Walbridge Memorial Convalescent Wing

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Have properly sized and located compartments to protect residents from smoke.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Construction Deficiencies

Install noncombustible or limited-combustible interior walls.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Smoke Deficiencies

Have properly sized and located compartments to protect residents from smoke.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly.

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Quality of Life and Care Deficiencies

Ensure the activities program is directed by a qualified professional.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Smoke Deficiencies

Have properly sized and located compartments to protect residents from smoke.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Through document review and observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 25. This was evidenced by: 1) Annual: Not Provided2) Quarterly: Not Provided3) Semi Annual: Not Provided4) 3 Year Full Trip: Not Provided NFPA 101, 9.7.5 Maintenance and Testing.All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and main.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 99, and 110. This was evidenced by: 1) Generator fuel quality (annually) (110 8.3.8): Not Provided NFPA 101 9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 99 .. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, and 10. This was evidenced by: 1) Portable Fire Extinguishers (Monthly/Annually)(101 19.3.5.12 & 10 7.2): report from 12.12.25 Pye Barker report shows multiple fire extinguishers out of service date NFPA 101 9.7.4.1* Where required by the provisions of another sectionof this Code,.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, and 99. This was evidenced by: 1) Medical Gas (annually)(101 99 5.1.14.4.4): Not provided NFPA 99 5.2.14* Category 2 Maintenance.Facilities shall have a routine maintenance program for their piped medical gas and vacuum systems. NFPA 99 A.5.2.14 Medical gas and vacuum systems should be survey.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by: 1) Fire Safety Plan (101 19.7.2.2): Need to be updated to address phone call to fire department and preparation of evacuation and evacuation of smoke compartments NFPA 101 19.7.1 Evacuation and Relocation Plan and Fire Drills. 19.7.1.1 The administration of every .. Through observation and document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by: 1) Subdivision of Building Spaces (101 19.3.7): The facility has only one smoke compartment. Per NFPA 101 at least 2 smoke compartments are required. The facility has used an FSES to meet requirements in the past, FSES will need to be updated and approved. (Note FS.. Through observation during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with NFPA 101. This was evidenced by: 1) Telecoms room has non- rated plywood lining the walls. (NFPA 101 19.1.6.6) NFPA 101 19.1.6.4Interior nonbearing walls in buildings of Type I or Type II construction shall be constructed of noncombustible or limited-combustible materials, unless otherwise permitted by 19.1.6.5. NFPA 101 1.. The Colorado Division of Fire Prevention and Control conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag #K000) are informational only and are a representation of the facility' s general characteristics. This facility is a type II (111) single-story structure and is licensed for thirty (30) residents, Census was 29 the day of the survey. The facility is separated from the adjoining hospital by 2-hour se..

A emergency preparedness survey was completed on 12/8/25 to 12/11/15. One deficiency was cited. A recertification survey with Incident #1946839 was completed on 12/8/25 to 12/11/25. Nine deficiencies were cited. Based 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. Findings include:I. Professional reference According to the Food and Drug Administration Food Code (2022), retrieved on 12/17/25, "Water temperat.. Based 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. Findings include:I. Facility po.. Based 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, Reside.. Based 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.Findings include:I. Professional referenceAc.. Based 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 fail.. Based 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 Re.. Based 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:.. Based on record review and interviews, the facility failed to develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. Specifically, the facility failed to ensure the emergency preparedness plan was reviewed and updated annually.Findings include:I. Facility policy and procedureThe Emergenc.. Based 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. Findings include:I. Facility policy and procedureThe Menu Planning policy, revised September 2023.. Based 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.Findings include:I. Facility polic..

The Colorado Division of Fire Prevention and Control conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag #K000) are informational only and are a representation of the facility' s general characteristics. This facility is a type II (111) single-story structure and is licensed for thirty (30) residents, Census was 29 the day of the survey. The facility is separated from the adjoining hospital by 2-hour separations. The structure is equipped throughout with a full National Fire Protection Association (NFPA) 13 automatic fire suppression system. This survey, conducted on February 19, 2024, included an inspec.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 99, and 110. This was evidenced by: 1) No evidence of weekly voltage checks on batteries NFPA 110 8.3.7 Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer' s specificationsThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, and 25. This was evidenced by: 1) Fire Sprinkler Weekly/Monthly report: Not Provided2) Fire Sprinkler Annual report: Not Provided3) Fire Sprinkler Quarterly report: Not Provided4) Fire Sprinkler Semi-Annual report: Not Provided5) Fire Sprinkler 5 Year report: Not ProvidedBased on a record review it was determined that the facility failed to maintain the fire sprinkler system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.NFPA 101, 9.7.5 Maintenance and Testing.All automatic sprinkler and st.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, and 72. This was evidenced by: 1) Fire Alarm Annual inspection report not provided2) Fire Alarm Semi-Annual: Not Provided3) Smoke Detector Sensitivity Report: Not ProvidedBased on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applica.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by: 1) The fire door inspection report shows multiple fails on the report dated 7.31.23NFPA 101, 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protectives, except as otherwise specified in thi.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by: 1) No carbon monoxide detector installed in "East Sun Room" with gas fireplace2) No carbon monoxide detector installed in "North Sun Room" with gas fireplaceNFPA 101 Heating, Ventilating, and Air Conditioning (101 19.5.2.3(2)(f)): Electrically supervised carbon monoxide detection in accordance with Section 9.8 shall be provided in the room where the fireplace is located.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. The deficient item was di..

A recertification survey was conducted on 12/11/23 to 12/14/23. Nine deficiencies were cited. An Emergency Preparedness survey was conducted from 12/11/23 to 12/14/23. No deficiencies were cited. Based 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.. Based 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 th.. Based 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.Fin.. Based 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 activit.. 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 alter.. Based 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.Findings in.. Based 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.. Based 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 seal.. Based 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 identif..

A licensure survey was completed on 12/11/23 to 12/14/23. Two deficiencies were cited. 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 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). During her interview, she was withdrawn and had been isolating herself in her room. She said she may never be able to use her right arm like she used to ever again and she was upset about it. She said every night she thought about dying and was ready to go. She did not understand why she had not died yet. The facility failed to identify, monitor and timely provide support to address the resident' s newly developing depression, nor did the facility implement a person-centered care plan to include a timely referral for other types of.. Based on record review and interviews, the facility failed to ensure a qualified social services staff was employed to meet the social and emotional needs of the residents.Specifically, the facility failed to employ a qualified social worker.The facility failed to have a qualified social worker to identify, assess and implement measures to address Resident #9, #19 and #10' s ongoing depression to include statements of wanting to die (cross-reference S705 behavioral health). Findings include:I. InterviewThe social service director (SSD) was interviewed on 12/12/23 at 4:07 p.m. She said she was a certified nurse aide (CNA) and recently filled the role of SSD. She said she did not have her certification and had completed a training the facility sent her to. She said she was not a licensed social worker and did not have a college degree. She said she needed to complete her SSD training to get her certification. She said she had been a CNA for approximately 10 years and became the SSD within the last one to two years.The nursing home administrator (NHA) and director of nursing (DON) were interviewed on 12/14/23 at approximately 4:00 p.m. The DON said the facility recently became aware of the needed qualifications for an SSD when the DON updated some policies. As of 12/13/23, the facility had established a contract with a consultant for the facility.-However, the SSD did not ha..