A list of the most recent deficiencies for Michigan Masonic Home. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-26 | 2023-11-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-10-26 | 2023-11-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-27 | 2022-11-25 | N |
| Provide activities to meet all resident's needs. | Health | 2022-10-27 | 2022-11-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-27 | 2022-11-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-26 | 2022-11-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-26 | 2022-11-16 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-10-26 | 2022-11-14 | 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 | 2022-10-26 | 2022-11-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-26 | 2022-11-11 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-10-26 | 2022-11-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-26 | 2022-11-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-26 | 2022-11-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-26 | 2022-10-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-26 | 2022-10-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-26 | 2022-10-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-02 | 2022-05-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-03 | 2022-03-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-03 | 2022-01-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-03 | 2022-01-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-03 | 2022-01-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-03 | 2022-01-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-03 | 2022-01-14 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-03 | 2022-01-14 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-03 | 2022-01-14 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-12-03 | 2022-01-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-12-03 | 2022-01-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-03 | 2022-01-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-06 | 2021-10-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-08 | 2021-09-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-06 | 2021-09-23 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2021-08-06 | 2021-09-10 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-08-06 | 2021-09-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-08-06 | 2021-09-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-08-06 | 2021-09-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-06 | 2021-09-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-06 | 2021-09-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-06 | 2021-09-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-06 | 2021-09-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-06 | 2021-09-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-06 | 2021-09-09 | 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 | 2021-08-06 | 2021-09-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-06 | 2021-09-09 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-08-06 | 2021-09-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-06 | 2021-09-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-06 | 2021-09-09 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-08-06 | 2021-09-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-06 | 2021-09-09 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-06 | 2021-09-09 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-27 | 2021-09-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-07-27 | 2021-09-09 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-07-27 | 2021-09-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-27 | 2021-09-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-27 | 2021-09-09 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2021-07-27 | 2021-09-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-01 | 2021-06-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-01 | 2021-06-04 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-04-01 | 2021-04-20 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-01 | 2021-04-20 | Y |
