Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waldron Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Failure to maintain resident dignity and respect: A cognitively intact resident reported that the DON screamed at him and used profanity during a room interaction about toileting and cursing at staff, while other residents heard the raised voices. Two other residents reported disrespectful staff comments, including being accused of soiling themselves, and one resident said staff appeared angry after he filed a complaint and would not answer his call light.
Failure to Timely Report Allegation of Abuse: A resident with HTN and intact cognition reported that the DON yelled at, cursed at, and was disrespectful to the resident after addressing the resident about cursing at staff. Staff were told about the allegation but did not report it to the ED because the resident said he had already done so, and the ED stated she was not informed by staff.
Failure to provide safe, appropriate pain management occurred for a resident after hernia surgery. The resident had PRN Ultram ordered, but the MAR did not document two doses pulled from the Capsus machine as administered, did not show pain levels or effectiveness for those doses, and the record did not include attempted non-pharmacological interventions. Notes also described significant post-op pain, swelling, and complaints that staff were not helping control the pain.
Medication reconciliation and order entry failures affected two residents. One resident’s admission MAR omitted multiple ordered meds, including PRN Flexeril, osteoporosis injections, a supplement, vitamin B-12, an antibiotic, and eye drops, and the DON said related discussions and discontinuation orders were not documented. Another resident with obstructive uropathy, a suprapubic catheter, fever, and abnormal urine findings had NP orders for Levaquin and potassium that were not entered into the EMR until the next day, and urine assessments were not documented during the decline.
A resident with stroke-related hemiplegia, nicotine dependence, and moderate cognitive impairment had inconsistent smoking assessments in the record, with some indicating he did not smoke and another indicating he did smoke and could participate safely. Staff and the resident confirmed he was going outside to smoke cigarettes and vape, and he was observed smoking during a smoking activity. The facility’s smoking policy required direct supervision for all residents assessed as safe to smoke.
Hand hygiene was not followed during medication administration for multiple residents. An RN was observed handling medication carts, medication cards, and other items with bare hands, popping pills into her hand, and administering insulin and other meds without hand hygiene before glove use or before aseptic tasks. The DON stated staff should perform hand hygiene before donning gloves, before insulin administration, and should not touch medications directly with bare hands.
Residents did not receive mail on Saturdays and had to wait until Monday for mail that arrived over the weekend. During a resident council meeting, cognitively intact residents reported the delay, and the BOM confirmed that resident mail was held until Monday because the AD did not work weekends. The Admin stated the Nurse Mgr on duty was supposed to distribute mail on Saturdays.
A resident with cognitive impairment and urinary incontinence, recently treated for a UTI, did not receive the full prescribed course of oral antibiotics after hospital discharge. The resident was given only eight doses over four days instead of the ordered five-day regimen, contrary to physician orders and facility policy.
Staff failed to provide complete and accurate documentation regarding repeated verbal altercations between two cognitively intact residents, with unclear notes about the nature of the incidents and staff response, partly due to language barriers with an RN. Additionally, activity participation was not consistently documented for a resident with depression and diabetes, despite regular attendance, contrary to facility policy requiring objective and complete records.
The facility did not have a Registered Nurse (RN) on duty for 8 hours a day, 7 days a week, over several months, potentially affecting all 47 residents. The Administrator confirmed the lack of RN coverage, although they reported no residents were affected and no RN-specific tasks were incomplete. The facility's policy requires RN presence, which was not met.
The facility failed to properly monitor and document the chemical dishwasher's sanitizing process, only recording temperatures instead of chemical ppm as required. Additionally, pureed foods for five residents were held at inadequate temperatures, below the required 135 degrees Fahrenheit, with staff relying on microwaving before serving, contrary to facility policy.
The facility failed to ensure dietary staff were knowledgeable about the chemical dishwasher, leading to incorrect use of testing strips and lack of proper monitoring. The Dietary Manager and staff were unable to correctly interpret or log chemical sanitization levels, despite policy requirements.
The facility failed to ensure privacy and timely incontinent care for two residents. One resident was exposed to the hallway during toileting due to a missing privacy curtain, while another experienced frequent incontinence episodes due to long wait times for assistance. Staff cited insufficient help as a reason for delays, impacting residents' dignity.
A facility failed to conduct quarterly care plan meetings for a resident with chronic kidney disease, heart failure, and generalized anxiety disorder. The resident reported not having regular meetings, and records showed significant gaps between meetings. The Social Service Director was unaware of the missed meetings, which violated the facility's policy on resident participation in care planning.
A resident with a history of dementia and mobility issues fell during a transfer when staff failed to use a gait belt, despite requiring extensive assistance. The resident's care plan indicated a risk for falls, and later observations confirmed the necessity of a gait belt for safe transfers.
The facility failed to ensure that two residents were not subjected to missing narcotic medications, leading to an investigation that revealed missing documentation and suspicious behavior by staff. Despite no negative impact on the residents' comfort levels, the facility's failure to follow its policy on controlled medication storage and accountability constituted a significant deficiency.
The facility failed to implement policies and procedures related to drug diversion, resulting in missing narcotics and associated paperwork for two residents. An investigation revealed discrepancies in controlled substance logs and suspicious behavior by an RN during medication destruction. Residents did not report negative impacts on their comfort levels.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents with dignity and respect for 3 of 6 residents reviewed for dignity, involving Residents F, H, and L. Resident F, who was cognitively intact on the admission MDS, reported that the DON came to his room during the evening and screamed at him, cursed at him, and told him to get the h*ll out after addressing his cursing toward staff and a toileting-related request. The resident said he informed the ED about the incident. The investigation file included the DON’s statement that she entered the room to discuss the resident’s request for aides to put his penis in the urinal and that she told him not to yell and cuss at the CNAs when they offered help. RN 4 heard raised voices between the DON and Resident F, and residents in the smoking area also heard them yelling at each other. Resident L stated that after he reported a CNA for being disrespectful and saying he had *******[cuss word] peed his pants, some staff were mad at him and would not come into his room to answer his call light, while the CNA he reported would walk by and stare when his call light was on. Resident H reported completing a grievance because a staff member accused him of sh*tting his pants, which he found very disrespectful and upsetting. The facility’s Resident Rights Policy stated residents have the right to a dignified existence, self-determination, and communication, and to be treated with consideration, respect, and recognition of dignity and individuality.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure staff timely reported an allegation of abuse to the Executive Director for one resident. The resident’s clinical record showed diagnoses including high blood pressure, and an admission MDS completed on 2/7/26 indicated the resident was cognitively intact. During an interview, the resident stated that on the evening of 5/8/26 the DON came to the room to address the resident about cursing at nursing staff, and the DON screamed at the resident, told the resident to get the h*ll out, cursed at the resident, and was very disrespectful. The resident reported the incident to the ED on Monday 5/11/26. A confidential interview indicated the staff member had been told by the resident that the DON had yelled at him, but did not report it to the ED because the resident had said he had already reported it. The ED stated she had been at the facility on Saturday 5/9/26 and had not heard anyone talking about the incident, and no staff informed her about it while she was there. The ED stated she would have wanted to know what was being said about the incident and that staff should have reported it to her. The facility policy stated all allegations of staff-to-resident abuse must be reported immediately to the Administrator or DON.
Failure to Assess and Document Pain Management
Penalty
Summary
Failure to provide safe, appropriate pain management occurred for a resident who had an inguinal hernia repair and was identified as having chronic conditions and risk for discomfort. The resident’s care plan directed staff to assess for verbal and non-verbal signs of pain, monitor for discomfort, and attempt non-pharmacological interventions before giving medication as needed. A physician’s order also directed staff to observe the resident for pain every shift. The resident was cognitively intact and, after returning from the hospital, was ordered Ultram 50 mg every 8 hours as needed for pain. The record showed Ultram was administered multiple times, but two doses obtained from the Capsus machine were not documented on the MAR as given, and there was no documentation of the resident’s pain level at those times or whether the medication was effective. The clinical record also did not show what non-pharmacological interventions were attempted for pain control. Nursing notes and a nurse practitioner visit documented that the resident had significant post-surgical pain, swelling, and complaints about being unable to do anything for himself, while the DON stated staff should have documented each dose with a pain assessment and the non-pharmacological interventions attempted.
Medication Reconciliation and Delayed Order Entry
Penalty
Summary
The facility failed to completely and accurately reconcile admission orders for a resident with pulmonary disease, osteoporosis, and heart disease. On admission, the resident had physician orders for 35 medications and two hold orders, but eight medications were not transcribed to the facility MAR. The omitted medications included PRN Flexeril for muscle spasms, three osteoporosis injections, a meal supplement, oral vitamin B-12, an antibiotic given twice weekly, and twice-daily eye drops. The DON stated she had spoken with the physician about the eight medications at admission, but the conversation and any discontinuation orders were not documented. She also stated some medications were not prescribed because of a pre-admission agreement and others because the resident did not want to take them. The facility also failed to timely input and initiate physician orders for a resident with a change in condition. The resident had obstructive uropathy and a suprapubic catheter, and nursing notes documented coffee-tinged urine, fever, chills, cloudy amber urine, and an episode of being limp and non-responsive with shallow respirations and fixed, dilated pupils before later becoming alert during transfer. The NP evaluated the resident for fever and chills and documented acute cystitis, with a plan for empiric Levaquin and potassium for hypokalemia. Although the NP indicated the orders were given on the day of the visit and expected antibiotics to start as soon as reasonably possible, the orders were not entered into the electronic record until the following day. The record also showed gaps in assessment documentation during the resident’s decline. There were no assessments of urine color, clarity, or characteristics from the time of the fever and abnormal urine findings until the resident was sent to the emergency room. The physician services policy provided by the facility stated that orders for immediate care and needs must be provided and that verbal orders must be promptly recorded, dated, and signed in the EMR.
Inconsistent smoking assessment for resident with cognitive impairment and hemiplegia
Penalty
Summary
The facility failed to ensure a resident was accurately assessed to determine whether he was able to participate safely in smoking activity. Resident 3 had diagnoses including stroke with right-sided hemiplegia and nicotine dependence, and a quarterly MDS indicated he was moderately cognitively impaired. His care plan identified him as at risk for falls with safety and injury concerns related to smoking. However, the smoking assessments in the record were inconsistent, with one dated 3/3/25 indicating he did not smoke, another dated 6/9/25 indicating he did smoke and was able to participate safely, and another dated 9/9/25 again indicating he did not smoke. The Administrator provided a list showing Resident 3 participated in smoking, and the resident stated he went outside to smoke cigarettes and vape. Staff interviews confirmed he had been going outside for smoking activity, and during observation on 12/4/25 he was seen participating in the smoking activity and smoking two cigarettes. The facility’s smoking policy stated that all residents assessed and determined safe to smoke must smoke with direct supervision outside at designated times, and that no smoker is to smoke without supervision.
Hand Hygiene Not Followed During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene was used during medication administration for 4 of 6 residents observed. During an observation of insulin administration to a resident with diabetes and cardiovascular disease, RN 1 administered insulin by injection without wearing gloves and was observed touching multiple areas of the medication cart with bare hands before giving the insulin. RN 1 stated she used hand sanitizer after administering the insulin, and no hand hygiene was observed before the injection after she had touched the medication cart. During additional medication pass observations, RN 1 was seen preparing medications for a resident with hypertension by touching the computer mouse, medication cart drawers, medication cards, an inhaler, a pitcher of water, and drinking cups, and popping several medications from the cards into her bare hand before placing them in a medication cup. For a resident with paranoid schizophrenia, RN 1 prepared morning medications and then donned gloves to administer eye drops, with no hand hygiene observed before putting on gloves. For a resident who was legally blind, RN 1 again popped medications into her bare hand at the medication cart and later donned gloves to administer medications, eye drops, and eye ointment, with no hand hygiene observed before handling the medications or before donning gloves for the eye medication administration.
Delayed Resident Mail Delivery
Penalty
Summary
The facility failed to ensure residents received mail on Saturdays. During a resident council meeting, residents stated that mail was not delivered on Saturdays and that they had to wait until Monday to receive mail that arrived over the weekend. The residents identified in the record review were cognitively intact and included residents with diagnoses such as hypertension and diabetes mellitus. The Business Office Manager stated that the receptionist gave him all delivered mail, he sorted out the mail he needed, and the remaining resident mail was given to the Activities Director for delivery. He acknowledged that mail was not delivered to residents on Saturdays and that weekend mail accumulated until Monday. The Activities Director stated she did not work weekends and was unsure whether anyone passed out mail to residents. The Administrator stated the Nurse Manager on duty was supposed to pass out mail on Saturdays.
Incomplete Antibiotic Treatment for UTI
Penalty
Summary
A resident with a history of stroke and urinary tract infection, who was cognitively impaired and always incontinent of bladder, was discharged from the hospital with a prescription for Bactrim DS to be taken orally every 12 hours for five days. Hospital documentation indicated the resident had received two doses of intravenous antibiotics and was to continue the oral antibiotic for the next five days, with a prescription quantity of ten tablets. The resident's care plan included assistance with toileting and personal hygiene due to continence issues. Upon review of the Medication Administration Record, it was found that the resident received only eight doses of Bactrim DS over four days, rather than the prescribed five-day course. The DON confirmed that only four days of antibiotics were administered. Facility policy required that all physician orders be followed as prescribed, but the full course of antibiotic treatment was not completed for the resident.
Incomplete and Inaccurate Documentation of Resident Interactions and Activities
Penalty
Summary
The facility failed to ensure that documentation in resident medical records was complete and accurate, specifically regarding care-planned interactions between two cognitively intact residents and the documentation of activities for another resident. In the case of two residents who were care planned for bickering, progress notes described a 'fight' during supper but did not clarify whether the altercation was physical or verbal, who was involved in cursing, the impact of the interaction, or what actions staff took during or after the event. Interviews with the DON, Executive Director, and the RN responsible for the documentation revealed that language barriers contributed to unclear and potentially inaccurate charting, with the RN acknowledging difficulties with English and terminology in his documentation. Further review showed that both residents involved in the altercation had a history of similar interactions, and both reported no concerns about abuse, describing their disagreements as typical and transient. The facility's management was aware of the ongoing behavior and had care plans in place, but the documentation failed to provide objective, detailed accounts of the incidents as required by facility policy. The DON and ED confirmed ongoing issues with the RN's documentation accuracy due to language challenges, and the facility's process included daily reviews of documentation to identify such issues. Additionally, the facility failed to maintain complete activity records for another cognitively intact resident with major depressive disorder and diabetes. Documentation showed that activities were not recorded for seven out of the last thirty days, despite the resident's report of attending all available activities. The Activities Director confirmed that it was the responsibility of activities staff to document participation, and that passive and interactive activities were provided daily. The facility's policy required documentation to be objective, complete, and accurate, which was not met in these instances.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the required Registered Nurse (RN) coverage of 8 hours a day, 7 days a week, over a period of five months, potentially affecting all 47 residents. The review of schedules revealed that there were no RNs present for several days in April, May, June, September, and October 2024. The Administrator confirmed the lack of RN coverage during these months. Despite this deficiency, the Administrator stated that no residents were affected, and there were no incomplete tasks that required an RN. The facility's staffing policy, as provided by the Director of Nursing, mandates RN presence for the specified hours and days, which was not adhered to during the reviewed period.
Deficiencies in Dishwasher Monitoring and Food Temperature Maintenance
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of a chemical dishwasher, which was expected to be tested three times daily. During a kitchen tour, it was observed that the only documentation available was for the temperature logs of the wash and rinse cycles, not for the chemical solution used in the dishwasher. The Dietary Manager (DM) confirmed that the dishwasher had been changed from a high temperature to a chemical/low temperature model a few months prior, but the facility continued to only record temperatures without adding a chemical log. The DM indicated that the dietary aid was responsible for testing the chemical parts per million (ppm) in the dishwasher, but this was not being documented as required by the facility's policy. Additionally, the facility failed to maintain appropriate holding temperatures for pureed foods for five residents. During an observation, it was noted that pureed mixed vegetables, apple butter pork loin, and mashed potatoes were all held at 118 degrees Fahrenheit, below the required 135 degrees Fahrenheit. The pureed food containers were stored in a hot water container off the serving line, and the staff member indicated that they would heat the pureed food in the microwave before serving it to residents. This practice was not in compliance with the facility's policy, which required all hot food items to be cooked, held, and served at a minimum temperature of 135 degrees Fahrenheit.
Deficiency in Dietary Staff Knowledge of Chemical Dishwasher
Penalty
Summary
The facility failed to ensure that dietary staff were knowledgeable about the operation and monitoring of a chemical dishwasher. During a kitchen tour, it was observed that a dietary staff member was using incorrect testing strips for the chemical dishwasher and was unsure of the proper temperature and chemical sanitization levels required. The staff member did not know the correct parts per million (ppm) for chemical sanitization, which is crucial for ensuring proper dishwashing sanitation. Further observations revealed that the Dietary Manager was also using the wrong chemical testing strips and was unable to interpret the readings correctly. Although high temperature logs were maintained, there was no log for chemical testing, indicating a lack of monitoring. The Administrator mentioned that education on the new dishwasher was provided during installation, but the Dietary Manager could not locate the educational materials. The facility's policy stated that low-temperature dishwashers should have specific wash temperatures and sanitization levels, which were not being adhered to.
Failure to Ensure Privacy and Timely Care for Residents
Penalty
Summary
The facility failed to uphold residents' dignity by not ensuring privacy during toileting and not providing timely incontinent care. In one instance, a resident was left alone in a shower room for privacy, but the room lacked a privacy curtain, exposing the resident to the hallway when the door was opened multiple times. The staff involved were unaware of the missing curtain, which had been removed for washing by the laundry staff. The Director of Nursing acknowledged that the absence of the privacy curtain could have impacted the resident's dignity. In another case, a confidential resident, who was cognitively intact and occasionally incontinent, reported long wait times for assistance with toileting, sometimes up to an hour. This delay led to frequent episodes of bladder incontinence, causing the resident to feel embarrassed. The staff confirmed that they struggled to provide timely care due to insufficient help. The facility's policy on resident rights emphasized the importance of treating residents with dignity and respect, which was not upheld in these instances.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to hold quarterly care plan meetings for a resident, identified as Resident 8, who was reviewed for care plans. Resident 8's clinical record was examined, revealing diagnoses including chronic kidney disease, heart failure, and generalized anxiety disorder. During an interview, Resident 8 reported not having regular care plan meetings. The electronic health record showed that care plan meetings were conducted on 8/4/23, 2/5/24, and 7/9/24, indicating a six-month gap followed by a five-month gap between meetings. The Social Service Director acknowledged that care plan meetings should occur quarterly and was unaware of how these meetings were missed. The facility's Comprehensive Care Plan Policy emphasizes the resident's right to participate in care planning, which was not adhered to in this case.
Failure to Use Gait Belt Results in Resident Fall
Penalty
Summary
The facility failed to utilize an assistive device, specifically a gait belt, during a transfer, resulting in a fall for a resident. The resident, who required extensive assistance from two people for transfers, fell on a specific date when staff did not use a gait belt during the transfer. The Director of Nursing confirmed that the resident did not have any medical condition that would prevent the use of a gait belt. Observations later showed that the resident was dependent on two staff members and a gait belt for transfers, indicating the necessity of the device. The resident involved had a medical history that included vascular dementia, anxiety, weakness, unsteadiness on feet, lack of coordination, muscle wasting, and Alzheimer's disease. The resident's care plan indicated a risk for falls due to impaired safety awareness related to dementia and other conditions. The State Optional Minimum Data Set assessment noted the resident's moderate impairment in daily decision-making and the need for extensive assistance with transfers and toileting. The initial occurrence note documented a witnessed fall in the bathroom, where the resident was lowered to the floor without injury.
Failure to Secure and Document Controlled Substances
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents B and C, were not subjected to missing narcotic medications. The issue was first identified when Resident B requested pain medication from an LPN, who then noticed that the Percocet medication and its count sheet were missing. This prompted an immediate investigation by the facility, which revealed that several cards of narcotics and associated paperwork were missing for both residents. The facility was unable to definitively determine who was responsible for the misappropriation, although security footage showed suspicious behavior by RN 4 during the destruction of Resident C's discontinued hydrocodone medication. The investigation revealed that Resident B had received multiple orders of Percocet over several months, but the controlled substance logs for these orders could not be located. Similarly, Resident C had received multiple orders of hydrocodone, but the documentation for these orders was incomplete or missing. Interviews with the residents indicated that they had not experienced a negative impact on their comfort levels, despite the missing medications. However, the facility's failure to properly account for and secure these controlled substances constituted a significant deficiency. The facility's policy on controlled medication storage and accountability was not followed, leading to inconsistent documentation and the inability to reconcile the receipt, usage, and disposition of the narcotics. The facility's Executive Director and Director of Nursing acknowledged these issues and indicated that they were being addressed through staff education and ongoing audits. Despite these efforts, the initial failure to secure and properly document the controlled substances resulted in a serious lapse in the facility's duty to protect its residents from the wrongful use of their belongings or money.
Failure to Implement Policies on Drug Diversion
Penalty
Summary
The facility failed to implement policies and procedures related to the misappropriation of resident property, specifically involving drug diversion for two residents. The issue was identified when Resident B requested pain medication, and the LPN realized that the controlled substance count for Percocet was incorrect. This led to an investigation revealing that several cards of narcotics and associated paperwork were missing. The facility was unable to definitively determine who was responsible for the misappropriation, although security footage showed suspicious behavior by RN 4 during the destruction of Resident C's discontinued hydrocodone medication. The investigation revealed that Resident B had received multiple orders of Percocet, but the controlled substance logs for these orders were missing, indicating a significant discrepancy. Similarly, Resident C's records showed inconsistencies between the controlled substance logs and the medication administration records, with missing documentation for several orders of hydrocodone. The facility's policy on controlled medication storage and accountability was not followed, leading to these discrepancies and the potential misappropriation of narcotics. Interviews with the residents involved indicated that they did not experience a negative impact on their comfort levels due to the missing medications. However, the facility's failure to properly document and account for controlled substances represents a serious deficiency in their procedures. The facility's Executive Director and Director of Nursing acknowledged the issues and indicated that staff education and audits were being conducted to address the problem, but these actions were taken after the deficiencies were identified.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Waldron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Especially Kidz Health & Rehab | 7.1 mi | ★★★★★ | 6 | 0 |
| Willows Of Shelbyville | 7.1 mi | ★★★★★ | 16 | 0 |
| Ashford Place Health Campus | 9 mi | ★★★★★ | 0 | 0 |
| Morning Breeze Retirement Community And Healthcare | 12 mi | ★★★★★ | 0 | 0 |
| Hickory Creek At Greensburg | 12.3 mi | ★★★★★ | 10 | 0 |
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