SOUTH LYON SENIOR CARE AND REHAB CENTER, L L C MI DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/03/2010	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Isolated	Minimal harm or potential for actual harm
12/03/2010	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
12/03/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
12/03/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
12/03/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
12/03/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
12/03/2010	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
12/02/2010	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Minimal harm or potential for actual harm
12/02/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Widespread	Minimal harm or potential for actual harm
12/02/2010	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
12/02/2010	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
12/02/2010	properly installed electrical wiring and equipment.	Widespread	Minimal harm or potential for actual harm
12/11/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
12/11/2009	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
12/11/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
12/09/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
12/09/2009	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm
12/09/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
12/09/2009	protected exits that allow the resident to escape the building.	Isolated	Minimal harm or potential for actual harm
12/09/2009	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
12/09/2009	properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
12/09/2009	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
12/09/2009	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
12/09/2009	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
12/09/2009	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
12/09/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
01/23/2009	Tell the resident completely about his or her health status.	Isolated	Minimal harm or potential for actual harm
01/23/2009	Allow residents to easily see the results of the nursing home's most recent survey.	Pattern	Minimal harm or potential for actual harm
01/23/2009	Send and promptly deliver unopened mail to residents.	Pattern	Minimal harm or potential for actual harm
01/23/2009	Tell the resident or the resident's representative in writing how long the nursing home will hold the resident's bed when the resident temporarily leaves the facility.	Isolated	Minimal harm or potential for actual harm
01/23/2009	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
01/23/2009	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
01/23/2009	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
01/23/2009	Provide needed housekeeping and maintenance.	Widespread	Minimal harm or potential for actual harm
01/23/2009	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
01/23/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
01/23/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Widespread	Minimal harm or potential for actual harm
01/23/2009	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Minimal harm or potential for actual harm
01/23/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
01/23/2009	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
01/23/2009	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
01/23/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
01/23/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
01/23/2009	Provide bedrooms that don't allow residents to see each other when privacy is needed.	Pattern	Minimal harm or potential for actual harm
01/23/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
01/23/2009	Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Minimal harm or potential for actual harm
01/23/2009	Follow all laws and professional standards.	Isolated	Minimal harm or potential for actual harm
01/23/2009	Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
01/23/2009	Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
01/15/2009	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm
01/15/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
01/15/2009	exit stairways and towers that are smoke proof.	Isolated	Minimal harm or potential for actual harm
01/15/2009	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
01/15/2009	restrictions on the use of portable space heaters.	Pattern	Minimal harm or potential for actual harm
01/15/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm

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Where does this data come from?

The data on this website describes nursing home characteristics, quality measures, inspection results, and nursing staff information.

The data come from 2 sources:

1. Centers for Medicare & Medicaid Services (CMS) have an Online Survey, Certification, and Reporting (OSCAR) database - Includes the nursing home characteristics and health deficiencies issued during the three most recent state inspections and recent complaint investigations.

   The survey inspection results are collected by the state survey agencies, who perform onsite visits to nursing homes . The inspections occur at least once during a 15-month period, or any time in between as a result of a complaint received by the state. The inspections ensure that the nursing home residents receive quality care and services in a safe and comfortable environment in accordance with rules established by CMS. Complaints may be reported and inspected during the year (outside of the 9-15 month survey cycle). Inspections about a complaint that result in the citation of a health deficiency are reported to CMS and included in this website. Sometimes the inspection finds a problem that the nursing home identified and corrected before the inspection occurred. The fact and the nature of these prior problems (deficiencies) may be included in this website.

   The information on the nursing homes' characteristics derived from OSCAR are prepared by each nursing home at the beginning of the regular State inspection. This information is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure data accuracy. In addition, this information changes frequently as residents are discharged and admitted, or resident conditions change.

2. National database known as the Minimum Data Set (MDS) Repository

   The data for the quality measures come from the MDS Repository. The MDS is collected on regular intervals for every resident in a Medicare or Medicaid certified nursing home. Information is collected on the resident's health, physical functioning, mental status, and general well-being. These data are used by the nursing home to access the needs and develop a plan of care unique to each resident.

   Regulations require that a MDS assessment be performed at admission, quarterly, annually, and whenever the resident experiences a significant change in status. For residents in a Medicare Part A stay, the MDS is also used to determine the Medicare reimbursement rate. These assessments are performed on the 5th, 14th, 30th, 60th and 90th day of admission.

   All of this data is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure that it is accurate. Every attempt is made to assure the accuracy and timeliness of this information. However, this information changes frequently as residents are discharged and admitted, or resident conditions change. We advise interpreting this information cautiously and supplementing it with information from the Ombudsman's office, the State Survey Agency, or other sources.

   Some MDS items used to calculate the quality measures consider the resident's condition during previous days prior to the assessment date. The following table provides these "observation" or "look back" time frames.

Signs of Nursing Home Abuse:

• Unexplained injuries or bruises
• Over or under medication
• Visible cuts, bruises, or welts
• Rapid weight loss or weight gain
• Dehydration, malnutrition, and bedsores
• Unsanitary living conditions
• Infections
• Broken bones
• Sudden death