Walbridge Memorial Convalescent Wing

In the surveyor’s words

From the most serious findings on record at Walbridge Memorial Convalescent Wing, in the surveyor’s own words.

• Actual harm, isolatedF740Dec 14, 2023

  Based 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 [DATE] and broke her right arm. […]

• Actual harm, isolatedF686Aug 25, 2022

  Based 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. […]

• Actual harm, isolatedF689Aug 25, 2022

  Based on record review, observations and interviews, the facility failed to ensure the facility provided adequate supervision and monitoring for four (#1, #14, #15 and #23) residents out of seven residents reviewed for falls and accidents out of 15 sample residents. Specifically, the facility failed to implement timely interventions and create effective approaches to prevent the recurrence of falls. The facility failed to create and implement a structured fall management program to help mitigate falls and fall recurrences. Resident #23 fell 12 times from 1/17/22 to 8/15/22. Many of the falls resulted in minor injuries. The resident sustained a fracture on 7/24/22, which was his eleventh fall. There were limited new interventions put in place after each of the falls. […]

• Actual harm, isolatedF692Aug 25, 2022

  Based 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. […]

• Actual harm, isolatedF686May 27, 2021

  Based on observations, record review and interviews, the facility failed to ensure one (#17) of two residents reviewed for pressure ulcers out of 18 sample residents did not acquire an unstageable pressure ulcer. Resident #17, who was at risk for pressure ulcers and had no pressure ulcers as of 4/11/21, spent virtually all of his time lying in bed on his back. The facility failed to implement a turning and repositioning schedule, failed to implement a proper pressure relieving mattress to keep weight off the resident's heels, failed to acquire a timely wound nurse consultation, failed to revise the care plan to reflect actual skin breakdown, and failed to consistently document weekly wound assessments. […]