Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 159 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | — | 1 | 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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Waldron Rehabilitation And Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.