Wellbridge of Clarkston

Inspectors wroteThis citation pertains to intake 2988970. Based on interview and record review, the facility failed to ensure accurate medication transcription and administer medications according to the manufactures guidelines for one resident (R902) of one resident reviewed for medication administration.

Inspectors wroteThis citation pertains to intake 2790121. Based on observation, interview and record review, the facility failed to ensure care was provided in a safe manner to prevent accidents for one (R802) of two residents reviewed for accidents, resulting in unnecessary pain and a fall with subsequent fractured manubrium and multiple rib fractures and transfer to the emergency department for further evaluation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper medication storage in one of six controlled medication wall storage units.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant potentially affecting all 88 residents residing in he facility, resulting in the increased likelihood for cross-contamination and bacterial harborage and accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Resident (R64) of one resident reviewed for standards of practice, had complete and accurate vital monitoring per physician orders and professional standards of practice.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, monitor and document on skin wounds or growths for two (R57 and R66) of two residents reviewed for non-pressure skin conditions.

Inspectors wroteBased on observation, interview and record review facility failed to complete a thorough investigation and root cause analysis of a skin tear and timely follow-up with implementation of plan for one (R61) of one Resident (with fragile skin and multiple comorbidities) reviewed for accident hazards. This deficient practice has the potential for further accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Nursing standards of practice were utilized including transcribing/implmenting Phyiscan orders and notifying administration of new skin injuries for one resident (R902) of two resident's reviewed for non-pressure wound care.

Inspectors wroteThis citation pertains to MI00150120. Based on interview and record review, the facility failed to notify the Physician of a change in condition post fall for one (R901) of three residents reviewed for accidents.

Inspectors wroteThis citation pertains to intake: MI00149594. Based on interview and record reviews the facility failed to follow the facility policy on oxygen administration, ensuring orders were timely implemented for one (R404) of four residents reviewed for a change in condition.

Inspectors wroteThis citation pertains to intake MI00148800 Based on observation, interviews and record review, the facility failed to implement timely resident specific interventions and provide adequate supervision to prevent falls, for one (R702) of two residents reviewed for falls.

Inspectors wroteR60 On 6/4/24 at approximately 8:37 a.m., and again at 12:57 p.m., R60 was observed in their room, laying in their bed. R60's call light button was observed on the floor, out of reach of the resident The call light button was observed in the same spot and position during both observations. On 6/5/24 at approximately 8:54 a.m., 10:08 a.m., 11:16 a.m., and at 11:30 a.m., R60 was observed in their room, laying in their bed. R60's call light was observed on the floor out of reach of the resident. R60's call light button was in the same spot and position during all the observations. The DON (Director of Nursing) was shown R60's call light button that was out of reach during the 11:30 a.m., observation and reported that it should have been within her reach and that R60 needed a clip for their call button to hold it in place. [...]

Inspectors wroteThis citation pertains to intake #MI00141722, MI00142873, MI00140148, MI00140897 Based on observation, interview, and record review, the facility failed to ensure activity of daily living care including personal hygiene, bathing/showers, facial hair care, and dressing for eight residents, (R#'s 385, 391, 2, 39, 54, 238, 49, and 71) of 12 residents reviewed for activity of daily living (ADL) care, resulting in verbalized complaints, frustration, and embarrassment from poor personal hygiene.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate less than five percent when six medication errors out of 27 opportunities for error were observed for three (R44, R43 and R68) out of five residents reviewed during the medication administration observation, resulting in a 22.22% error rate.

Inspectors wroteThis citation pertains to intake # MI00143489. Based on interview and record review, the facility failed to verify an employee (Staff 'M') who was employed at the facility as a Registered Nurse (RN) had the required education, experience and valid nursing license to provide nursing services. This deficient practice had the ability to affect multiple residents that resided in the facility.

Inspectors wroteThis citation pertains to intake #MI00141722 Based on observation, interview, and record review, the facility failed to ensure treatment in a dignified manner for three residents (R#'s 54, 72, and 235) of four residents reviewed for dignity, resulting in the potential for feelings of embarrassment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a Resident's personal preferences for care was honored for one (R53) of one resident reviewed for self-determination/choices.

Inspectors wroteThis citation pertains to intake #MI00141722, and MI00142873. Based on interview and record review facility failed to follow-up and resolve a grievance promptly for one (385) of two Residents reviewed for grievances resulting in feelings of frustration.

Inspectors wroteThis citation pertains to intake(s): MI00140148 Based on interview and record review the facility failed to timely and accurately transcribe Physician orders for admission medications for one resident (R387) of one residents reviewed for admissions.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a splint was applied per Physicians order for one resident (R26) of two residents reviewed for range of motion.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders and ensure accurate documentation of an indwelling urinary catheter for one (R53) of two residents reviewed for urinary catheters.

Inspectors wroteThis citation pertains to intake(s): MI00140148 Based on interview and record review the facility failed to timely and accurately transcribe and Administer Physician ordered medications including anticoagulant (warfarin) and antirejection medicine (tacrolimus) for one resident (R387) of one residents reviewed for significant medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were appropriately inventoried and stored in one (R53) resident's room.

Inspectors wroteThis citation pertains to intake #'s MI00131428, MI00131482, MI00131728, MI00134560, MI00135871, and MI00137478. Based on observation, interview and record review, the facility failed to ensure there was sufficient nursing staff to meet resident needs which included R23, R28, R40 and R63, and multiple residents that attended the confidential resident council interview. This deficient practice has the potential to affect all residents that reside in the facility.

Inspectors wroteThis citation pertains to intake #'s MI00131873, MI00134560, MI00135871, MI00132686, and MI00137478, Based on observation, interview, and record review, the facility failed to ensure Activity of Daily Living (ADL) care was provided for five residents (R#'s 335, 28, 236, 37, and 76) of seven residents reviewed for ADL care, resulting in verbalized complaints, and feelings of dissatisfaction and discomfort.

Inspectors wroteThis citation pertains to intakes: MI00131873 & MI00132686. This citation has two Deficient Practice Statements (DPS). DPS #1 Based on observation, interview, and record reviews the facility failed to consistently administer Parkinson's medications timely, obtain and retain consultations of appointments completed for the Parkinson's pump and implement a care plan for the care and maintenance of a Parkinson's pump for one (R51) of one resident reviewed for Parkinson's disease care.

Inspectors wroteThis citation pertains to intake #MI00132802. Based on observation, interview and record review, the facility failed to ensure residents were treated in a dignified manner for one (R69) of three residents reviewed for dignity, resulting in the loss of autonomy, expressions of frustration, and loss of self-worth.

Inspectors wroteThis citation pertains to intake #MI00131873. Based on observation, interview and record review, the facility failed to accommodate the needs of one (R40) of four residents reviewed for preferences/accommodation of needs.

Inspectors wroteThis citation pertains to Intake Number: MI00133441 and MI00137478. Based on observation, interview, and record review, the facility failed to ensure medications were prepared, administered, and documented according to professional nursing standards of practice for three (R63, R238, and R586) residents reviewed for medications.

Inspectors wroteThis citation pertains to intake # MI00131482. Based on observation, interview and record review, the facility failed to provide timely incontinence care for one (R40) of three residents reviewed for bowel and bladder incontinence, resulting in discomfort and potential skin breakdown when they had to wait an extended period of time in a urine soaked brief.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure consistent weights were obtained per facility policy for one resident (R60) of two residents reviewed for nutrition.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide continuous supplemental oxygen as prescribed by the physician (R8) and ensure that a physician order was in place for supplemental oxygen provided to (R59) for two of three residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications had the appropriate indication for use for one (R59) of five residents reviewed for the medication regimen review.

Inspectors wroteThis citation pertains to intake #MI00133441. Based on observation, interview, and record review, the facility failed to lock the medication cabinet for one (R63) resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to timely provide laboratory services to two (R' 59 & 21) of two resident reviewed for laboratory services.