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Deficiency Records for Medilodge of Southfield
A list of the most recent deficiencies for Medilodge of Southfield. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Medilodge of Southfield. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-07-31 | 2024-08-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-31 | 2024-08-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-07-31 | 2024-08-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-31 | 2024-08-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-31 | 2024-08-20 | N |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2024-07-31 | 2024-08-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-31 | 2024-08-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-31 | 2024-08-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-07-31 | 2024-08-20 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2024-07-31 | 2024-08-20 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-07-31 | 2024-08-20 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-07-31 | 2024-08-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-31 | 2024-08-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-07-31 | 2024-08-20 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-07-31 | 2024-08-19 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-07-31 | 2024-08-19 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-07-31 | 2024-08-19 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-07-31 | 2024-08-19 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2024-07-31 | 2024-08-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-31 | 2024-08-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-07-31 | 2024-08-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-07-31 | 2024-08-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-07-31 | 2024-08-19 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-07-31 | 2024-08-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-07-31 | 2024-08-19 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2024-07-31 | 2024-08-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-07-31 | 2024-08-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-07-31 | 2024-08-19 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-07-10 | 2024-07-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-13 | 2024-06-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-06-13 | 2024-06-14 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-06-13 | 2024-06-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-15 | 2024-06-03 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-05-15 | 2024-06-03 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-05-15 | 2024-06-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-05-15 | 2024-06-03 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2024-04-01 | 2024-04-08 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2024-04-01 | 2024-04-08 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-04-01 | 2024-04-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-06 | 2024-03-08 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-02-14 | 2024-02-29 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-02-14 | 2024-02-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-14 | 2024-02-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-02-14 | 2024-02-29 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-14 | 2024-02-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-29 | 2023-09-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-29 | 2023-09-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-29 | 2023-09-08 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-08-29 | 2023-09-08 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-08-11 | 2023-09-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-11 | 2023-09-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-11 | 2023-09-08 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-11 | 2023-09-08 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-08-11 | 2023-09-08 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-11 | 2023-09-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-11 | 2023-09-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-11 | 2023-09-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-11 | 2023-09-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-11 | 2023-09-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-11 | 2023-09-08 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-08-11 | 2023-09-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-11 | 2023-09-08 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-11 | 2023-09-08 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-08-11 | 2023-09-08 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-08-11 | 2023-09-08 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-08-11 | 2023-09-08 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-08-11 | 2023-09-08 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-11 | 2023-09-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-11 | 2023-09-08 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-11 | 2023-09-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-11 | 2023-09-08 | Y |
| Dispose of garbage and refuse properly. | Health | 2023-08-11 | 2023-09-08 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-08-11 | 2023-09-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-11 | 2023-09-08 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-08-11 | 2023-09-08 | Y |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2023-08-11 | 2023-09-08 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-11 | 2023-09-08 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-09 | 2023-09-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-09 | 2023-09-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-08-09 | 2023-09-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-09 | 2023-09-06 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-08-09 | 2023-09-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-09 | 2023-09-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-09 | 2023-09-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-08-09 | 2023-09-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-09 | 2023-09-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-09 | 2023-09-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-09 | 2023-09-06 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-08-09 | 2023-09-06 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-08-09 | 2023-09-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-09 | 2023-09-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-09 | 2023-09-06 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2023-07-21 | 2023-08-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-21 | 2023-08-07 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-07-21 | 2023-08-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-25 | 2023-06-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-25 | 2023-06-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-25 | 2023-06-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-17 | 2023-03-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-17 | 2023-03-09 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-17 | 2023-03-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-17 | 2023-03-09 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-02-17 | 2023-03-09 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-07-25 | 2022-09-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-07-25 | 2022-08-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-25 | 2022-08-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-25 | 2022-08-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-25 | 2022-08-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-25 | 2022-08-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-25 | 2022-08-22 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-07-25 | 2022-08-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-25 | 2022-08-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-25 | 2022-08-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-07-25 | 2022-08-22 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-07-20 | 2022-08-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-20 | 2022-08-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-07-20 | 2022-08-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-20 | 2022-08-19 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-07-20 | 2022-08-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-20 | 2022-08-19 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-07-20 | 2022-08-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-07-20 | 2022-08-19 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-07-20 | 2022-08-19 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-07-20 | 2022-08-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-20 | 2022-08-19 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-07-20 | 2022-08-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-20 | 2022-08-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-20 | 2022-08-19 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-07-20 | 2022-08-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-20 | 2022-08-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-20 | 2022-08-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-20 | 2022-08-19 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-07-20 | 2022-08-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-20 | 2022-08-19 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-07-20 | 2022-08-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-20 | 2022-08-19 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-07-20 | 2022-08-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-23 | 2022-04-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-23 | 2022-04-21 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-03-23 | 2022-04-21 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-03-23 | 2022-04-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-23 | 2022-04-21 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-03-23 | 2022-04-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-23 | 2022-04-21 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-23 | 2022-04-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-23 | 2022-04-21 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-03-23 | 2022-04-21 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-23 | 2022-04-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-17 | 2021-10-27 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-10-01 | 2021-10-22 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-10-01 | 2021-10-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-01 | 2021-10-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-01 | 2021-10-22 | Y |
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