Wellbridge of Grand Blanc

Inspectors wroteThis citation pertains to Intake Number 2698891. Based on observation, interview, and record review, the facility failed to ensure adequate staff supervision in the common area and that appropriate assistance to the bathroom was provided to prevent falls or accidents for one resident (Resident #303) of 3 residents reviewed for falls, resulting in a fall requiring a transfer to the emergency room for evaluation and treatment of bleeding coming from a laceration of the scalp requiring six (6) staples (stitches) and a hematoma to the left side of the head

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents were treated with dignity and respect, failing to follow the care plan for a visually impaired resident by failing to describe meals when served, and failing to ensure that call lights were in reach or respond to resident call lights in a timely manner and not provide explanations when resident asked questions about their medications, identified for six residents (R72, R76, R86, R98, R128, R143) of seven residents reviewed for dignity, and a confidential group of residents. Resident #86 (R86): During the observation tour conducted on 09/23/25 at 11:00 AM, R86 was lying in bed and asked for some water. When surveyor ask if he had asked and if he was using his call light? He said he was not able to find them. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident received necessary care and services to maintain the highest practicable level of health by not providing timely IV (intravenous) antibiotic therapy or alternative treatment during a peripherally inserted central catheter (PICC) line occlusion, for one resident (R24) of 2 residents reviewed for IV therapy, resulting in R24 missing five consecutive doses of prescribed IV antibiotic vancomycin (an antimicrobial medication used to treat resistant bacteria) over two days, placing the resident at risk for a delay in resolution of infection and increased risk for further antibiotic resistance and clinical decline. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure completion of yearly Performance reviews and competencies for 6 of 6 Certified Nursing Assistants reviewed for yearly education, resulting in the potential for the nurse aides to not be able to safely provide the needed care and services for the residents. Facility Sufficient and Competent Nurse Staffing On 9/24/2025 at 2:30 PM, during an interview with Staff Education Nurse M she said the nurses and nurse aides had a 2-day classroom orientation where they completed online computer training and then they were assigned to a preceptor on the nursing units and were to complete competencies. Nurse M was asked if the staff completed hands on competencies and she said she went over Personal Protection Equipment/PPE's and Hand Hygiene with them. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose of waste and maintain the dumpster area to mitigate the presence of insects and rodents, potentially affecting all residents, staff, and visitors in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Properly store clean linen, sanitary supplies and Personal Protective Equipment (PPE), 2) Ensure distilled water for respiratory care was replaced properly for Residents #8, 3) Ensure appropriately associated precaution signage was posted, 4) Use/disposal of PPE was provided and consistent for Residents #24 (R24) and #153 (R153), and 5) Failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing, resulting in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting residents in following areas: 800, 600, and 100 hallways.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that bathroom doors and blinds in residents' rooms were in good working order for two residents (61 and 128) of four residents reviewed for a clean, comfortable, homelike environment.

Inspectors wrotePast Non-Compliance (PNC) was identified during investigation of the deficient practice and was accepted by the survey team upon exit from the facility for this citation. Following discussion with the State Manager, Past Non-Compliance was accepted with a Compliance Date of 6/25/25. Based on observation, interview and record review, the facility failed to ensure Resident safety when care-planned interventions were not followed for bed mobility for one resident (#128) of three reviewed for falls and accidents, resulting in Resident 128 falling from the bed, pain to the knee and need for x-rays.

Inspectors wroteBased on interview and record review the facility failed to ensure nurses completed yearly competencies and training for 3 of 5 nurses, reviewed for education and competencies, resulting in the potential for nurses to lack the necessary skills and qualifications to adequately care for the needs of the residentsFacility Sufficient and Competent Nurse Staffing On 9/24/2025 at 2:30 PM, during an interview with Staff Education Nurse M she said the nurses had a 2-day classroom orientation where they completed online computer training and then they were assigned to a preceptor on the nursing units and were to complete competencies. Nurse M was asked if the staff completed hands on competencies and she said she went over Personal Protection Equipment/PPE's, Hand Hygiene, electronic medical record/emr documentation, blood glucose checks, bladder scanner, and the Ekg machine. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store and handle medications in accordance with acceptable pharmaceutical standards of practice: 1) for 2 of 3 medication rooms 2) ensure medication refrigerators were clean, and 3) ensure medications were stored to professional standards of practice, including vaccinations, resulting in the potential for contamination of medications, incorrect administration of medications, a lack of therapeutic benefits necessary to promote healing for residents, increase the potential for adverse effects. Facility Medication Storage and Labeling: On [DATE] at 9:28 AM, during a review of the South over-the-counter medication and supplies storage room with Assistant Director of Nursing/ADON AA, several expired items were identified: Multiple packets of A&D ointment, triple antibiotic and bacitracin all dated 5/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide palatable food products and meet residents' food preferences, for 7 residents (24, 61, 72, 74, 89, 121 and 143) of 7 residents reviewed for food and choices and a Confidential Group of Residents, resulting in residents' feelings of frustration and anger. Resident #61 (R61) A review of R61's medical record revealed an admission into the facility on 9/2/25 with diagnoses that included cystitis, heart failure, diabetes, and heart disease. A review of R61's Minimum Data Set assessment revealed a Brief Interview of Mental Status score of 9/15 that indicated moderately impaired cognition, and the Resident used a wheelchair for mobility. On 9/24/25 at 9:46 AM, Resident 61 was observed in his room, seated in a wheelchair. The Resident was interviewed, answered questions and engaged in conversation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that appropriate communication between the hospice agency and the facility was accessible in a timely manner for one resident (Resident #39) of the three sampled residents reviewed for hospice care.

Inspectors wroteThis Citation pertains to Intake Number MI00152519. Based on interviews and record review, the facility failed to ensure that the GLP-1 (Glucagon-like peptide-1) injection medication was protected from staff misappropriation for one resident (Resident #601) of three residents reviewed for misappropriation of medication.

Inspectors wroteThis Citation pertains to Intake Number MI00145400. Based on observation, interview and record review, the facility failed to provide a safe and monitored environment to prevent falls with injuries and fractures for one resident (Resident #30) of 2 residents reviewed for falls, resulting in Resident #30 having three falls with injuries and sustaining fractures with two of the falls. Findings Include: Resident #30: Accidents On 9/30/2024 at 11:01 AM, Resident #30 was observed in his room, lying in a low bed. The call light was in his hand. The resident said he fell in the hallway and once in the bathroom. He said he had hurt his arm and leg. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #30 was initially admitted to the facility on [DATE] with diagnoses: Parkinsonism, arthritis, peripheral vascular disease, heart disease. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified social worker on a full-time basis to meet the psychosocial, mental, and behavioral health care needs of the residents. This deficient practice had the potential to affect all 124 residents that reside within the facility. Findings Include: On 10/1/2024 at 12:05 PM, an interview was conducted with Transitional Care Coordinator D regarding her role at the facility. Coordinator D explained while she does assist with social work roles, she is not a qualified Social Worker but is currently enrolled in a Bachelor of Social Work program. She shared a Social Worker from a sister facility does review assessments she completes and sends edits if needed. On 10/1/2024 at 1:15 PM, an interview was conducted with the Administrator regarding fulfilling their social worker position. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a comprehensive person-centered care plan was established for two residents (Resident #32, Resident #41) of twenty-five residents reviewed for care planning, resulting in Resident #32, a hemodialysis resident, to continue to gain weight with no updated care plan interventions and the likelihood for unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to complete timely comprehensive activity assessments and ongoing programming to meet the interests of one resident (Resident #77) one resident reviewed for activities, resulting in, Resident #77's activity assessments not being completed since 03/2023 and a lack of activity programming to meet the resident's independent leisure pursuits. Findings Include: Resident #77: During initial tour on 10/1/2024 at 8:33 AM, Resident #77 was observed resting quietly in her room. When asked about activities she participates in, she stated many of the activities she physically cannot complete due to limited mobility in her hands. Resident #77 expressed prior to being admitted she was very active and always on the go and now she just lays in bed everyday with nothing to do. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a urinary drainage bag and tubing was properly placed off the floor for one resident (Resident #46) of two residents reviewed for urinary catheters, resulting in the likelihood of cross-contamination and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely re-weighs for weight loss or weight gain for two residents (Residents #32, Resident#41), resulting in a lack of weight monitoring completion, follow-up of abnormal weights, and the potential for unidentified nutritional deficiencies and a decline in overall health.

Inspectors wroteBased on observation, interview and record review the facility failed follow physician's orders for enteral feeding for one resident (Resident #83) of one resident reviewed for enteral feeding, resulting in the resident not receiving the ordered amount of enteral feeding. Findings Include: Resident #83 (R83): Resident #83 is [AGE] years old and admitted to the facility on [DATE] with diagnoses that include, aphasia, dysphagia and history of a transient ischemic attack. On 09/30/24 at 10:04 AM, R83 was observed in bed, well dressed, groomed and free of any odors. Observation revealed that R83 had their enteral feeding infusing, the rate of the infusion on the pump was set at 70 ml/hr, the bottle of Glucerna was dated 09/30/24, dated for a start time of 09/29/24 at 11:00 pm. On 10/01/24 at 09:30 AM, observation revealed that R83 had their tube feeding infusing at 70ml/hr. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide medications as ordered for one resident (Resident #113) of one resident reviewed for pain management, resulting in Resident #113 experiencing pain and calling 911 and leaving the facility. Findings Include: Resident #113: A record review of the electronic medical record indicated Resident #113 was admitted to the facility on [DATE] at 9:50 PM with diagnoses: recent left knee joint replacement, pain, arthritis, anxiety, hypothyroidism, atrial fibrillation, asthma, claustrophobia, anemia, and essential tremor. The resident discharged back to the hospital a few hours later on 7/30/2024 at approximately 1:23 AM. A record review of the progress notes for Resident #113 revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure clinical staff posting of licensed and un-licensed staff levels were posted in a visible area for residents and visitors to review, resulting in the inability for residents and visitors to know what clinical staff were working on those days.

Inspectors wroteBased on observation, interview and record review, the facility failed to care plan an antipsychotic injectable medication (Invega) and to ensure community mental health services coordination of care for one resident (Resident #467) out of one resident reviewed for community mental health services, resulting in feelings of worry and concern with the likelihood of an overall decrease in psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to obtain consent for antipsychotic usage for one resident (Resident #53), resulting in Resident #53 being administered an antipsychotic medication without the appropriate consent and risk-versus-benefit analysis of the medication explained to the resident or the resident's responsible party and the increased likelihood for serious side effects and adverse reactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 8 of 19 medication punch cards in the 100 Hall Controlled/Narcotic substance medication cabinet were free of puncture holes, resulting in the likelihood for misappropriation of medication by one narcotic punch card to have 2 tablets with taped over punch holes noted upon inspection and the likelihood of cross contamination and ineffective medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that narcotic medications were accurately documented according to professional standards of practice for one resident (Resident #901).

Inspectors wroteThis Citation pertains to Intake Numbers MI00123400 and MI00124171. Based on observation, interview and record review, the facility failed to provide timely assistance with Activities of Daily Living (ADL) that included oral, nail and incontinence care and bathing activities for six residents (Resident #6, Resident #14, Resident #29, Resident #35, Resident #130, and Resident #191) of seven residents reviewed for ADL care, resulting in unmet care needs, poor hygiene and the potential for infection, skin irritation, body odor, embarrassment, diminished feelings of self-worth and loss of dignity.

Inspectors wroteThis Citation pertains to Intake Numbers MI00123400 and MI00124171. Based on observation, interview, and record review the facility failed to ensure there was adequate staff to meets the needs of the residents, resulting in resident verbalizations of waiting long periods of time for call lights to be answered, receive assistance with Activities of Daily Living (ADL): bathing, nail care, toileting and incontinence care, and the timely administration of medications timely as ordered for eight residents (Residents #6, #11, #35, #39, #72, #184, #185, and #187), and a Confidential Group of residents from twenty residents reviewed for activities of daily living care, resulting in resident dissatisfaction, frustration and unmet care needs. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure secure storage, accountability, and reconciliation of the controlled substance Ativan in the medication refrigerator of the South Medication Room, for one of two medication storage rooms reviewed for medication storage and labeling task, resulting in the potential for narcotic diversion.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that medical supplies were stored in sanitary conditions and expired supplies were disposed of properly for one of two medication rooms, one emergency crash cart and three clean utility/supply rooms reviewed for medication and medical supply storage, resulting in the potential for medical procedures to be performed with expired medical equipment and decreased efficacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests in the kitchen, satellite kitchen and Resident #28's room, potentially effecting all residents in the building. Findings Include: FACILITY Kitchen On 8/02/23 at 9:00 AM, during an initial tour of the main kitchen with Chef Manager N and Corporate Dietary Manager O, several small flies/drain flies were observed in the kitchen flying around. On 8/2/2023 at 9:40 AM during a tour of the satellite kitchen used for meal serving to the 200-500 halls, observed to have several small flies/drain flies crawling on a large container of honey. Requested pest management logs. Corporate Dietary Manager O said pest management handled by Facilities Manager P. She said the pest control company came to the facility monthly. [...]

Inspectors wroteThis Citation pertains to Intake Numbers MI00123400 and MI00124171. Based on observation, interview and record review, the facility failed to ensure that one resident was treated in a dignified manner for Resident #65, of two residents reviewed for dignity, resulting in Resident #65 having soiled briefs left on a clean bed and thrown on the floor. Findings Include, On 08/03/23 at 1:55 PM, during a tour of the facility a bag with soiled linen was observed on the floor in room [ROOM NUMBER]. A hospice aid entered the room and said she was there to see a resident in room [ROOM NUMBER]. She had not yet been in the room. Upon walking up and down the 300 hallway, no facility staff were observed. Resident #65: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #65 was admitted to the facility on [DATE] with diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to review and revise care plans with resident changes to ensure that interventions necessary for care and services were provided for two residents (Resident #50, Resident #72) of twenty residents reviewed, resulting in the potential for unmet care needs. Findings Include: Resident #72: Pressure Ulcer/Injury A record review of the Face sheet and Minimum Data Set assessment indicated Resident #72 was admitted to the facility on [DATE] with diagnoses: recent history of a stroke, left-sided weakness diabetes, acute respiratory failure, hypertension, heart failure, and weakness. On 8/1/2023 the resident was identified to have a pressure ulcer on the right heel unstageable. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent a facility-acquired pressure ulcer for one resident (Resident # 72) and ensure appropriate interventions were in place and enacted for one resident (Resident#72) of two residents reviewed for pressure ulcers, resulting in Resident #72 developing a facility-acquired pressure ulcer that changed from a blister to black necrotic tissue. Findings Include: Resident #72: Pressure Ulcer/Injury A record review of the Face sheet and Minimum Data Set assessment indicated Resident #72 was admitted to the facility on [DATE] with diagnoses: recent history of a stroke, left-sided weakness diabetes, acute respiratory failure, hypertension, heart failure, and weakness. On 8/1/2023 the resident was identified to have a pressure ulcer on the right heel unstageable. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that Restorative Nursing services were provided to one resident (Resident #11) of 2 residents reviewed for range of motion and restorative services, resulting in a potential for Resident #11 to have a decline in range of motion and mobility Findings Include: Resident #11: Rehab and Restorative A record review of the Face Sheet and Minimum Data Set (MDS) assessment for Resident #11 indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, fibromyalgia, gout, weakness, asthma, heart disease, hypothyroidism, hypertension, depression, anxiety, peripheral vascular disease, history of falls. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary management and care of an indwelling urinary catheter for two residents (Resident #49, and Resident #60) and assessment and management of care for one resident (Resident #227) who performed straight catheterization herself of three residents reviewed for urinary catheters, resulting in the potential for complications including infection and a decline in condition. Findings Include: Resident #49: Urinary Catheter or UTI On 8/03/23 at 2:56 PM during a tour of the facility Resident #49 was observed lying in bed in her room. The room smelled strongly of urine. She was observed to have a Foley catheter; the catheter had sediment in the tubing. The resident said she'd had the catheter during her stay at the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assessment was completed for self-administration of nebulizer breathing treatments and that the nebulizer equipment was stored per facility policy for one resident (Resident #50) of three residents reviewed for respiratory care, resulting in the potential for adverse effects, inadequate administration of medication, exacerbation of symptoms and infection. Resident #50: A review of Resident #50's medical record revealed an admission into the facility on 9/11/21 and re-admission on [DATE] with diagnoses that included chronic obstructive pulmonary disease, dementia, paranoid schizophrenia, age-related cognitive decline, pneumonia, mood disorder, depression, and heart disease. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that dialysis communication forms were complete and included accurate weight assessment for one resident (Resident #129) of two residents reviewed for Dialysis care, resulting in the potential for a decline in condition and the inability for a prompt response to care needs. Findings Include: Resident #129: Dialysis On 8/03/23 at 3:35 PM , Resident #129 was observed sitting in a wheelchair in her room. She said she had nausea; and stated, It happens sometimes. She said she had recent abdominal surgery. Resident #129 said she went to dialysis 3 days a week/Monday, Wednesday, Friday. She pointed to a dialysis fistula in her left arm. A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #129 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent significant medication errors and accurate documentation of medication administration for three residents (Resident #39, Resident #65 and Resident #178 ) of eight residents reviewed for medication errors, resulting in medications being administered to the residents hours after they were due, leading to resident frustration and anger with the potential for mistreatment of the resident's medical conditions, side effects, adverse effects and a decline in condition. Findings Include: Resident #39: Antibiotic Use A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #39 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: right foot infection, diabetes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that handwashing and Personal Protective Equipment were used for two residents (Resident #21, Resident #39) of nine residents sampled for medication administration, resulting in the likelihood for cross contamination, prolonged resident illness, antibiotic usage with possible hospitalization.