Wellbridge of Brighton

Inspectors wroteThis citation pertains to Intake 2990713. Based on interview and record review, the facility failed to follow up following an outside consultation, and receive an After Visit Summer (AVS) for one resident (R700) of two reviewed for outside appointments, resulting in missed antibiotic treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary treatment and care consistent with professional standards of practice to promote healing of a compromised skin integrity to the coccyx area (area above the buttock region) and prevent new and or worsening pressure ulcer development for one resident (R5) of one reviewed for pressure ulcers resulting in R5 developing an unstageable pressure ulcer( a severe wound characterized by full-thickness tissue loss, where the base of the wound is obscured by slough or eschar, making it difficult to assess the true extent of tissue damage) to their coccyx area.

Inspectors wroteBased on interview and record review, the facility failed to support continuity of a previous resolved grievance for one resident (R37) of one reviewed for grievances. Findngs include:Clinical record review revealed R37 was admitted to the facility on [DATE] with impaired mobility deficits related to recent hospitalization for respiratory and congestive heart failure. R37 required wound care for a diabetic right foot ulcer and required supplemental oxygen. Brief Interview of Mental Status (BIMS) assessed on 11/14/25 scored 15/15 indicating R37 was cognitively intact. On 1/12/26 at 9:49 AM, during initial interview and introductions, R37 voiced concern they previously complained to the facility that Certified Nurse Assistant (CNA) B hurts them when they are repositioned or placed into a Hoyer lift (mechanical lift). [...]

Inspectors wroteThis citation pertains to intake 1220695Based on interview and record review, the facility failed to report an alleged violation to the state agency (SA) related to Injuries of Unknown Origin for one resident (R701) of one reviewed for abuse.

Inspectors wroteThis citation pertains to intake 1220695Based on interview and record review, the facility failed to conduct a thorough investigation for one resident (R701) of one reviewed for Injuries of Unknown Origin.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accuracy of assessments, coordination of care with a wound care clinic, and ensure recommended interventions were followed for one (R18) of four residents reviewed for pressure ulcers, resulting in R18 being sent to the hospital from the wound care clinic for surgical debridement and intravenous (IV) antibiotics of an infected Unstageable (full-thickness skin and tissue loss in which the wound bed is obscured by slough or eschar) Pressure Ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the main kitchen and the south satellite kitchen in a sanitary manner. This deficient practice had the potential to affect all residents in the facility that consume food.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were administered per the facility's policy and professional standards of practice for two (R's 41 & R78) of four residents observed for medication administration and provide wound care treatment and documentation of treatment changes according to professional standards of practice for one (R3) of one resident reviewed for non-pressure wounds.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure expired medications were discarded and medications were stored securely for three Residents (R37, R61 and R70) of four residents reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility maintained proper infection control practices regarding the cleaning and disinfecting of glucometers per the facility's policy and manufacturer's instructions for two (R's 41 & 61) of four residents observed for the medication administration task.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective interventions were implemented for one (R44) of one resident reviewed for communication.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure orders were implemented for a CPAP (continuous positive airway pressure) machine for one (R231) of one resident reviewed for respiratory equipment.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one (R18) of one residents reviewed for medical records.

Inspectors wroteThis citation pertains to intakes: MI00146401 and MI00146531 This citation had two Deficient Practice Statements (DPS). DPS #1 Based on observation, interview, and record review the facility failed to provide adequate supervision for one Resident (R903) of two Residents reviewed for accidents resulting in an unbeknownst exit of a cognitively impaired, wheelchair bound resident from the facility and a fall with injury.

Inspectors wroteBased on interview and record review, the facility failed to administer and/or document administration of scheduled medications according to professional standards for ten (R905, R906, R907, R908, R909, R912, R913, R914, R915, R916) of fifteen residents reviewed for medication administration.

Inspectors wroteBased on interview and record review the facility failed to maintain complete and accurate medical records for ten (R905, R906, R907, R908, R909, R912, R913, R914, R915, R916) of fifteen residents reviewed for medication administration.

Inspectors wroteThis citation pertains to Intakes: MI00146401 and MI00146565 Based on observation, interview and record review the facility failed to assess for pain and administer pain medications as ordered by the physician for two (R903 and R916) of two residents reviewed for pain, resulting in unrelieved pain, feelings of frustration, and helplessness.

Inspectors wroteBased on interview, and record review, the facility failed to ensure there was thorough record keeping to accurately account for administration of controlled substances for one (R916) of one resident reviewed for pharmacy services.

Inspectors wroteThis citation pertains to Intake Number: MI00144507. Based on interview and record review, the facility failed to ensure multiple allegations of abuse and mistreatment were reported to the Abuse Coordinator and the State Agency for one (R801) of two residents reviewed for abuse.

Inspectors wroteThis Citation is for Intake MI00142516 and Intake MI00143475. Based on observation, interview and record review the facility failed to promptly assess, implement effective treatments and prevent the pressure ulcer (PU) development for two (R804 and R806) of three residents reviewed for pressure ulcers resulting in further clinical compromise and psychological distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff adhered to the appropriate transmission-based precautions (TBP) for one (R1) of two residents reviewed for TBP for COVID-19, resulting in the increased potential for transmission of COVID-19, in which the facility had an active COVID-19 outbreak. This deficient practice had the potential to affect all residents that were assigned to that staff, which included those that were not on contact and droplet TBP.

Inspectors wroteThis citation pertains to Intake Number: MI00139785. Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by staff for one (R41) of one resident reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of staff to resident abuse immediately to the Administrator for one (R41) of one resident reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was consistently provided with showers/bed baths for one (R16) resident reviewed for activities of daily living, resulting in the potential for unmet care needs.

Inspectors wroteThis citation contains two Deficient Practice Statement(s): DPS #1 Based on observation, interview, and record review the facility failed to ensure the proper assistance level was provided to one (R66) of three residents reviewed for accidents, resulting in a fall that required the resident to be transferred to the hospital.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure physician ordered medications were consistently available for two (R's 3 & 230) of two residents reviewed for medication availability.