Waldron Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Waldron Rehabilitation and Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Oct 9, 2024

  Based 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. Findings include: Review of the schedules provided by the Administrator, on 10/4/24 at 1:00 p.m., indicated there were no RNs in the facility for seven out of 30 days in April 2024, seven out of 31 days in May 2024, four out of 30 days in June 2024, six out of 30 days in September 2024, and two out of eight days in October 2024. During an interview with the Administrator on 10/8/24 at 2:27 p.m., they verified the facility did not have RN coverage in April, May, June, September, and/or October of 2024. […]

• No harm, potential for more than minimal, widespreadF812Oct 9, 2024

  Based 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) Findings include: 1. A tour of the kitchen was conducted, on 10/3/24 at 12:00 p.m., with the Dietary Manager (DM). During an observation of the chemical dishwasher, the only documentation log for monitoring of the dishwasher was obtaining temperatures only for wash and rinse cycles three times a day. […]

• No harm, potential for more than minimal, widespreadF812May 21, 2021

  Based on observation, interview and record review, the facility failed to ensure communication with staff when an issue occurred to where a high-temperature dish machine was not meeting temperature requirements, dietary staff not having knowledge of the type of dish machine in use, utilizing a dish machine without monitoring temperature based on the dish machine temperature logs, and not initiating a secondary plan to serve meals when the dish machine was identified as not meeting temperature requirements. The facility failed to ensure food was stored properly related to undated and unlabeled food and not covering food items that were being served to residents in their rooms. This had the potential to affect all 54 residents that receive food from the kitchen. Findings include: 1. […]

• No harm, potential for more than minimal, patternF802Oct 9, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF880Dec 8, 2023

  Based 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). Findings include: The clinical record for Resident 14 was reviewed on 12/8/23 at 11:54 a.m. indicated, the resident tested positive for COVID-19 on 12/7/23 and was on contact droplet isolation for 10 days. The clinical record for Resident 31 was reviewed on 12/8/23 at 11:58 a.m. indicated, the resident tested positive for COVID-19 on 12/7/23 and was on contact droplet isolation for 10 days. […]