Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at South Lyon Senior Care And Rehab Center during CMS and state inspections, most recent first.
Unsanitary kitchen conditions were observed during a tour with the Dietary Director, including scaling on the ice machine, food debris on ready-to-use plastic bins, and a drainpipe from the rinse sink and high-temp dish machine without an air gap. The Dietary Director acknowledged the findings and stated the bins needed cleaning, an air gap would need to be installed, and the ice machine scaling would be removed.
Failure to Prevent Avoidable Falls During Transfers and Wheelchair Use: A resident with dementia, ataxia, falls, and TBI had three avoidable falls. Staff left the resident seated on the edge of the bed while retrieving a WC, used a sit-to-stand lift without an order or care plan indication, and later the resident slid out of a WC when the anti-rollback device was loose and not functioning properly.
A resident with DM2, HLD, acute cholecystitis, and protein calorie malnutrition had ordered CBC, CMP, and HgbA1c testing that was not completed, and no lab results were found in the chart for either set of orders. The ADON stated the contracted lab service had been inconsistent and that the resident’s ordered labs were never drawn or done.
Failure to Follow Infection Control Practices During Catheter and Wound Care: A resident on enhanced barrier precautions received suprapubic catheter site and wound care without the nurse donning an isolation gown. The nurse also failed to perform hand hygiene and change gloves after removing the old dressing and before continuing cleansing and applying ointment to the reddened site. Both the nurse and the Infection Control Nurse acknowledged the missed infection control steps.
A resident with diabetes experienced acute confusion, slurred speech, and physical agitation overnight. Despite these symptoms, staff did not perform or document a blood glucose check, and the LPN reported the resident as improving without comparing to baseline. The resident repeatedly called 911 and was eventually sent to the hospital by EMS, where he was found to have severe hypoglycemia. Facility staff did not fully assess or communicate the resident's change in condition as required by policy.
The facility failed to maintain a clean and homelike environment, with observations of damaged drywall, soiled privacy curtains, and debris in resident rooms. Bathrooms had fecal matter on toilets and rusted commode frames. Despite being fully staffed, the housekeeping department did not address these issues, and privacy curtains remained dirty due to back-order delays. The facility lacked documentation for room audits and a specific policy for maintaining cleanliness.
A facility failed to conduct a required PASARR Level II evaluation for a resident with mental illness diagnoses. The resident's PASARR Level I Screening indicated mental illness, but the necessary follow-up evaluation was not completed, and the exemption form was improperly filled out. The social worker confirmed the oversight during interviews.
A resident with severe cognitive impairment and limited mobility sustained a blister on their finger due to their bed being positioned against a wall heater, causing the bed frame to become hot. The facility failed to document the incident promptly and did not conduct a thorough investigation. The resident's medical records showed inconsistencies, and the physician did not document the blister in their notes.
The facility experienced a medication error rate of 6.9% due to two incidents involving residents. In one case, a nurse failed to administer a prescribed nasal spray, while in another, a nurse did not instruct a resident on the correct dosage of a nasal spray, leading to an overdose. The Director of Nursing acknowledged these issues, which violated the facility's medication administration policy.
A resident was not consistently provided with the necessary assistive dining devices, such as lidded cups and a maroon mug with a lid, as specified in their dietary profile. Observations showed that the resident received meals without the required lids or straws, contrary to their meal ticket instructions. The facility lacked a policy on adaptive dining equipment.
Unsanitary Kitchen Conditions and Improper Drain Connection
Penalty
Summary
The kitchen was not maintained in a sanitary manner during the initial tour with the Dietary Director. Surveyors observed a buildup of scaling on both sides of the ice machine in the upper hinge area and food debris on multiple ready-to-use plastic bins. Surveyors also observed a drainpipe connecting a rinse sink and the high-temp dishwashing machine without an air gap, creating a direct connection between the equipment drain and the floor drain. When these concerns were reviewed with the Dietary Director, the director stated the plastic bins would need to be cleaned, that a company would need to be contacted to install an air gap on the drainpipe, and that they would try to remove the scaling from the ice machine.
Failure to Prevent Avoidable Falls During Transfers and Wheelchair Use
Penalty
Summary
The facility failed to prevent avoidable falls for one resident who had diagnoses including dementia, major depressive disorder, high blood pressure, neuromuscular dysfunction of the bladder, adjustment disorder, ataxia, falls, and traumatic brain injury. The resident’s MDS assessments showed dependence on staff for sit-to-stand and chair-to-bed transfers, and the care plan included transfers with 2-person assist. However, the care plan did not mention any indication for use of a sit-to-stand lift. The resident experienced three falls. During one transfer, a CNA left the resident sitting on the edge of the bed to retrieve the wheelchair, and the resident slid onto the floor mat. During another fall, staff used a sit-to-stand lift even though the resident had no order, care plan, or indication for that device, and the resident’s legs weakened during the transfer. In a third event, the resident attempted to stand from a wheelchair in the Bistro, the wheelchair moved, and the resident slid out onto the floor; the wheelchair’s left anti-rollback device was loose and flipped over, and the report identified the anti-rollback as not functioning properly.
Failure to Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure laboratory diagnostics were completed for one resident reviewed for diagnostics. The resident had diagnoses including type 2 diabetes mellitus, hyperlipidemia, and acute cholecystitis. The medical record showed physician orders for CBC with differential, CMP, and HgbA1c, as well as an earlier order for CBC with differential and CMP. A physician note also documented cognitive decline, moderate protein calorie malnutrition with albumin 2.8, history of cholecystitis, and type 2 diabetes. A dietary note stated the resident’s weight was stabilizing after significant loss and noted no new labs to evaluate, with weekly weight, intake, and labs to be monitored. The record review found no laboratory results for the ordered labs from either order set. A nurse note documented that the CBC with differential and CMP were scheduled and entered to the contracted lab company for draw, but the results were not present in the chart. During interview, the ADON stated the facility had problems with the contracted lab company coming out for draws, that scheduled lab visits on Mondays, Wednesdays, and Fridays were inconsistent, and that the resident’s December 2025 and March 2026 labs were ordered but never drawn and were not done. The facility’s Lab and Diagnostic Test Results policy was reviewed, but none of the resident’s lab results from those orders were provided by the end of the survey.
Failure to Follow Infection Control Practices During Catheter and Wound Care
Penalty
Summary
The facility failed to implement appropriate infection control practices during suprapubic catheter site care and wound site care for one resident who was on enhanced barrier precautions. A sign posted outside the resident’s room indicated the resident required an isolation gown and gloves during high-contact care to prevent multidrug-resistant organism transmission. The resident was observed in bed with a urinary catheter drainage bag clipped to the bed rail and a suprapubic catheter visible through the abdomen. During observed catheter site and wound care, Nurse I entered the room without donning an isolation gown and used clean gloves to set up supplies. After removing the occlusive dressing and cleansing the insertion site and catheter tubing, Nurse I was not observed to perform hand hygiene or change gloves before continuing care. The nurse then applied antibiotic ointment to the reddened tissue before discarding gloves, performing hand hygiene, and putting on a new pair. Nurse I stated they should have worn an isolation gown and should have changed gloves and performed hand hygiene after removing the old dressing. The Infection Control Nurse also agreed that an isolation gown, hand hygiene, and new gloves were required during the care.
Failure to Assess and Respond to Resident's Change in Condition Resulting in Severe Hypoglycemia
Penalty
Summary
A resident with a history of type 2 diabetes mellitus, chronic obstructive pulmonary disease, and a major contusion of the left kidney experienced a significant change in condition during the night. The resident was observed by staff to be highly disoriented, kicking, and mumbling incoherently. The resident's oxygen saturation was found to be low, and after the nasal cannula was reapplied, the oxygen level improved, but the resident continued to display altered mental status and slurred speech. Despite these symptoms, the nursing staff did not perform or document a blood glucose check during the episode, even though the resident was diabetic and experiencing acute neurological symptoms. The resident repeatedly called 911 for help, and a police officer responded to the facility but was informed by staff that the resident was fine. The resident's family was also contacted by the resident and, upon hearing his slurred speech, called 911 out of concern for a possible stroke. When EMS arrived, the resident was transported to the hospital, where he was found to have severe hypoglycemia with a blood glucose level of 24 mg/dl. Hospital records indicated that the resident had symptoms consistent with hypoglycemia, including slurred speech, right-sided facial droop, and weakness, which improved after administration of dextrose. Interviews with facility staff revealed that the LPN and CNA on duty noted the resident's abnormal behavior and vital signs but did not recognize or appropriately respond to the change in condition. The LPN reported the resident's improvement to the physician and DON, but this was based on comparison to the initial episode rather than the resident's baseline. The physician was not informed of the resident's ongoing speech difficulties, and the facility's documentation and investigation focused on communication issues rather than the clinical response to the resident's acute change in condition. Facility policy required detailed assessment and reporting of acute changes, but this was not followed in the resident's case.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by numerous observations of environmental deficiencies in multiple resident rooms, shower rooms, and hallways. Observations revealed damaged drywall, soiled privacy curtains, and scattered debris in resident rooms. In particular, rooms were noted to have damaged walls, sticker residue, and exposed particle board on furniture, which could not be properly sanitized. Additionally, bathrooms shared by residents were found with fecal matter on toilets, split sink caulking, and rusted commode frames. The facility's housekeeping department, led by a Housekeeping Supervisor, was reported to be fully staffed, yet the cleanliness issues persisted over consecutive days. The Administrator confirmed the findings during environmental rounds and acknowledged the presence of soiled privacy curtains, which were on back-order. Despite audits conducted in October 2024 and February 2025, numerous privacy curtains remained dirty, and the facility's efforts to clean them were insufficient to remove visible stains. The Administrator also noted that the facility's floors were not being stripped due to colder temperatures and chemical odors, contributing to the unclean environment. Interviews with the Administrator and Housekeeping staff revealed a lack of documentation for room round audits and an absence of a specific policy for maintaining a clean, comfortable, and homelike environment. The facility relied on a copy of the regulation instead. Observations of the facility's environment, including the build-up of dust and debris in hallways and the condition of soap dispensers and plumbing, further highlighted the facility's failure to provide necessary housekeeping and maintenance services to ensure a sanitary and orderly interior.
Failure to Conduct PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure a referral was made for a Level II evaluation for a resident with mental illness diagnoses, as required by the PASARR process. The resident, who was admitted with diagnoses including hemiplegia, generalized anxiety disorder, and brief psychotic disorder, had a PASARR Level I Screening form indicating the presence of mental illness. Despite this, the necessary Level II evaluation was not conducted, and the exemption criteria form was left incomplete and unsigned. During interviews, the social worker acknowledged the absence of a Level II evaluation and admitted that the exemption form was incorrectly filled out, as the resident did not have a dementia diagnosis. The facility's PASARR policy requires that when there are affirmative answers in Section II of the screening form, a Level II evaluation must be completed unless exemption criteria are met and certified, which was not done in this case.
Resident Burned Due to Unsafe Bed Positioning
Penalty
Summary
The facility failed to ensure the safe positioning of a resident's bed in proximity to a wall heating unit, leading to an incident where a resident sustained a blister on their right ring fingertip. The resident, who had severe cognitive impairment and was unable to communicate effectively, was found with their bed positioned against a wall heater, causing the bed frame to become hot. This resulted in the resident's finger touching the hot bed frame and forming a blister. The incident was not documented until the following day, and there was a lack of immediate investigation into the circumstances surrounding the incident. The resident involved had multiple medical diagnoses, including severe cognitive impairment, limited mobility, and communication deficits. They were totally dependent on staff for care and required a Hoyer lift for transfers. Despite these needs, the facility did not adequately supervise or assess the resident's environment to prevent the accident. The documentation of the incident was delayed, and there were inconsistencies in the physician's notes regarding the resident's mental status and level of assistance required. The facility's investigation into the incident was incomplete, lacking details such as who discovered the blister, when the resident was last checked, and any staff interviews or statements. The Assistant Director of Nursing and the Director of Nursing were unable to provide a thorough explanation for the lack of documentation and investigation. The physician involved also failed to document the blister in their progress notes, and there were discrepancies in their assessments of the resident's condition.
Medication Administration Errors Result in 6.9% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.9%. This deficiency was identified through observations and record reviews involving two residents. On one occasion, Nurse 'B' administered medications to a resident but omitted a prescribed nasal spray, fluticasone propionate, which was documented as given. This discrepancy was discovered during a review of the resident's physician's orders and Medication Administration Record (MAR). In another instance, Nurse 'K' prepared and handed a nasal spray to a resident without providing instructions on the correct dosage. The resident self-administered an incorrect number of sprays, exceeding the prescribed amount. The facility's Director of Nursing acknowledged the omission and the lack of instruction as concerns, which were contrary to the facility's policy that mandates medications be administered safely, timely, and as prescribed.
Failure to Provide Assistive Dining Devices for Resident
Penalty
Summary
The facility failed to ensure the consistent use of assistive devices for eating for a resident identified as R59. During observations, it was noted that R59, who is non-verbal and communicates through nodding or shaking their head, was provided with a breakfast tray that included a cup of juice and a chocolate shake supplement without the required lids or straws. This was contrary to the instructions on R59's meal ticket, which specified that all cups should have lids, and hot liquids should be served in a maroon mug with a lid. Further observations revealed that during lunch, R59 was given a bowl of tomato soup poured into a coffee mug without a lid by a CNA, which was not the maroon cup with a lid as indicated on their meal ticket. Additionally, a glass of apple juice and a cup of chocolate shake supplement were provided without lids. A review of R59's Dietary Profile assessment confirmed the need for lidded cups with straws and a maroon mug with a lid to prevent spillage and promote safety. The facility did not have a policy on adaptive dining equipment, and the administrator confirmed this via email.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near South Lyon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency At Whitmore Lake | 5.1 mi | ★★★★★ | 3 | 0 |
| Wellbridge Of Novi | 7.4 mi | ★★★★★ | 3 | 0 |
| Caretel Inns Of Brighton | 7.7 mi | ★★★★★ | 6 | 0 |
| Northville Manor | 8.9 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Milford | 10.4 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.