
Survey Dates: 2023-07-10 to 2023-07-17
Medicare Census: 6
Medicaid Census: 45
Other Payor Census: 8
RN Coverage Hours Missing: 6
Audit Frequency: 3
Audit Review Period: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shannon Terrell | Nurse Consultant | Signed the report |
| Housekeeper 4 | Mentioned in relation to catheter bag placement and missing items | |
| Director of Nursing | Director of Nursing | Responsible for catheter bag coverage, staffing, and notification of physician |
| Executive Director | Executive Director | Provided policies and interviewed about staffing and documentation |
| CNA 10 | Mentioned in relation to memory care unit activities and resident care | |
| LPN 4 | Mentioned in relation to fall interventions and resident care | |
| RN 8 | Mentioned in relation to pain management and resident care | |
| RN 9 | Mentioned in relation to pain management and resident care | |
| Housekeeper 11 | Mentioned in relation to memory care unit staffing and resident safety | |
| Social Services Director | Social Services Director | Provided CNA care sheet and interviewed about grievances |
| Vice President of Leadership Development | Vice President of Leadership Development | Provided inventory policy and interviewed about resident belongings |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 56
Deficiencies: 2
Jun 14, 2023
Visit Reason
This visit was for the investigation of Complaint IN00410146, which involved federal and state deficiencies related to the allegations cited at F657 and F689.
Findings
The facility failed to revise the care plan for activity of daily living (ADL) care needs for 1 of 5 residents reviewed, and failed to ensure mechanical lifts were operated by the recommended number of staff for 1 of 3 residents reviewed. Deficiencies were cited related to care plan timing and revision and free of accident hazards/supervision/devices.
Complaint Details
Complaint IN00410146 was investigated, with federal and state deficiencies cited related to the allegations at F657 and F689.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to revise the care plan for activity of daily living (ADL) care needs for Resident E to accurately reflect current ADL care needs. | SS=D |
| Failed to ensure full body and sit to stand type mechanical lifts routinely have the number of staff persons to operate the lifts as recommended by the manufacturer or the resident's care plan for Resident B. | SS=D |
Report Facts
Census: 56
Total Capacity: 56
Residents reviewed for ADL care plans: 5
Residents reviewed for mechanical lift use: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leah Scott | Director of Nursing | Named in relation to care plan revision and mechanical lift findings |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 16, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00401253 completed on February 16, 2023.
Findings
Waldron Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review Complaint Investigation Survey.
Complaint Details
Investigation of Complaint IN00401253 completed on February 16, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 53
Capacity: 53
Deficiencies: 1
Feb 15, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00401253, which was substantiated with a federal/state deficiency cited at F655.
Findings
The facility failed to develop a baseline care plan related to fall risk within 48 hours of admission for a resident admitted with a known history of falls with injury. Specifically, Resident D did not have a baseline care plan addressing fall risk upon admission despite documented history and fall events.
Complaint Details
Complaint IN00401253 was substantiated with a federal/state deficiency cited at F655 related to failure to develop a baseline care plan for fall risk.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop a baseline care plan related to fall risk within 48 hours of admission for a resident with a known history of falls with injury. | SS=D |
Report Facts
Census: 53
Total Capacity: 53
Medicare Census: 5
Medicaid Census: 33
Other Payor Census: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Leah Scott | Director of Nursing | Named in relation to findings and interviews regarding baseline care plan development and fall risk care plans. |
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