South Lyon Senior Care and Rehab Center

Based on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner resulting in the potential to spread foodborne illness to all residents that consume food from the kitchen.Findings Include: On 04/13/2026 9:31 a.m., the initial tour of the kitchen was conducted with Dietary Director L (DD L) and the following areas of concern were observed:A buildup of scaling was observed on both sides of the ice machine in the upper hinge area.A build-up of food debris was observed on multiple ready to use plastic bins. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. A drainpipe that connected a rinse sink and the high temp dish washing machine was observed to be without an air gap providing a space for backflow/overflow.According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent avoidable falls for one resident (R43) of one resident reviewed for falls, resulting in three avoidable falls. Findings include: On 4/13/26 at 9:22 AM, R43 was observed lying in their bed. The bed was in the lowest position with left side of the bed against the wall and a fall mat on the floor to the right side of the bed. On 4/14/2026 at 11:36 AM, a review of R43's facility provided Incident/Accident (I/A) reports were reviewed and revealed the following:An I/A for a fall on 10/10/25 that read, .Nursing Description: This writer was entering (room #) to check VS (vital signs) of the roommate, and writer observed (R43) sitting on the ground on his floor mat next to his bed with his CNA (Certified Nurse Aide) standing beside him. I asked what happened and CNA explained that after assisting resident to the edge of the bed to transfer to WC (wheelchair) he (the CNA) stepped away from the resident's side to grab the WC next to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a laboratory diagnostics (labs) were completed for one resident (R19) of two residents reviewed for diagnostics.Findings include:On 4/14/26 the medical record for R19 was reviewed and revealed the following: R19 was initially admitted to the facility on [DATE] and had diagnoses including Type two diabetes mellitus, Hyperlipidemia and Acute cholecystitis.A Physician order dated 3/26/26 revealed the following: cbc (complete blood count) with diff (differential), cmp (comprehensive metabolic panel), hgba1c (hemoglobin A1C) on 2/27/26 <sic>A second Physician order dated 12/20/25 revealed the following: cbc with diff, cmp on monday 12/22/25A Physicians' evaluation dated 3/25/2026 revealed the following: Physician's note-note text: patient seen and examined in bed .a/p (assessment/plan) cognitive decline moderate pcm (protein calorie malnutrition) alb (albumin) 2.8 dietician to follow repeat albumin h/o (history of) cholycyctites .dm-2 (type-two…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to implement appropriate infection control practices during catheter site and wound site care for one resident, (R43) of one resident reviewed for catheter site and wound care, resulting in the potential for the spread of infection. Findings include: On 4/13/26 at 9:22 AM, a sign posted outside R43's room indicated they were on enhanced barrier precautions (an infection control strategy requiring an isolation gown and glove use during high-contact resident care to prevent Multidrug-Resistant Organism transmission). R43 was observed lying in bed. A urinary catheter drainage bag was clipped to the bed rail. R43 was asked about their catheter and voluntarily lifted their shirt to expose their abdomen revealing a suprapubic catheter (a tube inserted into the bladder through a small abdominal incision, rather than the urethra, to drain urine). On 4/14/26 at 11:10 AM, an observation of S/P (suprapubic) catheter site care and catheter site wound care was observed with Nurse 'I'. Nurse 'I' gathered the required supplies…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY On 2/18/25 at 8:55 AM, the privacy curtain between bed 118-1 and 118-2 was observed to be heavily soiled with yellow and brown stains. On 2/18/25 at 12:11 PM, an observation of the Burgundy [NAME] unit was conducted and revealed the following: The toilet in room [ROOM NUMBER] had fecal matter on the rim. The bathroom floor had sandpaper type strips adhered that were coming unpeeled from the tile. Underneath the soap dispenser was a large patch of unsanded, unpainted drywall mud. The drip tray for the soap dispenser had an accumulation of pinkish/brown liquid contained in it. The sink plumbing in room [ROOM NUMBER]'s bathroom were exposed with a build-up of dust and cobweb debris. Visitors in the room had complaints about the exposed dirty plumbing and the heavily soiled privacy curtain. They said they didn't think the curtain had been changed in a, couple of years. The bathroom sink plumbing in room [ROOM NUMBER] was observed with a large accumulation of dust and cobwebs on the pipes along with dust and stains…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a referral was made for a level II evaluation (a comprehensive evaluation completed by the local community mental health agency) for one (R49) of one residents reviewed for PASARR (Preadmission Screening/Annual Resident Review) screenings. Findings include: On 2/18/24 at approximately 12:01 PM, a review of R49's clinical record revealed the resident was initially admitted into the facility on 1/7/24 with diagnoses that included: hemiplegia and hemiparesis (weakness/paralysis) following cerebral infarction (stroke), generalized anxiety disorder and brief psychotic disorder ( according to the DSM-5/diagnostic and statistical manual of mental disorders, this diagnosis is a sudden onset of psychotic behavior that lasts less than one month - that includes at least one the following psychotic symptoms: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) . A review of the resident's Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status (BIMS) score of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure safe positioning of a resident's bed in proximity to a wall heating unit and ensure a complete and thorough investigation into the circumstances of the incident for one (R164) of four residents reviewed for accidents. Findings include: On 2/18/25 at 11:00 AM, R164 was observed laying in bed, on a bariatric sized adaptive mattress. The resident was able to participate with small, basic discussion but was unable to provide any specific details about their situation. During a brief record review, a nursing progress note on 2/12/25 at 3:16 PM read, .Writer went to assess resident's finger. Yesterday, therapy observed blister to right ring fingertip. Resident is unable to communicate with staff effectively and has limited bed mobility, leans to the right in bed. Resident was lying in bed, bed <sic> at this time was against the wall which was touching the heater. Heater caused the bed frame to become hot to touch. Residents finger was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure a medication error rate less than five percent when two medication errors were observed from a total of 29 opportunities for two residents (R#'s 20 and 52) of four residents observed during medication administration, resulting in a medication error rate of 6.9%. Findings include: On 2/18/25 at 9:07 AM, Nurse 'B' was observed preparing medications for administration to R20. Upon completion of the preparation, Nurse 'B' administered the medications including one nasal spray (ipratropium) for the treatment of a runny nose associated with allergies or the common cold. At the end of the observation, Nurse 'B' confirmed all medications due at that time were given. On 2/20/25 at 9:41 AM, the medications administered to R20 were compared against their physician's orders and Medication Administration Record (MAR). At that time, it was discovered R20 had a second nasal spray (fluticascone propionate) for the treatment of allergies to be administered with their morning medications that was not observed as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the consistent use of assistive devices for eating for one resident (R59) of seven residents reviewed for dining. Findings include: On 2/18/25 at 8:57 AM, R59 was observed in their bed eating breakfast. R59 was non-verbal but appeared to appropriately answer simple yes/no questions by nodding/shaking their head. A review of their meal ticket indicated all cups should contain lids and a maroon mug with a lid was used for hot liquids. R59's tray contained a cup of juice and a cup of chocolate shake supplement without lids or straws. On 2/18/25 at 12:47 PM, R59 was in their room with a lunch tray that contained a bowl of tomato soup. Certified Nurse Aide (CNA) 'L' was in the room and poured the soup into a coffee mug with no lid, saying it was easier for R59 to consume. The cup was not observed to be the maroon cup with a lid as indicated on their meal ticket. It was further observed a glass of apple juice and a cup of chocolate shake…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake(s): MI00140898 and MI00140842. Based on interview and record review the facility failed to report allegations of abuse to the State Agency (SA) for one resident (R702) out of four residents reviewed for abuse. Findings include: Complaints were filed with the SA that alleged R702 was physically abused by a staff member. A review of the R702's clinical record revealed the resident was admitted to the facility on [DATE] and readmitted after a hospital stay on 11/7/23 with diagnoses that included: muscular dystrophy, kidney failure and type II diabetes. Review of the resident's Minimum Data Set (MDS) revealed R702 had a Brief Interview for Mental Status (MDS) of 14/15 (cognitively intact). Continued review of R702's clinical record documented, in part, the following: Nurses Note (5:10 PM): Resident pale .having increased lethargy/fatigue and complaining of pain to BLLE (bilateral left lower extremity) .agreed to send resident to (name redacted) Hospital. Transported by (name…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.