WellBridge of Romeo

Based on observation and interview, the facility failed to provide access to past survey results, affecting 117 residents residing in the facility.Findings include: On 12/15/25 at 9:45 AM, during a tour of the facility, a table was noted with a sign on it saying, previous state survey results book can be found at this location. At 2:00 pm and 3:30 PM there was no book observed on the table. On 12/16/25 at 9:00 AM, 12:00 PM and 3:00 PM, there was no book observed on the table. On 12/17/25 at 9:00 am and 10:00 AM, there was no survey book available on table. On 12/17/25 at 10:05 AM, R9 was observed sitting up in wheelchair watching television. R9 was asked about the survey book and where it was located. R9 could not recall seeing a survey book or knowing where it was located. A review of the medical record revealed R9 admitted into the facility on 7/22/2025 with the following medical diagnoses, Infection of Amputation Stump and Congestive Heart Failure. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 15/15…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to apply heel boots per physician's order for one resident (R61) out of two reviewed for skin conditions. Findings include:On 12/17/2025 at 9:11 AM, R61 was observed in bed with socks on their feet and their heels resting on the bed.A review of the medical record revealed R61 admitted into the facility on 6/8/2024 with the following medical diagnoses, Encephalopathy and Pain in Right Hip. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 3/15 indicating an impaired cognition. R61 also required staff assistance with bed mobility and transfers.A review of the physician orders revealed the following, Bilateral heel lift boots on while in bed every shift. Start Date: 7/1/2024. Status: Active.A review of the December (2025) Treatment Administration Record (TAR) revealed a check (indicating boots applied) on the night shift on 12/16/2025 and day shift on 12/17/2025.On 12/17/2025 at 9:15 AM, an interview was conducted with Certified Nursing Assistant (CNA) B.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a responsible party (RP)/family member/Durable Power of Attorney (DPOA) was notified when a resident left the facility against medical advice (AMA) for one resident (R111) of one reviewed for notification of changes. Findings include: A record review of R111's electronic medical record revealed the following progress note, 8/13/24 02:53 AM: 8/12/24, around 20:40 (8:40 PM) [R111] stated to writer that [they] [were] leaving [Nursing Home] tonight with [their two friends]. [R111] stated that [they] [were] going to the [Upper Peninsula] and [they] will not be returning to [nursing home]. Conversation had with [R111] encouraging [them] to stay at facility and [they] continued to refuse. [R111] asked plans for transportation, where [they] will be staying once [they] left the facility as well as who is going to provide care for [them] when needed. [R111] stated that [their] friend [had] transportation, provides shelter and her two friends will help…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure interventions for repositioning were implemented for care of a pressure injury (skin impairment) for one resident (R35) of three reviewed for pressure ulcer care. Findings include: On 10/08/24 at 10:38 AM, R35 was observed to be on their back in bed with the head of the bed elevated around thirty degrees; their lower legs were elevated on a pillow and an active low air loss mattress was in place. On 10/08/24 at 12:07 PM, R35 was observed to be in bed as before, legs elevated, and the head of the bed elevated around thirty degrees. At 12:43 PM, R35 appeared positioned in bed as before. Licensed Practical Nurse (LPN) D nurse raised the bed a little higher to around 45 degrees and stood next the bed to assist R35 to eat. On 10/08/24 at 1:33 PM, resident observed to be awake, eyes open with the TV on. R35 was observed to be in bed on their back with the head of the bed elevated around 30 to 45 degrees. The legs appeared elevated. R35…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00146218. Based on observation, interview, and record review, the facility failed to document targeted behavior and non-pharmacological intervention attempts and prior to use of a psychotropic medication (ativan/lorazepam) for one resident (R35) of three reviewed for medication use. Findings include: On 10/08/24 at 10:38 AM, R35 was observed to be awake and alert and easily answered yes and no questions and provided detail to answers. At 1:33 PM, R35 was observed to be awake, eyes open with the TV on. R35 reported they were generally not feeling well but was awake and alert. At 4:21 PM and 4:40 PM, R35 was observed to be in bed. At 4:40 PM, R35 had two visitors and was engaged in a conversation. On 10/09/24 at 4:50 PM, R35 appeared asleep on each encounter and did not remain awake or with eyes open after query. On 10/10/24 R35 appeared asleep and did not open their eyes to a knock on the door or a call of their name. At 11:24 PM, the visitor indicated R35 did not awaken to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes MI00143027, MI00143206, and MI00142945. Based on observation, interview, and record review the facility failed to protect and report an allegation of abuse to the abuse coordinator in a timely manner, for one resident (R902) of three residents reviewed for abuse. Findings include: A review of the Intake revealed, It was alleged the resident was physically and verbally abused by an employee. A review of R902's medical record revealed, R902 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Acute and Chronic Respiratory Failure with Hypoxia. A review of R902's Minimum Data Set (MDS) assessment dated [DATE] noted, R902 with an intact cognition and dependent of staff to complete activities of daily living. On [DATE] at 10:50 AM, R902 was observed sitting on the side of the bed. R902's face was observed with bruising around both of their eyes. R902 was asked how their eyes became bruised. R902 explained that they didn't know, but it was not related to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop a care plan to address the feeding assistance requirements and interventions for one (R92) of five residents reviewed for plans of care, resulting in the potential for unmet care needs. Findings include: Review of the facility record for R92 revealed an initial admission date of 07/14/22 with the most recent admission being 03/25/23 with diagnoses that included Vascular Dementia, Osteomyelitis of the Ankle/Foot and Diabetes Mellitus. The Minimum Data Set (MDS) assessment dated [DATE] (Significant Change in Status Assessment) indicated R92 required partial/moderate assistance for eating. The Brief Interview for Mental Status (BIMS) assessment score of 0/15 indicated severe cognitive impairment. On 08/14/23 at 9:21 AM, R92 was observed receiving assistance for eating breakfast. They required consistent cueing for alertness and appeared to be very minimally able to participate. On 08/15/23 at 4:02 PM, R92 was observed sitting up in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to administer intravenous (IV) medication per professional standards of nursing practice for one resident (R278) of five reviewed for medications, resulting in the potential for error and/or adverse reactions. Findings include: On 8/14/23 at 10:47 AM, R278 gave this surveyor their name during initial tour screening. R278 was noted to have an intravenous (IV) medication infusing through a PICC (peripherally inserted central catheter) line in their left arm. Closer observation of the label on the medication bag revealed an almost empty bag of Daptomycin (antibiotic) - 1000 milligrams (mg) per 50 milliliters (mL). The full patient name written on the bag did not match the name of R278. (same first name as R278; different last name). The medication was administered through dial-flow tubing. Registered Nurse (RN) A was nearby and was asked to enter the room at this time. RN A confirmed that the name on the IV medication bag did not match R278's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance during meals for one sampled resident (R68) of three reviewed for activities of daily living (ADLs), resulting in difficulty eating and the potential for discomfort. Findings include: On 8/14/23 at 8:43 AM, R68 was observed in bed sitting in a fowler's position (semi-sitting position at a 45-60 degree angle) with a cushion device underneath their knees. Two call lights were clipped/hanging behind the resident's bed and out of reach. R68 was attempting to eat breakfast and had spilled a cup of fruit onto the table in front of them. R68 struggled to pick up pieces of spilled fruit to try and eat. No staff were present to assist the resident. When queried if they were comfortable, R68 stated, Not in this position, no. R68 was somewhat confused but was oriented to person and place when queried throughout the interview. A review of R68's record revealed that the resident was initially admitted into the facility on 7/7/17 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to consistently implement effective fall prevention interventions and adequately supervise one (R125) of three closed record residents reviewed, resulting in multiple falls. Findings include: A review of R125's census information revealed that the resident was originally admitted into the facility on 5/18/23 and transferred to the hospital less than 24 hours later. The resident was then re-admitted on [DATE] and transferred to the hospital on 7/4/23. R125 was again re-admitted on [DATE] and passed away in the facility on 7/22/23. An initial record review revealed that R125 experienced five falls during their admission on the following dates: 5/25/23 (unwitnessed), 6/3/23 (unwitnessed), 6/13/23 (witnessed), 6/20/23 (unwitnessed), and 6/22/23 (witnessed). The resident's diagnoses while in the facility included Traumatic Subdural Hemorrhage With Loss Of Consciousness Of 6 Hours To 24 Hours, Subsequent Encounter, Muscle Weakness, Dementia, Altered Mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to obtain a physician order for oxygen use and store oxygen equipment in a sanitary manner for one resident (R70) of one reviewed for oxygen use, resulting in the potential for equipment contamination and unmonitored oxygen utilization. Findings include: On 8/14/23 at 11:10 AM, R70 was interviewed and indicated they were drowsy but having some pain. R70 was noted to be receiving hospice services. Nasal cannula oxygen tubing was noted lying on the residents bed and connected to a concentrator at two liters per minute (2L). R70 complained of a scab in their nose that is irritated by the oxygen. R70's CPAP (continuous positive airway pressure machine for sleep apnea) mask was observed hanging over their bedside dresser without a storage barrier. R70 repeated that they were feeling drowsy and indicated they wanted their oxygen applied. A review of R70's record did not reveal a physician's order for oxygen administration. Further review revealed that the resident is cognitively intact and was admitted into the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.