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Deficiency Records for South Lyon Medical Center
View the most recent health deficiencies and inspection results for South Lyon Medical Center. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for South Lyon Medical Center. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2025-07-24 | 2025-08-27 | N |
| Implement a program that monitors antibiotic use. | Health | 2025-07-24 | 2025-08-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-07-24 | 2025-08-26 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2025-07-24 | 2025-08-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2025-07-24 | 2025-08-25 | 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 (including nights and weekends) and emergencies. | Health | 2025-07-24 | 2025-08-25 | N |
| Ensure that residents are free from significant medication errors. | Health | 2025-07-24 | 2025-08-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2025-07-24 | 2025-08-25 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2025-07-24 | 2025-08-20 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2025-07-24 | 2025-08-15 | N |
| 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. | Health | 2025-07-24 | 2025-08-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2025-07-24 | 2025-07-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-07-24 | 2025-07-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-07-24 | 2025-07-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-02-03 | 2025-03-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-02-03 | 2025-03-17 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2025-02-03 | 2025-03-13 | Y |
| 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 | 2024-07-23 | 2024-08-31 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-07-23 | 2024-08-30 | 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 | 2024-08-30 | 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 | 2024-08-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-07-23 | 2024-08-30 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-07-23 | 2024-08-30 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-07-23 | 2024-08-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-23 | 2024-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-23 | 2024-08-30 | 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 | 2024-08-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-07-23 | 2024-08-30 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-07-23 | 2024-08-28 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-07-23 | 2024-08-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-07-23 | 2024-08-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-07-23 | 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 | 2024-07-23 | 2024-08-27 | 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 | 2024-08-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-23 | 2024-08-27 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-07-23 | 2024-08-27 | N |
| 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 | 2024-08-27 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-07-23 | 2024-08-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-07-23 | 2024-08-26 | 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 | 2024-08-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-07-23 | 2024-08-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-07-23 | 2024-08-01 | 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 | 2024-08-01 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-07-23 | 2024-07-30 | N |
| Provide training in compliance and ethics. | Health | 2024-07-23 | 2024-07-30 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-07-23 | 2024-07-30 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-07-23 | 2024-07-29 | 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 | 2024-07-29 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-07-23 | 2024-07-28 | 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 | 2024-07-23 | 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 |
| 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 |
| Implement a program that monitors antibiotic use. | 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 |
| 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 |
| Post nurse staffing information every day. | 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 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | 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 exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-09-26 | 2023-10-31 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-09-26 | 2023-10-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-26 | 2023-10-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-26 | 2023-10-31 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2023-09-26 | 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 |