WellBridge of Pinckney

In the surveyor’s words

From the most serious findings on record at WellBridge of Pinckney, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 18, 2025

  This 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. Findings include:A complaint received by the State Agency alleged R801's bed was not in the lowest position when they sustained a fall resulting in injury.On [DATE] at 10:22 AM, a review of R801's closed clinical record revealed they admitted to the facility on [DATE], elected Hospice Services on [DATE] and expired in the facility on [DATE]. […]

• Actual harm, isolatedF689Jul 9, 2025

  This 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. Findings include: A complaint was filed with the State Agency (SA) that alleged during care R701, who was bedridden, was turned too far to the right and fell out of bed, landed face down resulting in fractures to their nose, right ankle and multiple bruising on their face, arms, legs requiring hospitalization.On 7/9/25 at approximately 8:50AM, R701 was observed lying in bed. The bed was in a high position and did not have enablers bars. […]

• Actual harm, isolatedF684Dec 27, 2023

  This 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. Findings include: A review of a complaint submitted to State Agency(SA) documented concerns of failure to assess and properly treat, lack of rehabilitation, fall with injury and notify a change in condition. On 12/27/23 at 9:30 AM, Family A(the complainant) was interviewed regarding R705's stay at the facility. […]

• Actual harm, isolatedF684Jul 21, 2023

  This citation pertains to Intake #MI00138141. Based on observation, interview and record review, the facility failed to timely assess, monitor and appropriately treat a resident with a history of respiratory distress for one (R702) out of three residents reviewed for change in condition/oxygen levels, resulting in in the development of respiratory distress (O2 level at 66%) requiring emergency hospital treatment and admission. Findings include: A Complaint was filed with the State Agency (SA) that alleged EMS (emergency medical service) was told by a nurse caring for R702 that their oxygen levels remained at 66% on room air for over an hour before they called EMS causing the resident to decompensate due to an inability to breath and hypoxia. […]

• Actual harm, isolatedF684Feb 23, 2022

  Based on interview and record review, the facility failed to ensure accurate medication reconciliation upon admission to the facility from the hospital for one (R809) of two residents reviewed for quality of care, resulting in a hospitalization due to metabolic [CONDITION(S)] (alterations in brain chemistry) secondary to severe [CONDITION(S)] (underactive [CONDITION(S)]) progressing to myxedema (a life threatening condition caused when the level of [CONDITION(S)] hormones become very low) after the resident did not receive their [CONDITION(S)] medication for three months. […]