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Deficiency Records for South Lyon Medical Center
A list of the most recent deficiencies for South Lyon Medical Center. 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 South Lyon Medical Center. 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? |
|---|---|---|---|---|
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-07-24 | 2024-09-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-24 | 2024-09-30 | 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 | 2024-07-24 | 2024-08-31 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-07-24 | 2024-08-28 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-07-24 | 2024-08-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-07-24 | 2024-08-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-07-24 | 2024-08-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-07-24 | 2024-08-26 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-07-24 | 2024-08-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-09-26 | 2023-10-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-26 | 2023-10-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-26 | 2023-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-26 | 2023-10-31 | N |
| Post nurse staffing information every day. | Health | 2023-09-26 | 2023-10-31 | 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 | 2023-09-26 | 2023-10-31 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-09-26 | 2023-10-31 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-09-26 | 2023-10-31 | 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 | 2023-09-26 | 2023-10-31 | 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 | 2023-10-03 | 2023-10-31 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-10-03 | 2023-10-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-03 | 2023-10-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-03 | 2023-10-31 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2023-10-03 | 2023-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-26 | 2023-10-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-26 | 2023-10-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-26 | 2023-10-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-26 | 2023-10-11 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-09-26 | 2023-10-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-13 | 2022-12-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-13 | 2022-12-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-09-13 | 2022-11-30 | N |
| 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 | 2022-09-15 | 2022-10-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-15 | 2022-10-31 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-15 | 2022-10-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-15 | 2022-10-31 | N |
| Report COVID19 data to residents and families. | Health | 2022-09-15 | 2022-10-31 | 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 | 2022-09-15 | 2022-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-13 | 2022-10-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-09-13 | 2022-10-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-13 | 2022-10-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-09-15 | 2022-10-17 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-09-15 | 2022-10-17 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-09-15 | 2022-10-13 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-09-15 | 2022-10-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-15 | 2022-10-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-15 | 2022-10-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-09-15 | 2022-10-12 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-09-15 | 2022-10-12 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-09-13 | 2022-10-12 | 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 | 2022-09-13 | 2022-10-12 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-09-15 | 2022-10-10 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-15 | 2022-10-10 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-09-13 | 2022-10-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-09 | 2022-04-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-09 | 2022-04-27 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-09 | 2022-04-27 | Y |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2024-07-23 | Not Fixed | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-23 | Not Fixed | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-23 | Not Fixed | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-07-23 | Not Fixed | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-07-23 | Not Fixed | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-23 | Not Fixed | N |
| 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 | 2024-07-23 | Not Fixed | 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 | 2024-07-23 | Not Fixed | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-07-23 | Not Fixed | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-07-23 | Not Fixed | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-07-23 | Not Fixed | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-07-23 | Not Fixed | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-23 | Not Fixed | N |
| Implement a program that monitors antibiotic use. | Health | 2024-07-23 | Not Fixed | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-07-23 | Not Fixed | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-07-23 | Not Fixed | 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 | 2024-07-23 | Not Fixed | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-07-23 | Not Fixed | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-07-23 | Not Fixed | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-07-23 | Not Fixed | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-07-23 | Not Fixed | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2024-07-23 | Not Fixed | N |
| Provide training in compliance and ethics. | Health | 2024-07-23 | Not Fixed | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-07-23 | Not Fixed | N |
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