Walbridge Memorial Convalescent Wing

Inspectors wroteBased on record review and interviews, the facility failed to provide a menu that offered a variety of food options. Specifically, the facility failed to ensure residents were not served a repetitive menu that offered a high quantity of chicken and pork.

Inspectors wroteBased on observations and interviews, the facility failed to ensure food was served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure dishes were properly sanitized.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the residents' right to a safe, clean, comfortable and homelike environment for four (#13, #26, #27 and # 28) of seven residents out of 19 sample residents. Specifically, the facility failed to provide washcloths and hand towels in Resident #13, Resident #26, Resident #27 and Resident #28's rooms.

Inspectors wroteBased on record review and interviews, the facility failed to timely investigate an allegation of abuse involving one (#26) of three residents reviewed for abuse out of 19 sample residents. Specifically, the facility failed to timely investigate and report an allegation of misappropriation of property for Resident #26.

Inspectors wroteBased on observations, record review and interviews, the facility failed to to ensure received treatment and care in accordance with professional standards of practice for one (#19) of six residents out of 19 sample residents. Specifically, the facility failed to: -Ensure residents' medications were not pre-poured; and,-Administer Resident #19's eye drops in accordance with professional standards.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for two (#20 and #16) of four residents out of 19 sample residents. Specifically, the facility failed to:-Implement a recommended brace for Resident #20 to prevent a contracture; and,-Complete an occupational therapy assessment for Resident #16 to evaluate if an assistive device was necessary to prevent contracture, despite a documented decline in the resident's ability to feed herself.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from accidents or hazards for one (#4) of two residents reviewed for accident hazards out of 19 sample residents. Specifically, the facility failed to implement effective fall interventions to prevent falls for Resident #4.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being one (#16) of five residents reviewed for unnecessary medications out of 19 sample residents. Specifically, the facility failed to discontinue or reevaluate a physician's order for Resident #16's as needed (PRN) Lorazepam (an antianxiety medication) after 14 days.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Specifically, the facility failed to implement enhanced barrier precautions for Resident #2 and Resident #8.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary mental health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for three (#19, #9 and #10) of four residents reviewed for mental health out of 29 sample residents. The facility failed to offer alternative mental health services when Resident #9 expressed wanting to die but refused counseling services. Resident #9 was admitted to the facility after a hip replacement and heart issues. Less than six months after she was admitted she was diagnosed with cancer. She did not have signs or symptoms of depression until she fell on 7/4/23 and broke her right arm. She lost her independence and said she felt disgusted with herself since she needed staff to help her with all activities of daily living (ADLs). [...]

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner. Specifically, the facility failed to ensure: -Expired foods were disposed of in the activity refrigerator the residents used; -Foods were dated and sealed in the activity refrigerator; -Foods were dated and sealed in the cabinets of the activity kitchenette; and, -Kitchen staff practiced good hand hygiene and proper glove use while preparing and serving ready-to-eat foods to the residents.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support. Cross-reference F679 for lack of meaningful activity programs

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure menus met the needs of the residents and were followed. Specifically, the facility failed to ensure: -Menu items were not omitted; -Provide accurate portions; -Follow menu extensions; and, -Serve residents their food textured according to their diet orders.

Inspectors wroteBased on observation, staff interviews and record review, the facility failed to ensure one (#15) of six sample residents reviewed for assistance with activities of daily living (ADL) out of 29 sample residents Specifically, the facility failed to ensure: -Resident #15 received timely incontinence care; and, -Resident #15 failed to receive timely repositioning.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide person-centered, individualized recreational activities to meet the psychosocial needs of two (#3 and #10) of five residents reviewed for activities of 29 sample residents. Specifically, the facility failed to ensure: -Create a program of activities either individuality or through group participation which promoted Resident #10's sense of well-being and supported his physical, cognitive, social and emotional health; -Develop an person-centered care plan with interventions to address Resident #10's activity and past leisure interests, to include his activity and socialization needs and overall psychosocial well-being approaches; -Implement the identified activity plan for Resident #10 and evaluate the response to the identified interventions; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two (#15 and #7) of four residents reviewed for dementia care out of 29 sample residents addressed their dementia care needs to maintain the highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #15 and Resident #17.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free of unnecessary psychotropic medications for two (#15 and #7) of five residents out of 29 sample residents. Specifically, the facility failed to: -Attempt a gradual dose reduction (GDR) for psychotropic medications for Resident #15; and, -Appropriately identify and track individualized targeted behaviors for psychotropic medications for Resident #7.

Inspectors wroteBased on record review and staff interviews, the facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (#9) of two residents out of 29 sample residents. Specifically, the facility failed to ensure clinical signs and symptoms of infection were identified and/or culture results were obtained prior to the administration of antibiotics for Resident #9.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure one (#23) of two residents reviewed for skin and pressure injuries, out of 15 sample residents, received care consistent with professional standards of practice to prevent and heal pressure injuries. Specifically, Resident #23 developed two facility acquired avoidable pressure ulcers on his back, one of which was unstageable. Resident #23 required assistance with staff for activities of daily living (ADLs) such as dressing but staff did not identify skin concerns on the resident's back until the resident had an unstageable pressure injury with 100% necrotic tissue. The resident was identified at risk for pressure ulcers but had limited pressure ulcer preventive measures in place. The resident also had a decline in condition, food intake and mobility. [...]

Inspectors wroteVII. Resident #14 A. Resident status Resident #14, age [AGE], was admitted on [DATE]. According to the admission computerized physician orders (CPO), diagnoses included age-related physical debility, repeated falls, and chronic atrial fibrillation. According to the 6/12/22 MDS assessment, the resident was cognitively impaired with a score of six out of 15 on the brief interview for mental status exam. The resident required extensive one person physical assistance with bed mobility, toileting, and transfers. It was noted the resident did not have any falls since admission. B. Record review The admission fall assessment completed on the day of admission 3/8/22 identified the resident was at high risk for falls. Fall #1 A fall note on 3/28/22 at 6:46 p.m. showed the resident fell. [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure one (#1) of three residents reviewed for nutrition/hydration, out of 15 sample residents, maintained acceptable parameters of nutritional status to avoid unintended weight loss. The facility failed to identify and implement timely interventions to maintain the resident's weight. The facility failed to timely respond to Resident #1's significant weight loss. Resident #1 lost 15 pounds (lbs) in one week, resulting in 11.6% total weight loss between 7/10/22 and 7/17/22. The facility did not timely consult with the registered dietitian (RD) after the resident lost 15 lbs. The facility did not incorporate new interventions in response to the weight loss. The resident lost an additional 7 lbs between 7/17/22 and 8/21/22, revealing a total weight loss of 22 lbs at 17.1%. [...]

Inspectors wroteBased on observations, record review, and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in one of one dining rooms and two of four resident hallways. Specifically, the facility failed to ensure: -Residents were offered hand hygiene prior to meals in the dining room; and, -Staff performed hand hygiene between resident rooms while passing resident room trays.

Inspectors wroteBased on record review and interviews, the facility failed to have an updated comprehensive care plan for one (#14) out of 15 sample residents. Specifically, the facility failed to implement nutrition care planning for a resident identified for weight loss and nutrition at risk for Resident #14.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for dementia care out of 15 sample residents received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to create and implement a program of activities designed to meet the psychosocial needs of Resident #1, promoting quality of life through dementia care. I. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses included dementia, anxiety, cardiomegaly (enlarged heart), osteoarthritis, atrial fibrillation and glaucoma. The 5/22/22 minimum data set (MDS) assessment identified a brief interview for mental status (BIMS) could not be completed. [...]