South Lyon Medical Center

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to promote and protect a resident's right to be treated with respect and dignity and to make informed decisions when the facility declined to readmit the resident following an acute hospitalization. This deficient practice had the potential to result in psychosocial harm to the resident due to lack of lodging/place to live and services.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to provide documented evidence a thorough investigation was conducted for incidents with the potential to indicate abuse and neglect for 3 of 4 Facility Reported Incidents (FRIs) investigated. This deficient practice had the potential for ongoing physical and/or psychosocial harm to residents due to allegations of neglect and abuse not being thoroughly investigated and documented to ensure appropriate protections were put in place to prevent future neglect and abuse.

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to document the specific needs the facility could not meet and attempts to meet the resident's needs when the facility declined to readmit a resident following an acute care hospitalization. This deficient practice had the potential for residents to be discharged from the facility without a safe discharge plan.

Inspectors wroteBased on clinical record review, interview and document review, the facility failed to provide written notice of the facility's bed-hold policy to a resident and the resident's family member/legal representative upon transfer to an acute care hospital. This deficient practice had the potential to result in psychosocial harm to residents due to not being able to return to the facility and to the resident's previous room.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure the safety of a resident with wandering behaviors when 1 of 13 sampled residents (Resident #9) eloped from the facility and staff failed to check all doors egressing to the outside when an audible door alarm was activated. The deficient practice had the potential for continued elopements from the facility resulting in injuries to the residents.

Inspectors wroteBased on document review and interview, the facility failed to ensure an Infection Preventionist (IP) was employed by the facility at least part time each month from 12/27/2024 to 05/12/2025. This deficient practice had the potential to result in lapses in infection control and the Antibiotic Stewardship (ASP) program with potential for infections to spread throughout the facility and residents to be treated with ineffective antibiotics.

Inspectors wroteBased on observation, clinical record review, interview, and document review, the facility failed to ensure a resident with intellectual disabilities (Resident #20) was provided the necessary care and services to address the resident's scratching and picking at their arms and legs. This deficient practice had the potential to cause the resident preventable discomfort and placed the resident at risk of skin infections from scratching and picking at skin.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure 1 of 13 sampled residents (Resident #1) was provided medication for pain relief per the physician's order and failed to ensure medications prescribed for pain as needed (PRN) included the severity of pain the medication was prescribed for. This deficient practice had the potential to result in discomfort, prolonged or unmanaged pain and/or an adverse drug event.

Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to ensure coordination of care between the facility and the dialysis center, a written contract and/or agreement with the dialysis provider, and a dialysis policy was developed for the care of a resident on dialysis for 1 of 13 sampled residents (Resident #2). This deficient practice had the potential to result in unmonitored and uncoordinated care for all residents on dialysis in the facility, and a preventable adverse event.

Inspectors wroteBased on interview and document review, the facility failed to ensure the facility had a full time Director of Nursing (DON). This deficient practice could have allowed all 27 residents residing in the facility on the affected date to go without proper assessments or certain cares Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNA) perform and compromise the supervision of proper assessments and proper care due to lack of oversight.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's Oxygen flow was administered per physician orders for a resident with chronic obstructive pulmonary disease for 1 of 13 sampled residents (Resident #9). This deficient practice had the potential to result in low Oxygen saturations and harm to the resident.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure the Facility Assessment (FA) was accurate and included nicotine dependence and addiction with the facility's common diagnoses and conditions. This deficient practice had the potential to result in facility staff not receiving adequate training on the care of residents with nicotine dependence and addiction diagnoses and the needs of those residents not being met.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's Oxygen administration was documented in the resident's medication administration record (MAR) for 1 of 13 sampled residents (Resident #9). This deficient practice had the potential to result in unmanaged Oxygen saturation levels.

Inspectors wroteBased on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify a concern and ensure corrective action was implemented related to the lack of tracking and trending of infections and antibiotic use within the Antibiotic Stewardship Program (ASP). This deficient practice had the potential to result in unnecessary antibiotic use and the development of antibiotic-resistant organisms.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure Transmission-Based Precautions (TBP) were implemented according to facility policy and Centers for Disease Control and Prevention (CDC) recommendations for 1 of 13 sampled residents (Resident #6). This deficient practice had the potential to increase risk of spreading infectious organisms throughout the facility.

Inspectors wroteBased on document review and interview, the facility failed to ensure the facility maintained an Antibiotic Stewardship Program (ASP) including tracking and trending of infections and antibiotic use from 08/2024 through 05/30/2025. This deficient practice had the potential to result in residents not receiving the correct or best antibiotic for infections resulting in prolonged or exacerbated infections and the spread of infections throughout the facility.

Inspectors wroteBased on observation, document review, and interview the facility failed to demonstrate effective administration by not ensuring the Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO) adequately interpreted and implemented effective infection control protocols per the Centers for Disease Control and Prevention (CDC) guidance to effectively prevent the spread of COVID-19 (COVID) resulting in a wide spread outbreak of COVID amongst facility staff and residents.

Inspectors wroteBased on observation, record review, document review, and interview, the facility failed to ensure the Centers for Disease Control and Prevention (CDC) guidance and the facility's Infection Prevention and Control Plan (IPCP) were followed regarding the management of COVID-19 (COVID). This failure resulted in an outbreak of COVID within the facility resulting in 16 employees and 16 of 22 residents (Resident #14, #18, #4, #19, #9, #10, #3, #11, #16, #21, #15, #2, #5, #6, #17, and #12) becoming infected with COVID during September and [DATE]. Resident #12 was transferred to an acute care hospital for treatment of COVID symptoms the facility was not able to manage. Resident #12 expired during this hospitalization.

Inspectors wroteBased on interview and document review, the facility failed to ensure an allegation of neglect and abuse was reported to the State Agency (SA) within the required time frame for 1 of 22 sampled residents (Resident #18). This deficient practice could result in allegations of abuse not being investigated timely.

Inspectors wroteBased on observation, document review, and interview the facility failed to demonstrate effective administration by not ensuring the facility's influenza (flu) and pneumonia (PNA) vaccination program included 1) screening residents for eligibility to receive the vaccines, 2) the provision of education related to the risk and benefits of the vaccines to residents and/or the resident's representative preventing the resident or the resident's representative from making an informed decision regarding the vaccines, 3) a process for determining/selecting the correct PNA vaccine for each resident per the Centers for Disease Control and Prevention (CDC) guidance. This failure resulted in substandard quality of care.

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure 1) the facility's Antibiotic Stewardship Program (ASP) policy was reviewed annually, 2) education regarding the ASP/antibiotic use was provided to staff and residents, #3) a process was in place to ensure the Infection Preventionist (IP) was made aware when a resident had a new infection and an antimicrobial medication was prescribed, 4) an antibiotic time out was performed to ensure the best treatment was being provided to residents, and 5) the IP had a process in place related to communicating infection, treatment, and prescribing concerns to prescribing providers.

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure the Infection Preventionist ( IP) 1) completed a specialized IP training course, 2) provided education related to the Antibiotic Stewardship Program (ASP) to staff 3) understood and conducted an antibiotic time out (an active reassessment conducted of an antimicrobial prescription 48-72 hours after the first administration), 4) had a process in place to ensure residents and staff were offered vaccines (see tag F883 and F887), and 5) the IP communicated with providers regarding prescribing trends, needs, and outcomes, with the potential to effect the facility's entire census of 27 residents.

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure 26 of 27 residents residing at the facility were screened for eligibility to receive immunization with an influenza (flu) vaccine and/or a pneumonia (PNA) vaccine and failed to ensure education related to the vaccines was provided resulting in substandard quality of care (Resident #4, #27, #16, #10, #24, #11, #15, #14, #19, #6, #13, #5, #23, #2, #1, #3, #22, #21, #9, #7, #20, #18, #12, #26, #17, and #8).

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure 1) the Infection Control and Prevention Plan (IPCP) policy was reviewed annually, and 2) enhance barrier precautions (EBP) were being implemented for 2 of 2 residents with indwelling medical devices (Resident #1 and #4).

Inspectors wroteBased on interview and document review, the facility failed to ensure pertinent State agencies and advocacy groups contact information posted in the facility were in a language understandable to residents.

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a resident was protected from resident-to-resident verbal abuse and harassment for 1 of 12 sampled residents (Resident #16).

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to report and investigate an allegation of resident-to-resident verbal abuse and harassment for 1 of 12 sampled residents (Resident #16). This deficient practice could allow allegations of abuse to occur and not be reported for investigation.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure physician visits were completed timely for 3 of 12 sampled residents (Resident #26, #19, and #7).

Inspectors wroteBased on interview and personnel record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had an annual performance evaluation completed timely for 1 of 2 CNAs employed greater than one year, sampled for personnel record review (Employee #7).

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure the label on a bottle of Morphine oral suspension (a liquid medication) included a measuring guide for 1 of 27 sampled residents (Resident #2). Due to this failure the facility was not able to determine if the medication was correctly reconciled in the facility's Narcotics Reconciliation log and/or if the medication had been diverted.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure a psychotropic medication was prescribed to a resident with a diagnosed indication for use for 1 of 12 sampled residents (Resident #9).

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure medications were not repackaged for 1 of 27 sampled residents (Resident #3)

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a vegetable substitute of equal nutritive value was offered to 1 of 27 residents' trays observed during tray line (Resident #27).

Inspectors wroteBased on interview, observation, clinical record review, and document review, the facility failed to provide meals based on resident's preferences for 1 of 12 sampled residents (Resident #27).

Inspectors wroteBased on interview and document review the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify 1) the facility lacked screening and implementation for pneumococcal (PNA) and influenza vaccinations and education was not provided for declinations and consents were not obtained for vaccinations given 2) the Infection Preventionist (IP) had not completed a specialized IP training course 3) the Infection Control and Prevention Plan (IPCP) policy was reviewed annually and contained outdated information, and 4) the facility's Antibiotic Stewardship Program (ASP) policy was reviewed annually and contained outdated information.

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure a Certified Nursing Assistant (CNA) was screened for eligibility to receive a COVID-19 (COVID) booster vaccine, education regarding the vaccine was provided and the CNA had an opportunity to make an informed decision to receive or decline the vaccination, and 2) 1 of 6 residents reviewed for immunization with a COVID booster vaccine were screened for eligibility to receive the vaccine, education regarding the vaccine was provided to the resident or the resident's representative, and the resident or the resident representative had the opportunity to make an informed decision to receive or decline the vaccine.

Inspectors wroteBased on personnel record review, interview and document review, the facility failed to ensure communications training was completed by staff for 1 of 20 sampled employees (Employee #4).

Inspectors wroteBased on personnel record review, interview and document review, the facility failed to ensure resident rights training was completed by staff for 1 of 20 sampled employees (Employee #4).

Inspectors wroteBased on personnel record review, interview and document review, the facility failed to ensure elder abuse training was completed timely for 7 of 20 sampled employees (Employee #4, #7, #10, #11, #17, #19, and #20).

Inspectors wroteBased on interview and document review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) training had been completed to include objectives of resident care needs for 1 of 20 sampled employees (Employee #4).

Inspectors wroteBased on interview and document review, the facility failed to provide timely infection control training to all staff to ensure proper procedures and standards of the program for 1 of 20 sampled employees (#4).

Inspectors wroteBased on interview and document review, the facility failed to ensure compliance and ethics training was completed timely for 1 of 20 sampled employees (#4).

Inspectors wroteBased on interview and document review, the facility failed to ensure behavioral health training was completed timely for 1 of 20 sampled employees (Employee #4).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was stored properly and residents received the portion sizes indicated on the facility's menu with the potential to affect the entire facility census of 27 residents.

Inspectors wroteBased on dining observation, interview, and document review the facility failed to ensure a resident was served at the same time as two other residents at the same table in the dining room for 1 of 3 residents at a table (Resident #8).

Inspectors wroteBased on record review, interview, and document review the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 14 sampled residents (Resident #18).

Inspectors wroteBased on observation, interview, clinical record review, and document review, the facility failed to ensure a baseline care plan was created timely for the treatment and care needs for 1 of 14 sampled residents (Resident #475).

Inspectors wroteResident #4 Resident #4 was admitted to the facility on [DATE], with a diagnosis of emphysema, unspecified. On 09/26/23 at 10:47 AM, Resident #4 was resting in bed while wearing a nasal cannula. The resident's oxygen concentrator was set at 2.5 liters per minute (LPM). A physician's order dated 09/24/23, documented oxygen via concentrator at 2.0 LPM via nasal cannula every hour for low oxygen saturation. On 09/26/23 at 10:50 AM, the Director of Nursing (DON) verbalized Resident #4 had an order for oxygen administration and was currently receiving oxygen administration via the nasal cannula from an oxygen concentrator. On 09/26/23 at 12:07 PM, the Registered Nurse (RN) confirmed Resident #4 was receiving oxygen administration and oxygen administration should be care planned. The RN confirmed Resident #4's Comprehensive Care Plan had not been updated to include oxygen administration. [...]

Inspectors wroteBased on observation, clinical record review, interview, and document review the facility failed to ensure 1) an order for comfort care included the indication for comfort care, 2) the facility had a policy and process to help direct care and concerns related to comfort care, and 3) a resident was reassessed for continued need to remain on comfort care for 1 of 14 sampled residents (Resident #3).

Inspectors wroteBased on observation, interview, clinical record review and document review, the facility failed to ensure a resident was supervised during eating while allowing resident to eat in a reclined position for a resident with chewing difficulty and medication administration for 2 of 14 sampled residents (Resident #16 and #18).

Inspectors wroteBased on observation, clinical record review, document review and interview, the facility failed to 1) obtain a physician's order for oxygen therapy for 1 of 14 sampled residents (Resident #475), and 2) administer oxygen therapy per a physician's order for 1 of 14 sampled residents (Resident #4).

Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to ensure medications were stored correctly and were not left unsupervised with a resident who could not self-administer medications for 1 of 14 sampled residents (Resident #18).

Inspectors wroteBased on document review and interview, the facility failed to demonstrate effective administration by not ensuring the facility's policy regarding comfort care included a procedure to direct the care and assessment needs of residents placed on comfort care.

Inspectors wroteBased on interview and document review the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify 1) the facility's Antibiotic Stewardship (ASP) policy and processes included the criteria the facility used to define infections and the use of data collection and monitoring tools, including an antibiotic time out, 2) the lack of a process to ensure COVID-19 (COVID) vaccines were ordered and administered timely to residents wishing to receive the vaccine, and 3) a policy and process was in place to guide appropriate care of residents placed on comfort care.

Inspectors wroteBased on clinical record review, document review, and interview the facility failed to ensure the facility's Antibiotic Stewardship Program (ASP) included a process for conducting antibiotic timeouts with the potential to affect any resident prescribed antibiotics in the facility.

Inspectors wroteBased on clinical record review, interview, and document review, the facility failed to ensure residents requesting a COVID-19 (Covid) vaccination received the vaccine in a timely manner to protect the residents from potential exposure from Covid positive staff for five of five residents who requested the vaccine (Residents #7, #8, #19, #475, and #476).

Inspectors wroteBased on observation and interview, the facility failed to ensure nursing hours were posted daily in the facility.