Walnut Grove Care & Rehab Center

In the surveyor’s words

From the most serious findings on record at Walnut Grove Care & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 28, 2025

  On 02/27/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to protect Resident #45 from verbal and psychosocial abuse. On 02/27/25 at 2:06 p.m., Resident #45 reported over the weekend staff blamed them for turning on the call light. Resident #45 stated CNA #1 came to their room to answer the call light and Resident #45 told CNA #1 they needed assistance with incontinent care. Resident #45 stated CNA #1 told them they were assisting another resident and would come back when they could. Resident #45 stated when CNA #1 returned they yelled at them and stated they would be there in a minute and to stay off the light. […]

• No harm, potential for more than minimal, widespreadF880Oct 24, 2023

  Based on observation and interview, the facility failed to properly inform visitors and staff of residents who were in isolation on transmission based precautions for three (#13, 19, and #48) of three sampled residents who tested positive for COVID. The IP identified 22 residents who tested positive for COVID. Findings: The Infection Control Manual, dated 5/11/23, read in part, .An isolation notice will be placed in plain view outside the entrance to the isolation/quarantine room . On 10/17/23 at 9:30 a.m., a white cross or plus sign was observed on the doors to Res #13, 19 and #48's rooms. On 10/18/23 at 8:00 a.m., a large letter Q was observed on the doors to Res #13, 19 and #48's rooms. The resident roster documented Res #13, 19 and #48 tested positive for COVID on 10/10/23. […]

• No harm, potential for more than minimal, patternF812Feb 28, 2025

  Based on observation, record review, and interview, the facility failed to ensure the low temperature warewasher had the appropriate amount of chemical to sanitize dishes for the facility. The administrator identified 55 residents ate meals from the kitchen. Findings: On 02/24/25 at 11:26 a.m., the CDM was observed using test strips for sanitizer in the low temperature warewasher and the sanitizer was not pumping through to release the chemical into the warewasher. An undated chemical company instruction manual, read in part,Test paper must read at least 50 parts per million. […]

• No harm, potential for more than minimal, patternF690Oct 24, 2023

  Based on observation, record review, and interview, the facility failed to assess residents for the continued need for indwelling urinary catheters for one (#2 ) of two sampled residents reviewed for an indwelling urinary catheter. The Resident Census and Conditions of Residents, dated 10/17/23, documented four residents who had an indwelling urinary catheter. Findings: Res #2's medical record documented diagnoses which included neuromuscular dysfunction of the bladder. Res #2 was readmitted to the facility from the hospital on 09/10/23, the re-admission nursing note, dated 09/10/23, documented Res #2 had an indwelling urinary catheter in place upon re-admission. A significant change resident assessment, dated 09/17/23, documented Res #2 had an indwelling urinary catheter in place. […]

• No harm, potential for more than minimal, patternF812Oct 24, 2023

  Based on observation and interview, the facility failed to ensure food was labeled and stored in a sanitary manner. The Resident Census and Conditions of Residents, dated 10/17/23, documented 57 residents receive their meals from the kitchen. Findings: A Refrigerator Storage policy, dated February 2010, read in part, .label all leftovers with recipe name and date (month, day, year) of storage. Discard refrigerated leftovers after 48 hours . On 10/17/23 at 9:30 a.m., an intial tour of the kitchen was conducted. The following was found in the refrigerator: a. Bologna in a ziplock bag dated 09/23. b. An unlabeled zip lock bag of hot dogs. c. Chopped eggs in a ziplock bag dated 9/4. d. Rice in a ziplock bag date 9/4. e. An unlabeled zip lock bag of a green herb. f. […]