Wellbridge of Pinckney

Inspectors wroteThis citation pertains to intake #2691527Based on interview and record review the facility failed to prevent an avoidable fall as well as conduct a thorough root-cause analysis investigation into a fall for one resident (R801), of three residents reviewed for falls resulting in fractures of their clavicle and thoracic vertebra number four.

Inspectors wroteThis citation pertains to Intake#1201757. Based on observation, interview and record review the facility failed to prevent a fall for one (R701) of three residents reviewed for falls, resulting in R701 falling out of bed and sustaining multiple fractures, bruising to their face, eyes, arms and legs that required hospitalization.

Inspectors wroteThis citation pertains to intake #1201662. Based on interview and record review, the facility failed to ensure appropriate documentation of administration and accountability of controlled substances for one (R702) of one resident reviewed for medication administration.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the implementation of accurate assessments, appropriate and effective care plans/interventions and adequate supervision for the safety of R89 (elopement) and R's 69, 3 and 16 (falls), five of seven residents reviewed for accidents.

Inspectors wroteR#34 On 4/1/24 at approximately 9:51 AM, R34 was observed lying in bed. The resident was alert and able to answer all questions asked. R34 reported that they had been a resident at the facility for about two years. When asked about the care provided at the facility, R34 responded that while most of the staff are very nice and most care is provided, they were upset that they are never seen by their doctor. R34 noted that they reported their concern to some of the staff members but could not specifically recall their names. A review of R34's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: type II diabetes, COPD (chronic obstructive pulmonary disease) and rheumatoid arthritis. A review of the resident's MDS noted that R34 had a BIMS score of 14/15 (cognitively intact cognition). [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to prevent a significant medication error for one (R67) of one resident reviewed for a significant medication error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order, assessment and specify the times to be used while in wheelchair for a seatbelt device per plan of care for one (R7) resident reviewed for physical restraints.

Inspectors wroteBased on observation, interview and record review, the facility failed to timely report an allegation of an elopement to the State Agency (SA), for one Resident (R89) of one resident reviewed for elopements.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to thoroughly investigate an elopement incident for one Resident of one resident reviewed for elopements.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medication according to professional standards of practice for one Resident (R12) of one resident reviewed for medications.

Inspectors wroteBased on observation, interview, and record review facility failed to ensure an indwelling foley catheter was secured appropriately for one Resident (R3) of two residents reviewed for catheter care resulting in the potential for catheter dislodgement, urethral trauma, and Urinary Tract Infection (UTI).

Inspectors wroteThis citation pertains to intake MI00145465, MI00145510 Based on interview and record review, the facility failed to permit one resident (R901) of two reviewed for discharge, to return to the facility and failed to provide the required facility-initiated discharge documentation.

Inspectors wroteBased on interview and record review, the facility failed to establish a comprehensive infection control program that identified resident infections, utilized laboratory and pharmaceutical data and ensured departmental surveillance and staff education on infection control. This deficient practice had the potential to effect all 75 residents (including R61 and R286) who resided in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to abide to the resident's advance directives for one (R42) of one resident revieweded for code status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure medications and administer medications/treatments according to accepted standards of clinical practice for three residents (R63, R56, R6) of three reviewed for standards of practice, resulting in the potential of medications not being administered correctly and for medications to be unsecured.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nail care was provided to a resident (R10) of three residents reviewed for activities of daily living (ADL's).

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective Antibiotic Stewardship program that included consistent implementation of protocols for appropriate antibiotic administration and ensured that infection criteria were met for three residents (R47, R61 and R286) resulting in the potential for unnecessary antibiotic usage and the development of multiple drug resistant organisms.

Inspectors wroteThis citation pertains to intake #MI00141606. Based on interview and record review, the facility failed to identify a change in condition and ensure timely care and treatment for one resident (R705) of one resident reviewed for a change in condition, resulting in delayed hospitalization and treatment, and the worsening of overall health.

Inspectors wroteBased on interview and record, the facility failed to transfer one resident (R705) per the care plan, of one resident reviewed for falling, resulting in a fall with injury to the back of head.

Inspectors wroteThis citation pertains to intake #'s MI00135571, MI00135911, MI00137740, MI00139155, and MI00139206. Multiple complaints were received by the State Agency that alleged the facility did not have adequate staffing to meet resident care needs. Based on interview and record review, the facility failed to ensure adequate staffing levels to meet resident needs for four residents (R#'s 905, and 906) of five residents reviewed for staffing, resulting in multiple complaints of frustration and unmet resident care needs. This deficient practice had the potential to affect all 90 residents in the facility.

Inspectors wroteThis citation pertains to intake #'s MI00135571, MI00135911, and MI00137740. Based on interview and record review, the facility failed to ensure wound care treatments were initiated upon admission and treatments were completed per physician's orders for one resident (R901) of three residents reviewed for pressure ulcers.

Inspectors wroteThis citation pertains to intake #'s MI00135571, MI00135911, MI00137740, MI00139155, and MI00139206. Based on observation, interview, and record review, the facility failed to display current and accurate nurse staffing information for all 90 residents as well as visitors in the facility, resulting in verbalized complaints of the facility's staffing levels.