SOUTH LYON MEDICAL CENTER

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.

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

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

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

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

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

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.

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.

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

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

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

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

Provide and implement an infection prevention and control program.

Implement a program that monitors antibiotic use.

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

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

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.

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

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

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

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

Ensure each resident receives an accurate assessment.

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

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

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

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

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

Post nurse staffing information every day.

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.

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

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

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

Implement a program that monitors antibiotic use.

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.

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

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.

PASARR screening for Mental disorders or Intellectual Disabilities

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

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

Ensure medication error rates are not 5 percent or greater.

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.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Provide and implement an infection prevention and control program.

Implement a program that monitors antibiotic use.

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

Report COVID19 data to residents and families.

Perform COVID19 testing on residents and staff.

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.

Ensure staff are vaccinated for COVID-19

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

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

Provide and implement an infection prevention and control program.

Ensure staff are vaccinated for COVID-19

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

PASARR screening for Mental disorders or Intellectual Disabilities

Ensure services provided by the nursing facility meet professional standards of quality.

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

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.

Provide and implement an infection prevention and control program.

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

Respond appropriately to all alleged violations.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

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.

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

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

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

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

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

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

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.

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.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

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

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

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

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.

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.

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

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

Honor the resident's right to manage his or her financial affairs.

Ensure residents have reasonable access to and privacy in their use of communication methods.

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

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

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.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.