Inspection Reports for
Waldron Rehabilitation and Healthcare Center

The facility failed to ensure residents received mail on Saturdays affecting all 46 residents. Medication orders were not fully reconciled or timely initiated for some residents. A resident was not accurately assessed for safe participation in smoking activities. Hand hygiene was not properly followed during medication administration for multiple residents.

This citation relates to Complaint 2581246.3.1-41(a)(2).

The facility failed to ensure proper completion of treatment for a urinary tract infection for one resident. Resident D received only four days of antibiotics instead of the prescribed five days as per hospital discharge orders.

The citation relates to complaints IN00459780 and IN00459777. The complaints involved possible abuse allegations between residents and issues with documentation of activities programming. The investigation found no substantiated abuse but identified documentation deficiencies.

The facility failed to ensure documentation was complete and accurate related to care-planned arguing between residents and documentation of activities programming. The arguing between two residents was verbal with no physical contact, and residents reported no concerns of abuse. Documentation issues were linked to language barriers of a staff member and incomplete activity records for one resident.

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.

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.

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.

The facility was found deficient in promoting resident dignity and privacy, holding timely care plan meetings, using assistive devices during transfers, maintaining adequate RN coverage, and ensuring proper knowledge and monitoring of the chemical dishwasher and food holding temperatures.

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.

The investigation was triggered by complaints IN00433363 and IN00434334 regarding narcotic diversion. The facility reported the issue to the Indiana Department of Health on 2024-03-28 and conducted an ongoing investigation. Security footage and medication audits were reviewed. Staff drug testing was negative. The facility was unable to definitively identify the responsible staff member(s).

The facility failed to prevent misappropriation of narcotic medications for two residents. An investigation revealed missing narcotics and associated paperwork, suspicious behavior captured on security footage, and inconsistent documentation of controlled substance administration. The facility implemented staff education and audits to address these issues.

Complaints IN00433363 and IN00434334 were substantiated with deficiencies cited at F602 and F607. Complaint IN00429563 had no deficiencies related to the allegations.

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.

The deficiencies relate to Complaints IN00425127, IN00424182, IN00425169, and IN00424732.

The facility failed to maintain a safe, clean, and homelike environment, including stained shower room tiles and a soiled recliner. Additionally, fall interventions were not properly applied to a resident's wheelchair, and one resident's admission weight was not obtained within 14 days of admission.

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.

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.

The facility failed to properly prevent and contain COVID-19 transmission for 4 of 40 residents observed during a random observation. Staff did not consistently use required personal protective equipment (PPE), such as eye protection, when entering isolation rooms, and contaminated meal trays were not properly disinfected.

Complaint IN00422935 and Complaint IN00421548 were investigated with no deficiencies related to the allegations cited.

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.

The investigation was triggered by complaints IN00419976 and IN00419986 alleging misappropriation of resident funds and failure to report and investigate abuse incidents timely and thoroughly.

The facility failed to secure and account for a resident's money withdrawn with staff assistance, did not timely report suspected abuse to the Indiana Department of Health, and did not conduct a thorough investigation of the misappropriation allegations. Additionally, the facility failed to timely obtain ordered urinalysis and complete post-fall assessments for some residents.

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.

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.

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.

The facility was found deficient in multiple areas including dignity and respect for residents, hydration, notification of Medicare non-coverage, room cleanliness, grievance handling, assistance with activities of daily living, activity programming especially on the memory care unit, fall prevention, catheter care, oxygen therapy, pain management, staffing adequacy, dementia care, and resident property inventory.

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.

This Federal tag relates to Complaint IN00410146. The complaint involved concerns about care plan accuracy and mechanical lift staffing.

The facility failed to revise the care plan to accurately reflect Resident E's current ADL needs and failed to ensure mechanical lifts were operated by the recommended number of staff for Resident B. Both deficiencies were found to pose minimal harm with few residents affected.

Complaint IN00410146 was investigated, with federal and state deficiencies cited related to the allegations at F657 and F689.

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 IN00401253 was substantiated with a federal/state deficiency cited at F655 related to failure to develop a baseline care plan for fall risk.

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.