Walker Rehabilitation Center, Inc

In the surveyor’s words

From the most serious findings on record at Walker Rehabilitation Center, Inc, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Nov 30, 2024

  Based 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. […]

• Immediate jeopardy, widespreadF837Nov 30, 2024

  Based 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. […]

• Immediate jeopardy, widespreadF867Nov 30, 2024

  Based 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. […]

• Immediate jeopardy, patternF600Nov 30, 2024

  48195 47408 44165 Based 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 [DATE] 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. […]

• Immediate jeopardy, patternF607Nov 30, 2024

  44165 Based 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. […]