Above average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wellbridge Of Grand Blanc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, repeated falls, and orders for 1-person assist with transfers and 2-person assist with a walker was left in a common area after lunch without staff supervision or call light access. Despite needing substantial/maximal assistance with toileting and being on Plavix, the care plan lacked specific bathroom-assistance interventions, and no staff accompanied or monitored the resident when she went alone into a nearby common-area bathroom. A CNA later heard the resident screaming and found her on the bathroom floor next to her wheelchair after an unwitnessed fall, with a scalp laceration and hematoma that required ED evaluation and six staples. Interviews confirmed no staff were present in the common area at the time, and leadership stated that residents have the right to go to the bathroom on their own, even though assessments and prior falls showed this resident needed supervision and assistance.
A resident with visual impairment was left without water and could not reach his call light, another resident with glaucoma was served a meal without staff describing the food items, and multiple residents reported long waits for call lights and unanswered requests for help or medication explanations. Staff were also observed speaking in a non-dignified manner in the dining room, and one resident had no effective way to call for assistance because his call light was kept out of reach without an alternate communication method.
Missed IV Vancomycin Doses Due to PICC Line Occlusion: A resident with MRSA infection, sepsis, and other serious diagnoses had a clotted PICC line that prevented timely IV vancomycin administration. Staff documented delays waiting for Cathflo and the contracted vascular access nurse, attempted limited troubleshooting measures, and the MAR showed five consecutive scheduled doses were missed before the line was ultimately restored.
Incomplete CNA annual competencies and performance reviews were identified for 6 of 6 CNAs reviewed. The Staff Educator said new hires completed a 2-day classroom orientation, online training, and unit-based competencies, but the files showed all competency items were initialed and signed as completed in one day, with many items marked by a line through them, missing pages, and no clear evidence of hands-on PPE or hand hygiene validation. The Administrator and Corporate Nurse stated yearly performance evaluations were not done, and the DON said there was no staffing policy.
Kitchen sanitation and hot holding deficiencies were observed when clean dish storage included a visibly soiled bowl in the clean dish area and hot-held meatballs were found below the facility’s 135°F standard. A resident also reported seeing dirty spoons stuck together and wrapped in a napkin by staff during a meal.
Improper dumpster area maintenance was observed when surveyors found a strong odor, plastic lids, plastic cups, a chip bag, and dark residue around the area behind the dumpster. The Maintenance Director stated that rounds were done only every so often, and the cited Food Code requires refuse areas to be kept free of unnecessary items.
A facility failed to properly store clean linen, sanitary supplies, and PPE, and surveyors found contaminated or disorganized laundry and supply areas in multiple hallways. For two residents on EBP/contact precautions, staff use of gowns and gloves was inconsistent, PPE was not readily available at one room, and one nurse handled gowns improperly during PEG tube care. The facility also had outdated or undated distilled water for Bi-PAP/C-PAP use, and staff were unfamiliar with chlorine residual testing despite a water management plan addressing Legionella control.
Bathroom doors and blinds were not in good working order for two residents with moderately impaired cognition and significant care needs. One resident using a wheelchair reported a sliding bathroom door that would not open and had been a problem since admission, while another resident reported a recurring difficult-to-open bathroom door and broken blinds that could not be adjusted. An LPN confirmed the blinds’ twist rod was broken and said the door issue had already been fixed once, and the MD observed one door was very difficult to open.
Failure to Follow Bed Mobility Care Plan: A resident with dementia and significant assistance needs fell from the bed during care when staff did not follow the 2-person assist bed mobility care plan. The resident had prior bed-fall incidents, including one during hospice care and another during a brief change, with resulting toe injuries, knee pain, and a negative knee x-ray showing osteoarthritis. The resident later reported fear of rolling off the bed again and stated staff had pushed her while turning her in bed.
The facility failed to ensure nurses completed yearly competencies and training for several nurses reviewed. Competency forms for an RN and an LPN were incomplete or self-validated, with no clear evidence another nurse observed and confirmed the skills, and some required skills such as trach care, IV line maintenance, and central line competencies were missing. HR was also seen asking an RN to complete a yearly competency because none was found in her file, and the DON stated there was no staffing policy.
Medication storage and labeling were not maintained according to accepted standards in multiple medication rooms. Expired ointments and dressings were found in the South storage area, lancet devices were mixed with unrelated items, and the South med refrigerator was dirty and overfilled with vaccinations, including some that felt damp. The North med room had sanding dust and debris on the counter from construction work. In addition, topical medications were left out in a resident room and not secured in the locked med area, and a resident’s Voltaren gel was observed on counters in the room until staff discussed locking it up.
A facility failed to provide palatable food and honor meal preferences for multiple residents. Observations and interviews showed missing tray items, incorrect foods, cold or lukewarm meals, and undercooked sausage; one resident reported nausea and vomiting after eating undercooked sausage, another found a paper clip in fruit, and a confidential group said room trays were often colder than desired. Resident council minutes also documented ongoing complaints about overcooked chicken, cold eggs, hard potatoes, and delayed breakfast trays.
Missing Hospice Documentation and Communication for a Resident Receiving Hospice Care: A resident with severe cognitive impairment and extensive ADL dependence was observed with a hospice nurse, but the CMS 802 did not reflect hospice status. Record review found no hospice agreement, initial hospice eval, care guide, visit notes, or visit schedule in the EMR, and staff stated the referral was emailed without further follow-up. The DON and Administrator acknowledged the hospice enrollment, but the hospice documentation was not available in the chart during survey review.
A resident's GLP-1 (Ozempic) injection medication was not protected from staff misappropriation when an RN, not assigned to administer the drug, was observed on video surveillance removing two Ozempic pens from the secured medication refrigerator without proper documentation or justification. The resident did not experience adverse effects, but the unauthorized removal of the medication was confirmed through internal investigation and staff interviews.
A resident with severe cognitive decline and mobility issues experienced multiple falls resulting in injuries and fractures due to inadequate supervision and monitoring. Despite the resident's risk factors and history of falls, the care plan interventions were not effectively updated to prevent further incidents. Interviews with staff highlighted a lack of specific supervision for the resident, and the facility's falls reduction policy was not adequately implemented.
The facility failed to employ a full-time qualified social worker to meet the psychosocial, mental, and behavioral health care needs of its residents. The Transitional Care Coordinator, who is not a qualified social worker, has been assisting with social work roles. The previous social worker resigned without notice, and a new hire did not show up for orientation. Two social workers from sister facilities are temporarily sharing the role. The facility is certified for 128 beds, and this deficiency potentially affects all 124 residents.
Two residents experienced significant weight changes without appropriate care plan updates. A resident undergoing hemodialysis gained 29.1 pounds over 17 days without interventions, while another resident lost 27 pounds post-surgery without care plan updates. The facility failed to follow its re-weigh policy, leading to unmet care needs.
A resident with limited mobility and cognitive intactness did not receive timely activity assessments or adapted activities to meet her needs. Despite expressing a desire for engagement, the facility failed to update her activity assessments since admission and did not document efforts to include her in suitable activities, contrary to their Life Enrichment Programs policy.
A resident's urinary drainage bag and tubing were improperly placed on the floor, risking cross-contamination and infection. The resident, with dementia and quadriplegia, required extensive assistance and had a Foley catheter due to urinary retention. Facility records lacked interventions to keep the drainage system off the floor, violating infection prevention guidelines.
The facility failed to ensure timely re-weighs for two residents, leading to a lack of weight monitoring and follow-up of abnormal weights. A resident with end-stage renal disease experienced significant weight gain without care plan interventions, while another resident experienced significant weight loss without re-weighs or interventions. The Registered Dietitian acknowledged the lack of timely re-weighs and care plan updates.
A resident with a history of aphasia and dysphagia did not receive the prescribed enteral feeding rate due to a failure by nursing staff to follow physician's orders. The feeding pump was set at 70 ml/hr instead of the ordered 75 ml/hr, despite the resident's recent weight loss. The DON confirmed that nurses are responsible for setting the correct rate.
A resident who had recently undergone knee replacement surgery did not receive prescribed pain medications during her stay at the facility. Despite the availability of oxycodone in the medication dispensing system, the nurse was still processing orders and awaiting pharmacy approval. The resident, upset by the lack of pain management, called 911 and left the facility against medical advice. No pain assessments or medications were recorded during her stay.
The facility did not ensure that clinical staff levels were visibly posted for residents and visitors, as required by the SOM. Surveyors observed the absence of such postings in key areas, and the HR Director had to assist in locating the information, which was found in a binder not easily accessible.
A facility failed to properly care plan for a resident on Invega and coordinate with community mental health services. The resident, diagnosed with schizoaffective disorder, bipolar disorder, and anxiety, expressed concerns about discharge and communication with their HOPE case manager. The care plan lacked details on community mental health services and the case manager's contact information. Staff interviews revealed poor communication and coordination, with discrepancies in discharge planning and medication administration.
A resident with cognitive impairments was administered the antipsychotic medication Abilify without obtaining informed consent, as required by the facility's policy. The resident's medical records lacked documentation of consent and a risk-versus-benefit analysis for the medication, despite staff acknowledging the need for such consent.
The facility failed to properly handle and store controlled substances, with 8 out of 19 medication punch cards in the narcotic cabinet showing puncture holes. An LPN found a resident's Armodafinil 50mg with taped-over holes, indicating a medication count discrepancy. The DON confirmed this was against policy and wasted the tablets. Further inspection revealed additional punctured narcotic punch cards, including lorazepam and Norco, highlighting non-compliance with medication handling policies.
A resident reported concerns about not receiving their Norco medication correctly, leading to the discovery of a discrepancy in the narcotic medication count. The facility's documentation did not match the actual pill count, and the DON and another nurse signed off on a dose after confirming with the administering nurse via phone. The facility's policy lacked guidance on documenting administered narcotics.
Unsupervised Common-Area Bathroom Use Leads to Unwitnessed Fall With Head Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for a cognitively impaired resident who fell in a common-area bathroom. The resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 5/15, dementia, Alzheimer’s disease, repeated falls, and a history of an intracapsular right femur fracture from a prior unwitnessed fall that required surgical repair. The resident’s MDS Section GG and MD orders showed she required at least one-person assistance for transfers and two-person assistance with a walker, and needed substantial to maximal assistance with toileting, hygiene, and lower-body dressing. She was also incontinent and on Plavix, a blood thinner that may cause bleeding. Despite these documented needs and risks, the care plan did not include specific interventions for assisting her to and from the bathroom, and the incontinence care plan intervention to provide assistive devices had not been updated or revised since its original date. On the date of the incident, the resident was seated with other residents in a common area after lunch, near the common-area bathroom by the dining room. At approximately 1:05 PM, she went alone into the common-area bathroom without staff assistance. No staff were present in the common area at that time, and there was no call light access in the common area when residents needed to use the bathroom. A CNA walking by heard the resident screaming for help and found her on the bathroom floor; the fall was unwitnessed. The CNA notified the RN, who responded and found the resident lying face down next to her wheelchair, with blood all over the floor and a laceration on the top of her head and a hematoma on the left side of her forehead. The fall incident report documented that the resident stated she had been using the bathroom and attempted to get back into her wheelchair when she fell. Interviews and record review confirmed that no staff had taken the resident to the common-area bathroom or were monitoring the residents in the common area at the time of the fall, despite the resident’s known impulsivity, tendency to forget she needed assistance, and care plan direction that she needed to be watched and not left without staff in the common area. The RN who responded to the fall confirmed that no staff were in the common area when the resident was found, only a group of residents. The social worker who completed the BIMS assessment reported that the resident was more confused in the afternoon, required one-person assistance for transfers, and should not have gone to the bathroom on her own. During interviews, the DON and Administrator asserted that residents have the right to go to the bathroom on their own and cannot be stopped, and the Administrator initially believed the fall had occurred in the resident’s own bathroom rather than the common-area bathroom. The facility’s Fall Reduction Program, which is intended to provide a safe environment and reduce risk, was in place but the implementation for this resident did not prevent her from being left unsupervised in the common area and accessing the bathroom alone, leading to an unwitnessed fall with a head laceration requiring six staples and a hematoma. On a subsequent observation, the resident was seen in the hallway, confused, teary-eyed, and self-ambulating in her wheelchair, unable to state her name or room number, with visible bruising on both sides of her head and a healing scalp laceration. A staff member was yelling her room number from down the hall rather than directly assisting her, and the DON ultimately led her into her room and shut the door. This observation further illustrated her ongoing confusion and need for direct assistance and supervision, consistent with the prior assessments and fall history documented in her record.
Failure to Maintain Resident Dignity, Communication, and Timely Response
Penalty
Summary
The facility failed to treat residents with dignity and respect by not following care plans and by not responding to resident needs in a timely manner. During observation and interview, a visually impaired resident was found in bed asking for water, with his call light on the floor under the bed and empty cups at the bedside. He stated he was partially blind, could not find his call light, and needed water. The DON confirmed he had no fluid restrictions. The resident’s care plan identified that he was legally blind in one eye and had hearing loss, and included interventions to encourage fluid intake and reinforce the need to call for assistance. A cognitively intact resident with glaucoma was observed at lunch with a meal tray in front of her, but staff did not describe the meal items to her even though her ticket was marked to “describe meal to resident.” She repeatedly asked what she was eating because she could not see, and no staff were observed identifying the food on her plate. Her care plan and Kardex both directed staff to describe meals to her because she was blind. In the dining room, a CNA was also observed pacing and yelling out room numbers and a resident’s name toward the service line, and staff were not addressing residents in a dignified, respectful manner. Several residents reported call lights were not answered promptly or were not kept within reach. One resident stated she had waited up to 30 minutes on multiple occasions for her call light to be answered and reported being told by a nurse that she was not there to explain a medication when the resident asked what it was. Another resident was observed with her call light clipped out of reach on the bed sheet; she reported she had been waiting for staff to return to help her get changed after breakfast and said the call light should have been on her gown pocket. She also reported the tray had been left in the room and staff had not returned. A confidential group of residents reported call light response times of about half an hour or longer, especially on weekends, and said staff sometimes shut the light off without helping or returning. A separate resident had his call light intentionally kept out of reach because family requested it, but no alternative means of communication was identified. The resident was observed lying in bed with the call light hanging on the wall, and the nurse aide stated he did not really talk much and had no alternative call device. The resident’s fiancée stated he could not call for help, and the record showed only family preference, frequent checks, and a bell at bedside, though no bell was observed. The physician orders did not identify any alternate means for him to communicate a need for assistance.
Missed IV Vancomycin Doses Due to PICC Line Occlusion
Penalty
Summary
The facility failed to ensure timely IV antibiotic therapy for a resident admitted for skilled nursing care related to DKA, weakness, and ongoing IV vancomycin infusion. The resident had multiple diagnoses including sepsis, MRSA infection, diabetes mellitus type 2, kidney stones, heart failure, and acute and sub-acute infective endocarditis. The resident also had moderately impaired cognition with a BIMS score of 12/15. During interview, the resident stated that his IV line was clogged and that it took 2 to 3 days for someone to fix it, during which he went without IV antibiotics for about 3 1/2 days. Record review showed that the PICC line became difficult to flush and vancomycin doses were held while staff waited for the contracted mobile vascular access company to respond. Nursing notes documented that the line could not be flushed, that the physician was notified, and that the company would not come until Cathflo was available in the facility. Staff attempted other measures, including a heparin dwell flush, removal of a filter attachment, and another saline flush, but these were unsuccessful. The chart also documented delays related to ordering and receiving Cathflo, as well as communication issues about when the contracted nurse would return to the facility. The MAR showed five consecutive scheduled doses of vancomycin were not given over two days. The resident’s vancomycin order was twice daily, and the missed doses included three morning doses and two evening doses. A later note stated the antibiotics had not been given for 2 days and 4 doses, while another staff interview estimated at least 4 missed doses. The contracted vascular access nurse ultimately documented that the PICC line was kinked under the Biopatch, was redressed, and then flushed with ease after Cathflo was instilled. The record also showed that the resident’s vancomycin trough on 09/22/2025 was low at 6.6 ug/mL.
Incomplete CNA Annual Competencies and Performance Reviews
Penalty
Summary
The facility failed to ensure completion of yearly performance reviews and competencies for 6 of 6 Certified Nursing Assistants reviewed for yearly education. During interview, the Staff Education Nurse stated that new nurses and nurse aides completed a 2-day classroom orientation with online computer training and were then assigned to a preceptor on the nursing units to complete competencies, and that she reviewed PPE and hand hygiene with them. However, review of the education files for Nurse Aides N, O, P, Q, R, and S showed the CENA Orientation & Annual Competency Checklist contained 74 competency items, and each aide initialed that they completed all items in one day and signed that the checklist was completed the same day as the Staff Educator's signature. Further review found that some competency items had no initials and were marked with a line through nearly all items. Nurse Aide O's form had a straight line through all competency entries and was signed as completed by the aide and Nurse Y; Nurse Aide P's competency file was missing the last page and had no identified completion date; and Nurse Aide R's form also had a straight line through all competency entries and was signed as completed by the aide and Nurse Y. There were no entries for PPE or hand hygiene on the competency checklist and no document confirming an in-person hands-on competency for each aide. The Administrator and Corporate Nurse E stated they did not complete yearly performance evaluations for the nurse aides and relied on the yearly competency checkoffs instead, and the DON stated there was no staffing policy.
Kitchen sanitation and hot holding deficiencies
Penalty
Summary
The facility failed to maintain best practices in the kitchen when clean dish storage and hot food holding were not maintained in accordance with professional standards. During the kitchen tour, dessert plates were observed stored with the interior exposed, and one bowl in the clean dish area was visibly soiled with a yellow liquid substance. When asked about the dishes, the Culinary Specialist confirmed they were supposed to be clean and took the soiled dish back to the dishwashing area. During lunch service, meatballs on the steam table in the northside kitchen were observed at 130 degrees Fahrenheit and then 122 degrees Fahrenheit on two separate checks. The Kitchen Manager stated the facility tries to keep hot holding at 135 degrees Fahrenheit. A resident also reported seeing a meal utensil issue during dining, stating that two spoons were stuck together and dirty, and that staff had wrapped them in a napkin without noticing the contamination.
Improper Dumpster Area Maintenance
Penalty
Summary
The facility failed to properly dispose of waste and maintain the dumpster area to reduce the presence of insects and rodents. During an environmental tour with the Maintenance Director, a strong odor was observed in the dumpster area, along with plastic lids, plastic cups, a chip bag, and dark residue surrounding the area behind the dumpster. When interviewed, the Maintenance Director stated that rounds were done only every so often. The report cites the 2022 Food Code, 5-501.115, which requires refuse storage areas and enclosures to be maintained free of unnecessary items.
Infection Prevention and Control Program Deficiencies
Penalty
Summary
The facility failed to properly store clean linen, sanitary supplies, and PPE in multiple areas, including the 800, 600, and 100 hallways. During the housekeeping tour, surveyors observed packaged catheters, a urinary drain bag, and bandages on the floor in a supply room in the 800 hallway, clean linen on the floor in the 600 hallway, and an unused brief, towels, and plastic cups on the floor in a supply room in the 100 hallway. In the laundry area, surveyors also observed two dryers with visible accumulation of fibers, fuzz, and fluff on the lint traps and surrounding areas after use, and laundry staff stated the lint traps were supposed to be cleaned after every load but had not been done. The blue transport cart used for laundry and PPE was observed with personal clothing, trash, and empty trash bags inside, and staff could not explain how often the carts were cleaned or who was responsible for cleaning them. Resident 24 had diagnoses including sepsis, MRSA infection, diabetes mellitus type 2, kidney stones, heart failure, and acute and sub-acute infective endocarditis, and had a BIMS score of 12/15. The resident had a PICC line and wounds and was ordered to have Enhanced Barrier Precautions and Contact Precautions with gown and glove use. Surveyors observed a pink butterfly note indicating EBP outside the room, but the resident reported staff always wore gloves and rarely a gown, and could not recall seeing a mask used during care. The resident later stated that gowns were only being worn consistently on the day before and the day of one observation, and confirmed that this had not been consistent before then. A contact precaution sign was later observed on the door, but a wooden slatted hamper by the room contained yellow gowns and was identified by staff as a hamper for clean gowns, with no sign indicating whether the gowns were clean or dirty. Resident 153 had diagnoses including vascular surgery, stomach ulcers, gastritis, feeding tube placement, dysphasia, diabetes mellitus type 2, and debility, with a BIMS score of 06/15. The resident had an EBP order for a PEG tube, but surveyors observed only a pink butterfly note outside the room and no PPE cart or bin present nearby on multiple observations. A CNA stated she would have to go down the hallway to find PPE and confirmed there was no PPE bin outside the room. During care, a nurse pulled a gown from the clean bin, found a knot in the neck ties, rolled the gown into a ball, and placed it back into the clean bin before taking another gown. The nurse later entered the room without closing the door, left and returned after realizing she did not have a pen, and was observed placing the gown into the dirty bin inside the resident’s room before putting on a new gown and returning to complete care.
Bathroom Doors and Blinds Not Functioning Properly
Penalty
Summary
The facility failed to ensure that bathroom doors and blinds in residents’ rooms were in good working order for two residents. Resident 61 was admitted with diagnoses including cystitis, heart failure, diabetes, and heart disease, had a BIMS score of 9/15 indicating moderately impaired cognition, and used a wheelchair for mobility. During an interview and observation in the resident’s room, the resident reported that the sliding bathroom door would not open, could be closed only with difficulty, and could not be reopened; the door was observed and pushed on but would not open further. The resident stated the problem had existed since admission and that staff were aware of it. Resident 128 was admitted with diagnoses including dementia, diabetes, respiratory failure, and stroke, had a BIMS score of 9/15 indicating moderately impaired cognition, and required substantial to maximal assistance with several ADLs and was dependent for toileting hygiene, transfers, and some mobility tasks. The resident reported that the bathroom sliding door was too difficult to open and that staff would kick at it to try to open it. The resident also reported that the blinds did not work and that the slats could not be adjusted as desired, stating the blinds had been an issue for a couple of months or longer. During an interview in the resident’s room, Nurse EE confirmed the blinds’ twist rod was broken and needed replacement and stated the issue had been ongoing for two or three months and had been conveyed to maintenance. The nurse also tried to open the bathroom door and found it very difficult to open, stating it had already been fixed once. The Maintenance Director later stated Resident 128’s door had been fixed the day before and that the blinds would be fixed or replaced, and observed Resident 61’s bathroom door was very difficult to open. The Maintenance Director also stated staff should use the maintenance system to report issues.
Failure to Follow Bed Mobility Care Plan
Penalty
Summary
The facility failed to ensure resident safety when care-planned interventions for bed mobility were not followed for a resident with dementia, diabetes, respiratory failure, and stroke. The resident’s MDS showed moderately impaired cognition and dependence on staff for multiple activities, including lying to sitting and transfers. The care plan identified bed mobility as requiring 2-person assistance after prior incidents, but the resident later reported that staff had pushed her over while turning her in bed and that she was afraid she would roll off the bed again. The resident’s incident record showed a fall from the bed on 5/22/25 while hospice care was being provided. The documentation stated the resident was on her right side, slipped off the bed, and landed on the floor; her 3rd, 4th, and 5th toenails were removed in the fall. A fall assessment identified that she had been receiving care with 1-person physical assist and that the care plan was updated to 2-person assistance for bed mobility. A second incident occurred on 6/18/25 during a brief change when a CNA was assisting the resident. The resident was reaching for a chair and pulling against the CNA, then pulled herself off the right side of the bed and onto the floor. She had pain, a skinned right knee, and injury to the ball of her right toe; an x-ray of the right knee was negative for fracture but showed moderate osteoarthritis. The fall assessment again identified that the resident had been receiving care with 1-person physical assist and that the care plan was updated to require 2-person assistance for bed mobility.
Nursing Competency and Training Deficiencies
Penalty
Summary
The facility failed to ensure nurses completed yearly competencies and training for 3 of 5 nurses reviewed, resulting in nurses potentially lacking the necessary skills and qualifications to adequately care for residents. During interview, the Staff Education Nurse stated new nurses received a 2-day classroom orientation, online computer training, and then were assigned to a preceptor on the nursing units to complete competencies. She also stated she reviewed PPE, hand hygiene, EMR documentation, blood glucose checks, bladder scanner use, EKG machine use, and IVs, with nurses verbalizing back the process. Record review of the Nurse Skills/Competencies Assessment forms for Nurses V and W showed 58 competency items, but the form did not identify whether the nurse was an RN or LPN and did not show that another nurse observed and validated the competency. Nurse V’s form was marked in the Annual box, and she initialed and signed that she completed all orientation hands-on competency skills on 6/10/2025 except for trach care, suctioning, C-Pap/BiPap, and insertion of a G-tube, which were not checked off. The Staff Education Nurse signed the document, but the evaluator signature box was empty. Nurse W’s form had no box marked for Initial/New hire, Annual, or Other, and she initialed and signed that she completed all hands-on competency training in one day on 5/30/2025 except for trach care, which was left blank. Further review showed the competency form included IV medication, IV insertion, IV administration, IV documentation, and IV dressing change, but there was no competency for maintenance of the IV line or for central lines including PICC lines. PPE and hand hygiene were marked as completed by Nurses V and W without documentation confirming an in-person hands-on competency. The HR Manager was later observed asking Nurse G to complete and sign her yearly competency because none could be found in her education file, and a blank competency form was in front of her. The Administrator later located a competency for Nurse G. The DON stated there was no staffing policy, and the facility assessment stated the facility must have sufficient nursing staff with appropriate competencies and skills to provide competent care and maintain an effective training program for all new and existing staff.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and handled in accordance with accepted pharmaceutical standards of practice in multiple medication areas. In the South over-the-counter medication and supplies storage room, several expired items were observed, including packets of A&D ointment, triple antibiotic, bacitracin dated 5/2025, and gauze dressings dated 12/2024. Lancet devices were also found mixed with unrelated items across several shelves and supply bins. In the South medication room, the medication refrigerator had spilled items on the top edge and inside bottom areas and was stacked full with vaccinations, including influenza and pneumonia vaccines; one outside vaccine box felt slightly damp. The North medication room countertop under the cabinets and over the refrigerator was covered in sanding dust and debris from wall work, with items left exposed on the counter.
Food Temperature, Preparation, and Tray Accuracy Concerns
Penalty
Summary
The facility failed to provide palatable food products and meet residents’ food preferences for multiple residents, based on observation, interview, and record review. During dining observations, Resident 24 was served a meal without silverware and with cottage cheese missing from the tray. Resident 72 was served from the opposite side of the table, was not told what was on the tray despite a blind alert on the ticket, and received rice instead of the French fries listed on the meal ticket, with butter also missing. Resident 89 received an entrée with two bowls of soup, although neither soup was requested, and cottage cheese listed on the ticket was missing. Resident 121 reported that lunch and breakfast were good but not hot, and said at least half of her meals were served lukewarm. Resident 74 stated her breakfast was cold and that some meals were bad, and she bought peanut butter so she could eat something. Resident 61, who had diagnoses including cystitis, heart failure, diabetes, and heart disease and had moderately impaired cognition, reported that breakfast sausage was not cooked all the way through, describing it as cooked on one side and pink on the inside. Resident 143, who was cognitively intact and had diagnoses including diabetes, hypertension, heart failure, and chronic kidney disease, reported that breakfast sausage was undercooked and that she became nauseated and vomited after eating part of it. She also reported fruit flies in her fruit and said that the prior week she found a paper clip in her fruit cup. CNA H confirmed that the sausage looked underdone and stated that all of her residents’ sausage looked that way at breakfast. A confidential group of residents reported that meals served to residents who dine in their rooms were colder than desired, with breakfast identified as the worst meal. Residents also reported that oatmeal was like soup before anything was added, the print on menus was small, and there was not enough variety in the menu. Resident council minutes from prior months documented ongoing concerns about overcooked chicken, hard potatoes in potato salad, cold eggs, and breakfast trays not arriving at a decent time. Kitchen staff acknowledged that residents sometimes complained about food temperature and stated that sausage had been temped in the kitchen, and they also acknowledged that paper clips were used on meal tickets.
Missing Hospice Documentation and Communication for a Resident Receiving Hospice Care
Penalty
Summary
The facility failed to ensure that communication between the hospice agency and the facility was accessible in a timely manner for one resident receiving hospice services. Resident #39 was admitted with diagnoses including Senile Degeneration of Brain, TIA, Vascular Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety, and had a BIMS score of 5/15, indicating severe cognitive impairment. The resident also required assistance with most ADLs, including incontinence care, toileting, bed mobility, and transfers. During survey observation, the resident was seen with a caregiver who was identified as the hospice nurse, yet the CMS Form 802 submitted to surveyors did not code the resident as receiving hospice care. Record review and staff interview showed that the resident had enrolled in hospice care, but the facility record did not contain a hospice agreement, initial hospice evaluation, care guide, hospice visit notes, or a hospice schedule. Social services staff stated that the referral was sent to the hospice agency by email and that she did not follow up further, while also confirming that the hospice documentation was not present in the EMR at the time of review. The Administrator acknowledged that the resident had been enrolled in hospice care and stated it was an error that the hospice information was not reflected in the record. The DON was queried about the absence of scanned hospice contract agreement notes and other hospice documentation, and the facility was reminded that it did not keep a hospice binder or post a hospice calendar, relying instead on electronic scanning into resident records. At the time of survey review, no hospice service notes, plan of care, or schedule of hospice visits were found in the resident's chart.
Failure to Protect Resident's GLP-1 Medication from Staff Misappropriation
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's GLP-1 (Ozempic) injection medication from staff misappropriation. The resident, who had diagnoses including Type 2 Diabetes Mellitus, Chronic Kidney Failure, Heart Failure, and Obesity, was prescribed Ozempic as part of her diabetes management regimen. The medication was stored in a secured medication room refrigerator, as per facility protocol. However, a discrepancy was noted when the medication could not be located during routine preparation for administration, and subsequent review of the medication administration record (MAR) and narcotic log did not account for the missing medication. An internal investigation, including review of video surveillance footage, revealed that an RN who was not assigned to administer the medication was observed removing two Ozempic pens from the medication refrigerator. The RN was seen taking the pens, removing one from its packaging, and leaving the medication room with both pens without documenting the removal in the MAR or shift count sheet. There was no documentation of a need for a second dose, nor any record of medication return or disposal in accordance with facility policy. The RN initially denied taking the medication but later admitted to the act when confronted with video evidence. The resident involved did not recall missing any medications and did not experience blood sugar complications during her stay. Interviews with the resident and her family indicated some confusion regarding her medication regimen, but the primary issue was the unauthorized removal of the medication by staff. The incident was reported to local authorities and the state, and the facility conducted an audit to ensure no other medications were missing.
Failure to Prevent Falls and Injuries in Resident
Penalty
Summary
The facility failed to provide a safe and monitored environment to prevent falls for a resident, resulting in multiple falls with injuries and fractures. The resident, who had severe cognitive decline and required substantial assistance with mobility, experienced three falls over several months. The first fall occurred in the hallway, resulting in a fractured right elbow, which was not witnessed by staff but by a visitor. The facility's investigation noted the resident's pain and subsequent treatment, but the care plan did not address the resident's tendency to walk independently. The second fall happened when the resident attempted to answer the door, leading to an abrasion on the right arm. Despite the resident's confusion and inability to walk independently, the care plan interventions were not updated to address these specific risks. The third fall resulted in a fractured left hip, with the resident found on the floor after attempting to stand independently. The care plan was revised to include interventions such as encouraging group activities and family visits, but these were not specific to preventing falls. Interviews with staff, including a nurse and the DON, revealed a lack of specific supervision and monitoring for the resident, despite an increase in overall nursing staff. The facility's policy on falls reduction emphasized individualized interventions and ongoing assessments, but these were not effectively implemented for the resident, as none of the falls were witnessed by staff, and the interventions were not tailored to the resident's needs.
Failure to Employ Full-Time Qualified Social Worker
Penalty
Summary
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 its residents. This deficiency was identified during an interview with the Transitional Care Coordinator, who admitted to assisting with social work roles despite not being a qualified social worker. The Coordinator is currently enrolled in a Bachelor of Social Work program, and a social worker from a sister facility reviews her assessments. The facility's Administrator confirmed that their previous social worker resigned without notice in December 2023, and a new hire in September 2024 did not show up for orientation, leaving the position unfilled. As a temporary measure, two social workers from sister facilities began sharing the full-time role, working Monday to Thursday. The facility is certified for 128 beds, and a Medicaid Bed Count waiver temporarily reduced their bed count to 116 from January to June 2024, but it returned to 128 in July 2024. Despite these efforts, the facility's failure to employ a full-time qualified social worker had the potential to affect all 124 residents residing in the facility.
Deficient Care Planning for Residents with Weight Changes
Penalty
Summary
The facility failed to establish a comprehensive person-centered care plan for two residents, resulting in significant deficiencies in care. Resident #32, who is undergoing hemodialysis, experienced a substantial weight gain of 29.1 pounds over a 17-day period without any updated care plan interventions. Despite the resident's complex medical history, including conditions such as end-stage renal disease and heart failure, the care plan was not revised to address the weight gain until prompted by a state surveyor. The Registered Dietitian (RD) acknowledged the weight gain and fluid overload risk but did not implement timely interventions or re-weighs, relying instead on post-dialysis weights from the dialysis center. Resident #41, who had recently undergone gall bladder surgery, experienced significant weight loss without appropriate care plan updates. The resident's weight dropped from 192.4 pounds to 165.9 pounds over a month, a loss of 27 pounds, without any care plan interventions being added. The facility's re-weigh policy was not followed, as re-weighs were not performed within the preferred 48-hour timeframe, and the resident's weight was only monitored weekly. The RD admitted that the re-weight was not conducted to verify the actual weight loss, despite the resident's complex medical conditions, including coronary artery disease and chronic kidney disease. The deficiencies in care planning for both residents highlight a failure to adhere to the facility's policies on weight monitoring and care plan updates. The lack of timely interventions and re-weighs for significant weight changes indicates a gap in the facility's ability to provide adequate care for residents with complex medical needs. These oversights resulted in unmet care needs and potential health risks for the residents involved.
Failure to Provide Adequate Activity Programming for Resident
Penalty
Summary
The facility failed to complete timely comprehensive activity assessments and provide ongoing programming to meet the interests of a resident, resulting in a deficiency. The resident, who was admitted with diagnoses including Peripheral Vascular Disease, Diabetes, Major Depressive Disorder, and Polyneuropathy, had only one activity assessment completed at the time of admission in March 2023. Despite being cognitively intact and able to express her needs, the resident reported that she was unable to participate in many activities due to limited mobility in her hands and that no adaptations were made to accommodate her participation. The resident expressed feelings of inactivity and lack of engagement, as she was often left to rest in her room without suitable activities. The Activities Director acknowledged the lack of updated assessments, which should have been completed every three months, and admitted that no adaptations were made to include the resident in group activities. The director also confirmed that there was no documentation of efforts to engage the resident in independent leisure pursuits, such as providing music, an iPad, or encouraging her to get out of bed. The facility's policy on Life Enrichment Programs, which mandates daily activities tailored to each resident's needs, was not adhered to, as evidenced by the lack of documented assessments and adapted activities for the resident.
Improper Placement of Urinary Drainage Bag and Tubing
Penalty
Summary
The facility failed to ensure proper placement of a urinary drainage bag and tubing for a resident, leading to a potential risk of cross-contamination and infection. On October 1, 2024, it was observed that the urine drainage bag of a resident was hooked to the bed frame and resting on the floor, with a loop of the catheter tubing also on the floor. A Certified Nursing Assistant (CNA) confirmed that the bag and tubing should not be on the floor and subsequently placed a basin under the drainage bag and tubing. The resident involved had been admitted to the facility with diagnoses including dementia, quadriplegia, and stroke, requiring extensive assistance with all activities of daily living and was severely cognitively impaired. The resident had a 16 French indwelling Foley catheter with a 10 ml retention balloon due to urinary retention. The facility's records indicated a protocol to check the catheter system every shift for patency and integrity, but there was no intervention documented to ensure the urine drainage bag and tubing were kept off the floor, contrary to guidelines for preventing catheter-associated urinary tract infections.
Failure to Monitor Weight Changes in Residents
Penalty
Summary
The facility failed to ensure timely re-weighs for weight loss or weight gain for two residents, resulting in a lack of weight monitoring completion and follow-up of abnormal weights. Resident #32, who has a complex medical history including end-stage renal disease and receives hemodialysis, experienced significant weight gain over a 17-day period without any care plan interventions being added. Despite the resident's weekly weight gain of approximately 6 pounds, no re-weighs were conducted, and the care plan was not updated until after the state surveyor's inquiry. Resident #41, who is cognitively intact and has a history of medically complex conditions, experienced a significant weight loss over a period of time without any care plan interventions. The resident's weight dropped from 192.4 pounds to 165.9 pounds, a loss of 27 pounds, without re-weighs being conducted to verify the actual weight. The facility's policy required re-weighs for a weight change of +/- 5 pounds, but this was not adhered to, and the re-weigh policy did not specify a time frame for re-weighs to be performed. The Registered Dietitian (RD) acknowledged the lack of timely re-weighs and the absence of care plan interventions for both residents. The RD stated that re-weighs should ideally be performed within 48 hours, but this was not done. The RD also noted that Resident #32's weights were taken from post-dialysis weights sent from the dialysis center, and Resident #41's weight monitoring was inconsistent, with the facility only relying on weekly weights after a significant weight loss.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
The facility failed to follow physician's orders for enteral feeding for a resident, resulting in the resident not receiving the prescribed amount of enteral feeding. The resident, who has a medical history including aphasia, dysphagia, and a transient ischemic attack, was observed with their enteral feeding set at 70 ml/hr, despite a physician's order for 75 ml/hr. This discrepancy was noted over two consecutive days, with the feeding pump incorrectly set at 70 ml/hr instead of the ordered 75 ml/hr. The resident experienced a weight loss of 5.6% over a short period, prompting the Registered Dietitian to increase the feeding rate to 75 ml/hr to address the weight loss. However, the nurses responsible for setting the pump rate did not adhere to the updated physician's order. The Director of Nursing acknowledged the error and confirmed that the nurses on the floor are responsible for ensuring the correct rate of infusion on the pump, as per the facility's policy on enteral nutritional feeding.
Failure to Provide Pain Management Leads to Resident Leaving Facility
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who had recently undergone a left knee joint replacement. The resident, who was admitted to the facility with multiple diagnoses including pain and anxiety, did not receive any of the prescribed pain medications during her stay. The resident was admitted late in the evening and requested pain medication shortly after admission, but the nurse was still processing the physician orders and awaiting pharmacy approval for the narcotic. Despite the availability of oxycodone in the medication dispensing system, the resident did not receive it and was offered Tylenol instead, which she refused. The resident became upset due to the lack of pain management and called 911 to be taken back to the hospital. The facility's records showed that there were no pain assessments conducted for the resident, and the Pain Level Summary report was blank. Additionally, there were no progress notes related to the resident's admission or stay, and no admission assessment or vital signs were recorded. The resident's Medication Administration Record also indicated that she did not receive any medications during her stay. Interviews with the facility's Administrator and Corporate Nurse revealed that the nurse was actively trying to obtain the necessary orders and medications, but the resident left against medical advice before the process was completed. The Administrator acknowledged that the resident was upset about not receiving her pain medication and that the facility had not adequately prepared to meet the resident's needs upon her late-night admission. The resident was subsequently transferred to a different nursing home after her hospital visit.
Failure to Post Clinical Staff Levels
Penalty
Summary
The facility failed to ensure that clinical staff posting of licensed and unlicensed staff levels were visible for residents and visitors to review. This deficiency was identified through observations, interviews, and record reviews conducted by surveyors. According to the State Operations Manual (SOM), facilities are required to post the total number and actual hours worked by licensed and unlicensed nursing staff responsible for resident care per shift. This information must be displayed in a prominent place accessible to residents and visitors. However, during multiple observations on different days, surveyors noted the absence of such postings in the front lobby and resident care areas, including the 100 and 600 halls. On one occasion, the surveyor had to request assistance from the Human Resource (HR) Director to locate the clinical nursing hours posting. The HR Director eventually found the 'Staffing Report & Concerns Contact' form dated 10/2/2024, which was tucked into the back side of the front cover of a white binder labeled 'Public Information' on a low-level coffee table in the front lobby. The form included the nursing hours for different shifts, but its placement was not readily visible or accessible to residents and visitors, as required by the SOM.
Failure to Coordinate Mental Health Services and Care Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to adequately care plan for a resident receiving an antipsychotic injectable medication, Invega, and did not ensure coordination with community mental health services. The resident, who was diagnosed with schizoaffective disorder, bipolar disorder, and anxiety, expressed concerns about their discharge and the need to communicate with their HOPE case manager. Despite these concerns, the resident's care plan did not include information about their community mental health services or the case manager's contact details. Upon review, it was found that the resident's electronic medical record lacked a physician's order to coordinate care with community mental health services. Additionally, the discharge planning documentation did not mention the resident's involvement with the HOPE network. The social worker had not assessed the resident, and the transitional care coordinator had only recently scheduled a meeting with the case manager. The resident's care plan also failed to address the administration of the Invega medication, which was provided by the HOPE network. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's mental health services and discharge planning. The unit manager confirmed that the resident was due for an Invega injection and that the medication was available in-house. However, the discharge plan incorrectly indicated that the resident would be moving to an assisted living facility, while the resident believed they were returning to their private apartment. This discrepancy highlighted the facility's failure to ensure proper coordination and communication with the resident's community mental health services.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of an antipsychotic medication, Abilify, for a resident diagnosed with multiple cognitive and mood disorders, including vascular dementia with agitation and major depressive disorder. The resident, who was cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 7 out of 15, was prescribed Abilify for depression starting in July 2024. Despite the facility's policy requiring informed consent and education on potential side effects for psychotherapeutic medications, no consent for Abilify was found in the resident's medical records. The records only contained consents for other medications, such as trazadone and Lexapro. Interviews with facility staff, including the Transitional Care Coordinator and a Registered Nurse, confirmed that Abilify, being an antipsychotic, required consent, which was not obtained. The staff acknowledged the oversight and noted that the initial assessment for Abilify was missed. Additionally, there was no documentation of a risk-versus-benefit analysis for the use of Abilify in the resident's medical record, further indicating a lapse in the facility's adherence to its medication management policies.
Improper Handling and Storage of Controlled Substances
Penalty
Summary
The facility failed to ensure proper handling and storage of controlled substances, as evidenced by the presence of puncture holes in 8 out of 19 medication punch cards in the 100 Hall Controlled/Narcotic substance medication cabinet. During an observation, it was noted that a resident's medication, Armodafinil 50mg, had two tablets with taped-over punch holes, indicating a discrepancy in the medication count. The Licensed Practical Nurse (LPN) on duty acknowledged the issue, attributing it to the night shift nurse who failed to waste the tablets as required by the facility's policy. The Director of Nursing Services (DON) confirmed that the practice of taping over punched holes was not acceptable and proceeded to waste the tablets. Further inspection revealed additional deficiencies, with six more narcotic punch cards showing puncture marks from either a fingernail or an ink pen. These included medications for both sampled and unsampled residents, such as lorazepam and Norco. The facility's policies on controlled substances and medication disposal were not adhered to, as evidenced by the improper handling and storage of these medications, which could lead to cross-contamination and ineffective medication administration.
Narcotic Medication Documentation Discrepancy
Penalty
Summary
The facility failed to ensure accurate documentation of narcotic medications for a resident, leading to a discrepancy in the medication count. The resident, who was cognitively intact and had a history of peripheral vascular disease, polyneuropathy, and anxiety disorder, expressed concerns about not receiving their Norco medication correctly. Upon review, it was found that the Medication Administration Record (MAR) indicated a scheduled administration of Norco every six hours, but there was a discrepancy between the Controlled Substance Proof-Of-Use Record and the actual count of pills in the blister pack. The discrepancy arose when the last recorded removal of a pill was at 11:00 PM, but the physical count showed one less pill than documented. The Director of Nursing (DON) and another nurse later signed the Proof-Of-Use Record for a dose supposedly given at 6:00 AM, based on a phone confirmation with the nurse who had forgotten to sign the record. The facility's policy on controlled substances did not address the documentation of administered narcotic medications, contributing to the oversight.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 354 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Grand Blanc
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Oaks At Woodfield | 2.6 mi | ★★★★★ | 2 | 0 |
| Medilodge Of Grand Blanc | 4 mi | ★★★★★ | 22 | 0 |
| Regency At Grand Blanc | 4.2 mi | ★★★★★ | 3 | 0 |
| Wellbridge Of Fenton | 6.1 mi | ★★★★★ | 9 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 6.4 mi | ★★★★★ | 23 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.