South Lyon Medical Center

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Gas, Vacuum, and Electrical Systems Deficiencies

Have power receptacles that are properly grounded.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Administration Deficiencies

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Emergency Preparedness Deficiencies

Conduct risk assessment and an All-Hazards approach.

Emergency Preparedness Deficiencies

Establish policies and procedures for medical documentation.

Emergency Preparedness Deficiencies

Provide emergency officials' contact information.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Resident Rights Deficiencies

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.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Nursing and Physician Services Deficiencies

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

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.

Pharmacy Service Deficiencies

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.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

Infection Control Deficiencies

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.

Administration Deficiencies

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Resident Rights Deficiencies

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Administration Deficiencies

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Infection Control Deficiencies

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Administration Deficiencies

Provide training in compliance and ethics.

Administration Deficiencies

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Egress Deficiencies

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Miscellaneous Deficiencies

Meet Health Care Facilities Code mechanical requirements.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

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.

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Infection Control Deficiencies

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.

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.