South Lyon Medical Center

Based 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.Findings include:On 07/24/2025 at 2:46 PM, the facility was not able to provide documented evidence of an ASP, including tracking and trending of infections and antibiotic use between 08/2024 and 05/30/2025. On 07/24/2025 at 2:47 PM, the Infection Preventionist (IP) confirmed the IP had not been documenting data related to tracking and trending of infections and antibiotic use. The IP explained how the IP tracked infections and antibiotic use and monitored for trends but did not document the findings. The IP began working at the facility on 05/12/2025 and began to perform tracking and trending of infections and antibiotic use on…

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, 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. Findings include: A facility COVID tracking sheet documented between [DATE] and [DATE], 16 employees and 16 of 22 residents residing in the facility tested positive for COVID. (See Tag F880 for details). On [DATE] at 3:04 PM, the Chief Nursing Officer (CNO) confirmed the facility had a COVID outbreak in the facility around October or November. The CNO explained the rooms at the far end of the hallway had been used in the past to isolate residents with COVID. The residents would have been able to ambulate in the hallways without coming 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, 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. Findings include: Employees An untitled and undated facility spread sheet utilized for tracking employee COVID status, documented during the months of September and [DATE], facility employees were tested for COVID as follows. -On [DATE], a consulting physician with a hire date of [DATE], tested positive…

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 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. Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type two diabetes mellitus with diabetic polyneuropathy and chronic obstructive pulmonary disease, unspecified. A Facility Reported Incident (FRI) was submitted to the SA on 11/27/2024, documenting an allegation of resident neglect and abuse by a Certified Nursing Assistant (CNA). The FRI documented the alleged incident occurred on 11/22/2024, and the Chief Nursing Officer (CNO) was notified of the allegations on 11/25/2024 by the long-term care unit secretary. On 01/29/2025 at 1:41 PM, the Director of Nursing Secretary (DON Secretary) verbalized the facility's abuse…

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, 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. Findings include: Influenza Vaccine The facility lacked documented evidence 23 of 26 residents eligible or potentially eligible to receive a flu vaccine were screened for eligibility to receive a flu vaccine and lacked documented evidence education related to the 2023/2024 flu vaccines was provided to 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.

Based 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. Findings include: Antibiotic Stewardship Policy A facility policy titled Antimicrobial Stewardship Program, revised on 10/2023, lacked the following components: -Antibiotic use protocols related to prescribing antibiotics, including documentation of the indication, dosage, and duration of use of antibiotics -A process for periodic review of antibiotic use by prescribing practitioners such as: review of labs and med…

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, 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. Findings include: Specialized Training A facility document titled Payroll Status Form, dated 10/13/2022, documented the facility's IP had a hire and status (role) date of 10/13/2022. The role was documented as Infection Preventionist. On 07/16/2024 at 7:39 AM, the IP verbalized the IP had completed the Centers for Disease Control and Prevention (CDC) Infection Preventionist Training Course…

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, 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). Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], with a diagnosis of multiple sclerosis. The resident was [AGE] years of age (YOA). Resident #27 Resident #27 was admitted to the facility on [DATE], with diagnoses including heart failure, unspecified, chronic obstructive pulmonary disease (COPD), unspecified, and unspecified asthma, uncomplicated. The resident was 95 YOA. Resident #16 Resident #16 was admitted to the facility on [DATE], with diagnoses including COPD, chronic…

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, 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). Findings include: Infection Control and Prevention Plan The facility's IPCP policy documented the policy was last reviewed by the facility on 10/2022. The facility was not able to provide evidence the policy had been reviewed and/or revised after 10/2022. The policy referred to IPCP as the hospital's IPCP, referenced duties for hospital staff, and did not include language indicating the policy included the Long Term Care facility. The IPCP lacked the following elements: -a list of reportable communicable diseases and a process for reporting to the appropriate state agencies. -prohibition of employees with communicable diseases or infected skin lesions from direct contact with residents or…

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 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. Findings include: On 07/16/2024 between 10:30 AM and 11:00 AM, during the Resident Council Interview, one of seven residents verbalized through a translator device, they were not aware of where the State agencies and advocacy groups contact information was located. This resident only read and spoke Spanish. On 07/16/2024 at 2:45 PM, the Director of Nursing verbalized none of the postings were understandable for the resident who read and spoke only Spanish. The DON confirmed the postings should be in a language understandable to the resident. The facility policy titled Resident Communication Rights, revised 07/2015, documented residents had the right to receive communication orally and in writing, including Braille or in a format and language the resident understands.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings include: Resident #16 Resident #16 was admitted to the facility on [DATE], with diagnoses including adjustment disorder with anxiety and chronic obstructive pulmonary disease. Resident #15 Resident #15 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and nutritional anemia, unspecified. On 07/16/2024 at 10:43 AM, Resident #16 verbalized a resident had been harassing them and calling them names. On 07/16/2024 at 11:04 AM, Resident #15 verbalized they believed Resident #16 had stolen a picture out of their room. The resident explained they believed Resident #16 must be gay because they took the picture. Resident #15 verbalized they…

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, 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. Findings include: Resident #16 Resident #16 was admitted to the facility on [DATE], with diagnoses including adjustment disorder with anxiety and chronic obstructive pulmonary disease. Resident #15 Resident #15 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and nutritional anemia, unspecified. On 07/16/2024 at 10:43 AM, Resident #16 verbalized a resident had been harassing them and calling them names. On 07/16/2024 at 11:04 AM, Resident #15 verbalized they believed Resident #16 had stolen a picture out of their room. The resident explained they…

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, 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). Findings include: Resident #26 Resident #26 was admitted to the facility on [DATE], with diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness, fall on same level, and unspecified dementia with other behavioral disturbances. The clinical record for Resident #26 included documentation of the physician visits during the first 90 days were dated 05/11/2024, and 07/01/2024. The record lacked documented physician visits in June of 2024 by either a physician or a nurse practitioner. On 07/23/2024 at 10:24 AM, the Director of Nursing (DON) confirmed Resident #26 lacked a physician's visit in June of 2024. The DON explained a physician visit should had been completed as the resident was to be seen every 30 days for the first 90 days. Resident #19 Resident #19 was admitted to the facility on [DATE], with…

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 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). Findings include: On 07/17/2024 at 11:04 AM, the Human Resources Supervisor participated in an interview to confirm the accuracy of the Personnel Records Checklist completed by the facility for 20 employees. Employee #7 Employee #7 was hired as a CNA with a start date of 04/01/2023. The CNA's personnel record lacked documented evidence of the completion of an annual performance evaluation. On 07/17/2024 at 1:53 PM, the Human Resources Supervisor confirmed the CNA's personnel record lacked documented evidence of the completion of an annual performance evaluation. The facility policy titled Performance Evaluation, revised 06/2019, documented employees would be evaluated by their supervisor annually in the month of their hire date.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, heart failure, unspecified, and unspecified atrial fibrillation. A physician's order dated 06/20/2024, documented Morphine Sulfate (concentrate) oral solution 20 milligrams/milliliters (mg/ml), give 0.1 ml by mouth every two hours as needed for pain related to chronic pain syndrome. A Controlled Drug Record for Resident #2 documented Morphine…

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, 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). Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including vascular dementia, unspecified severity, with other behavioral disturbance and depression, unspecified. On 07/17/2024 at 3:17 PM, a Registered Nurse (RN) verbalized Resident #9 was administered Buspirone three times a day for behaviors such as yelling out, banging their fists, and throwing items. A physician's order dated 10/19/2023, documented Buspirone Hydrochloride (HCI) 15 milligram (mg) tablets. Give one tablet by mouth three times a day for anxiety as evidenced by outbursts and inconsolable crying. A physician's order dated 10/19/2023, documented antianxiety medication Buspar (Buspirone) - monitor for clinical side effects associated with the medication: appetite changes,…

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, clinical record review, interview, and document review the facility failed to ensure medications were not repackaged for 1 of 27 sampled residents (Resident #3) Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including nondisplaced oblique fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing, age related osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with routine healing, other muscle spasm, and localized edema. A physician's order date 05/10/2024, documented hydrocodone-acetaminophen (Norco) oral tablet 5-325 milligram (mg). Give one tablet by mouth every six hours for chronic arthritic pain. A Controlled Drug Record belonging to Resident #3, documented on 07/17/2024, the remaining count of Norco was 105. On 07/17/24 at 7:52 AM, during an inspection of the section one medication cart, conducted with the Director of…

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 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). Findings include: Resident #27 Resident #27 was admitted to the facility on [DATE], with diagnoses including heart failure, chronic obstructive pulmonary disease and gastro-esophageal reflux disease without esophagitis. The lunch menu for 07/16/2024, documented roast turkey, Brussels sprouts, and corn pudding. Resident #27's Food Likes and Dislikes on the tray card, documented dislikes Brussels sprouts. On 07/16/2024 at 12:07 PM, during tray line observation, Resident #27's tray was plated with turkey, corn pudding and mashed potatoes were substituted for Brussels sprouts. On 07/16/2024 at 3:34 PM, the Registered Dietician (RD) verbalized when a resident had dislikes being served for the meal, the resident should be offered a substitute comparable in nutritional value. The RD confirmed mashed potatoes…

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, 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). Findings include: Resident #27 Resident #27 was admitted to the facility on [DATE], with diagnoses including heart failure, chronic obstructive pulmonary disease and gastro-esophageal reflux disease without esophagitis. Resident #27's Food Likes and Dislikes on the tray card, documented dislikes carrots. On 07/16/2024 at 11:32 AM, the Dietary Manager verbalized if a resident disliked what was being served, those items were to be marked on the tray card for the [NAME] to be aware of what was and was not to be on the resident's plate. The Dietary Aide was responsible for checking the tray card to make sure the plate did not contain resident dislikes. On 07/16/2024 at 3:34 PM, the Registered Dietician (RD) verbalized when a resident had dislikes being served for the main entree, the resident should not be served items 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.

Based 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. Findings include: Screening and Implementation for Pneumococcal (PNA) and Influenza vaccinations On 07/18/2024 at 8:29 AM, the Director of Nursing (DON) confirmed the facility did not have a process in place for screening residents for eligibility to receive a flu vaccine and did not provide education related to flu vaccines to the residents. The DON confirmed consents were signed at admit and new consents were not signed prior…

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, 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. Findings include: CNA The facility lacked documented evidence a CNA with the hire date of 10/25/2020, was screened for eligibility to receive a 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. The CNAs state immunization record documented the CNA recieved a…

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 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). Findings include: Employee #4 Employee #4 was hired as the Registered Dietician on 09/11/2003. Employee #4's personnel record lacked documented evidence of communication training. On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete Communication training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have Communication training. The facility policy titled Communication Training, effective 04/2022, documented employees were to complete Communication training at a minimum of annually.

Based 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). Findings include: Employee #4 Employee #4 was hired as the Registered Dietician on 09/11/2003. Employee #4's personnel record lacked documented evidence of resident rights training. On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete Resident Rights training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have Resident Rights training. The facility policy titled Resident Rights Training, effective 08/2022, documented employees were to complete Resident Rights education at a minimum of annually.

Based 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). Findings include: Employee #4 Employee #4 was hired as the Registered Dietician on 09/11/2003. Employee #4's personnel record documented elder abuse training completed 10/06/2022, however lacked documented evidence elder abuse training was completed in 2023. Employee #7 Employee #7 was hired as a Certified Nursing Assistant (CNA) on 04/01/2023. Employee #7's personnel record documented elder abuse training completed 10/29/2023, however was completed more then 30 days after hire. Employee #10 Employee #10 was hired as a Licensed Practical Nurse on 06/06/2024. Employee #10's personnel record lacked initial elder abuse training completed prior to starting work on the floor. Employee #11 Employee #11 was hired as a Registered Nurse (RN) on 01/22/2024. Employee #11's personnel record documented elder abuse training completed 06/12/2024,however was completed more then 30 days…

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 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). Findings include: Employee #4 Employee #4 was hired as the Registered Dietician on 09/11/2003. Employee #4's personnel record lacked documented evidence of QAPI training. On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete QAPI training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have QAPI training. The facility policy titled Quality Management Program, revised 11/2017, documented all staff shall receive annual training on the facility's QAPI program.

Based 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). Findings include: Employee #4 Employee #4 was hired as the Registered Dietician on 09/11/2003. Employee #4's personnel record lacked documented evidence infection control training had been completed. On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete infection control training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have infection control training. The facility policy titled Infection Control Training, effective 01/2021, documented education and training would be provided to all healthcare personnel annually.

Based on interview and document review, the facility failed to ensure compliance and ethics training was completed timely for 1 of 20 sampled employees (#4). Findings include: Employee #4 Employee #4 was hired as the Registered Dietician on 09/11/2003. Employee #4's personnel record lacked documented evidence of compliance and ethics training. On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete Compliance and Ethics training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have compliance and ethics training. The facility policy titled Compliance and Ethics Training, Effective 10/2022, documented all employees complete Compliance and Ethics continuing education. Education and training shall be provided to all staff annually.

Based on interview and document review, the facility failed to ensure behavioral health training was completed timely for 1 of 20 sampled employees (Employee #4). Findings include: Employee #4 Employee #4 was hired as the Registered Dietician on 09/11/2003. Employee #4's personnel record lacked documented evidence of behavioral health training. On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete Behavioral Health training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have Behavioral Health training. The facility policy titled Behavioral Health Care Training, effective 07/2022, documented employees were to complete Behavioral Health Care training at a minimum of annually.

Based 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. Findings include: Food Storage On 09/25/23 at 10:11 AM, in a reach-in refrigerator, there were two sealed packages of hard boiled eggs, each containing a dozen. The packages were labeled with a use-by date of 08/29/23. A third package was open and unsealed, containing six hardboiled eggs with the same use-by date of 08/29/23. The Dietary Supervisor verbalized the hardboiled eggs should have been used or thrown away by 08/29/23 because they could have made residents sick if consumed after the use-by date. The Dietary Supervisor explained the opened package of six hard boiled eggs should have been transferred to a different container for storage and labeled. On 09/25/23 at 10:24 AM, in the dry food storage room there was a bag of Cheetos, opened and spilling from the bag. On 09/25/23 at 10:29 AM, the Dietary Supervisor confirmed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE], with a diagnosis of chronic obstructive pulmonary disease, unspecified. On 09/25/23 at 11:55 PM, Resident #8 was sitting in a wheelchair at a table in the dining room with two other residents. Resident #8's table mates were served lunch trays and Resident #8 was not served a lunch tray. On 09/25/23 at 12:08 PM, a Certified Nursing Assistant (CNA) delivered Resident #8's lunch tray. On 09/25/23 at 12:18 PM, the CNA verbalized lunch was always delivered in two separate tray carts. The CNA explained the tray carts usually came out together but were sent out one at a time on 09/25/23, during the lunch service. The expectation was all residents sitting at a table would be served at the same time. The CNA…

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 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). Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], with diagnoses including Alzheimer's with late onset, vascular dementia, unspecified severity, with psychotic disturbance and dementia in other diseases classified elsewhere, moderate, with psychotic disturbance. Behavioral Progress Notes for June 2023, documented Resident #18 had five instances of verbal aggression. Behavior Progress Notes for the seven day look back period included the following: -On 06/28/23 the resident was being assisted with removing shoes and got agitated. The resident told the nurse Get out of here! The staff member left the resident's room for five minutes and returned to the room. The resident was pleasant. -On 06/29/23 the resident was entering other resident rooms. Staff attempted to stop the resident from entering…

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, 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). Findings include: Resident #475 Resident #475 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease with exacerbation, chronic respiratory failure with hypoxia and dependence on supplemental oxygen. Resident #475's clinical record lacked documented evidence a baseline care plan was completed for oxygen use. On 09/26/23 at 10:33 AM, a Registered Nurse (RN) verbalized Resident #475 was on 3 liters per minute of supplemental oxygen. The RN confirmed the resident was admitted to the facility with oxygen and there was no baseline care plan. On 09/26/23 at 10:48 AM, the Director of Nursing (DON) explained baseline care plans were required to be completed within 48 hours of a resident's admission to the facility and explained baseline care plans…

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 Resident #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. On 09/26/23 at 1:34 PM, the DON verbalized oxygen administration should be care planned since oxygen was a medication and an…

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, 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). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, type II diabetes mellitus, and other chronic pain. Diagnoses including dementia in other diseases classified elsewhere, unspecified severity, with agitation, Parkinson's disease, violent behavior, disease of pancreas, unspecified, other nonspecific abnormal findings of lung field, and elevation of levels of liver transaminase levels were entered into the resident's clinical record during the resident stay at 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings include: Resident #16 Resident #16 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnosis of unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and type 2 diabetes mellitus with diabetic polyneuropathy. On 09/25/23 at 11:26 AM, Resident #16 explained the resident did not like the resident's bed because it did not go up enough to sit the resident comfortably during eating. The resident verbalized the resident had a fear of choking due to the reclined back. Resident #16's physician ordered diet dated 04/13/23, documented No Concentrated Sweets diet Mechanical Soft texture, regular consistency.…

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, 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). Findings include: Resident #475 Resident #475 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease with exacerbation, chronic respiratory failure with hypoxia and dependence on supplemental oxygen. Resident #475's clinical record lacked documented evidence of a physician's order for the use of oxygen. On 09/25/23 at 4:03 PM, Resident #475 was in the dining room on oxygen administered via a nasal cannula. The resident's oxygen administration was set at three liters per minute (LPM). On 09/26/23 at 10:30 AM, a Certified Nursing Assistant (CNA) confirmed Resident #475 was receiving oxygen at three LPM. Resident #475's Medication Administration Record (MAR) and Treatment…

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 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). Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], with diagnoses including Alzheimer's with late onset, vascular dementia, unspecified severity, with psychotic disturbance and dementia in other diseases classified elsewhere, moderate, with psychotic disturbance. A Behavior Incident Progress Note dated 09/19/23, documented during the evening shift, the resident complained of a headache and was getting loud with a Licensed Practical Nurse (LPN). The LPN handed Resident #18 a Tylenol tablet and decided to leave the resident alone, without observation of the resident swallowing the medication, because the resident was upset. The LPN documented not knowing if the resident had taken the Tylenol tablet. On 09/26/23 at 12:35…

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 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. Findings include: The facility's policy related to comfort care did not include a process directing the care, assessment, and monitoring of residents on comfort care, including criteria to initiate or discontinue comfort care. On 09/26/23 at 2:56 PM, the Administrator confirmed the facility's policy related to comfort care lacked a procedure/process to guide the care of residents requiring comfort care. The Administrator confirmed the facility should have a policy related to the process for initiating comfort care, monitoring the resident for declines and improvements, and needed care and concerns. The facility policy titled Comfort Care, undated, documented in total comfort care was discussed on a case by case basis with the Medical Director and Nursing staff/resident/responsible party. Respecting their advanced directives 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.

Based 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. Findings include: Antibiotic Stewardship Program On 09/26/23 at 2:48 PM, the Administrator confirmed the QAPI committee did not identify concerns related to the ASP/policy's failure to include criteria to be used for the identification of infections, such as McGeer's criteria, and the lack of data collection and monitoring tools used to ensure appropriate antibiotic use, such as an antibiotic time out. The Administrator could not explain how the QAPI committee could have identified a concern…

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 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. Findings include: On 09/26/23 at 12:09 PM, the Chief Nursing Officer (CNO) verbalized the Pharmacist only reviewed antibiotics prescribed during the Pharmacist's on-site visits twice a month. The CNO confirmed a resident could complete a course of antibiotics prior to the Pharmacist reviewing to ensure the correct antibiotic was prescribed and the nursing staff did not perform an antibiotic time out or contact the Pharmacist for review of the antibiotic prior to administering the medication. On 09/26/23 at 12:28 PM, the Administrator verbalized the feedback to the prescriber did not happen in real time and the facility did not use any criteria or a formal documented process to determine appropriate antibiotic use prior to administration of antibiotics. The facility policy titled Antimicrobial Stewardship…

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 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). Findings include: Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified and type two diabetes mellitus without complications. Resident #8 Resident #8 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified and other forms of dyspnea. Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses of Parkinson's disease and chronic obstructive pulmonary disease, unspecified. Resident #475 Resident #475 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease with…

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.