Skip to main content

Inspection visit

Health inspection

SOUTH LYON MEDICAL CENTERCMS #29501124 citations on this visit
24 citations recorded

Citations

24 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0575GeneralS&S Dpotential for harm

    F575 - The facility must post, in a form and manner accessible and understandable

    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.

  • 0600GeneralS&S Dpotential for harm

    F600 - Freedom from Abuse, Neglect, and Exploitation

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

  • 0609GeneralS&S Dpotential for harm

    F609 - The facility must develop and implement written policies and procedures that:

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

  • 0712GeneralS&S Dpotential for harm

    F712 - Frequency of physician visits

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

  • 0730GeneralS&S Dpotential for harm

    F730 - Regular in-service education

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

  • 0755GeneralS&S Dpotential for harm

    F755 - Pharmacy Services

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

  • 0758GeneralS&S Dpotential for harm

    F758 - Medication Errors

    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.

  • 0761GeneralS&S Dpotential for harm

    F761 - Labeling of Drugs and Biologicals

    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.

  • 0804GeneralS&S Dpotential for harm

    F804 - Food and drink

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

  • 0806GeneralS&S Dpotential for harm

    F806 - Food and drink

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

  • 0835GeneralS&S Fpotential for harm

    F835 - Administration

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

  • 0865GeneralS&S Dpotential for harm

    F865 - Quality assurance and performance improvement (QAPI) program

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

  • 0880GeneralS&S Epotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0882GeneralS&S Fpotential for harm

    F882 - Infection preventionist

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

  • 0883GeneralS&S Fpotential for harm

    F883 - Influenza and pneumococcal immunizations

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

  • 0887GeneralS&S Dpotential for harm

    F887 - Infection control

    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.

  • 0941GeneralS&S Dpotential for harm

    F941 - Training Requirements

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

  • 0942GeneralS&S Dpotential for harm

    F942 - Training Requirements

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

  • 0943GeneralS&S Dpotential for harm

    F943 - Abuse, neglect, and exploitation

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

  • 0944GeneralS&S Dpotential for harm

    F944 - Quality assurance and performance improvement

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

  • 0945GeneralS&S Dpotential for harm

    F945 - Infection control

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

  • 0946GeneralS&S Dpotential for harm

    F946 - Compliance and ethics

    Provide training in compliance and ethics.

  • 0949GeneralS&S Dpotential for harm

    F949 - Training Requirements

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

  • 0881GeneralS&S Fpotential for harm

    F881 - Infection prevention and control program

    Implement a program that monitors antibiotic use.

FAQ · About this visit

Common questions about this visit

What happened during the July 23, 2024 survey of SOUTH LYON MEDICAL CENTER?

This was a inspection survey of SOUTH LYON MEDICAL CENTER on July 23, 2024. The surveyor cited 24 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SOUTH LYON MEDICAL CENTER on July 23, 2024?

Yes, 24 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a stateme..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

Share this reportEmail

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.