Cycle 1
Health 2025-02-20 · Fire 2025-02-20
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
South Lyon, MI
South Lyon Senior Care and Rehab Center
5-star overall rating with 4-star inspections with 6 recent health deficiencies
700 Reynolds Sweet Parkway, South Lyon, MI
(248) 437-2048
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
74
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nexcare Health Systems
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.70
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.35
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
4.19
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,671
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9869
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.18% · Performance 21.82% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6
Baseline 5.45% · Performance 6.04% · Measure score 6 · Achievement 6 · Improvement 0
Total nurse turnover
4.52
Baseline 40.32% · Performance 45.20% · Measure score 4.52 · Achievement 4.52 · Improvement 0
Adjusted total nurse staffing
2.32
Baseline 4.32 hours · Performance 3.74 hours · Measure score 2.32 · Achievement 2.32 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.43% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 194 · Observed rate 7.73% · Lower 95% interval 7.13% |
| Discharge to community | 64.74% |
50.57%
14.2 pts better
|
Better than the National Rate · Eligible stays 195 · Observed rate 58.97% · Lower 95% interval 57.32% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 101 · Denominator 101 |
| Falls with major injury | 0.99% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 101 |
| Discharge self-care score | 73.13% |
53.69%
19.4 pts better
|
Numerator 49 · Denominator 67 |
| Discharge mobility score | 68.66% |
50.94%
17.7 pts better
|
Numerator 46 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 1.98% |
2.29%
0.3 pts better
|
Numerator 2 · Denominator 101 · Adjusted rate 2.32% |
| Healthcare-associated infections requiring hospitalization | 6.04% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 110 · Observed rate 3.64% · Lower 95% interval 3.88% |
| Staff COVID-19 vaccination coverage | 16.24% |
8.2%
8 pts better
|
Numerator 19 · Denominator 117 |
| Staff flu vaccination coverage | 23.6% |
42%
18.4 pts worse
|
Numerator 38 · Denominator 161 |
| Discharge function score | 70.15% |
56.45%
13.7 pts better
|
Numerator 47 · Denominator 67 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 79 · Denominator 79 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 27.27% |
25.2%
2.1 pts better
|
Numerator 15 · Denominator 55 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.7
About the same
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.0 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
95.0%
3.6 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 100.0% · Q3 100.0% · Q4 96.4% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
95.0%
3.2 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.1%
1.4 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.7% · Q3 1.8% · Q4 9.1% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
4.1%
3.6 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 8.8% |
5.5%
3.3 pts worse
|
5.4%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 6.2% · Q3 10.4% · Q4 8.2% · 4Q avg 8.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.2% |
19.6%
4.6 pts worse
|
19.6%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 22.9% · Q3 23.1% · Q4 24.5% · 4Q avg 24.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.9% |
16.5%
10.6 pts better
|
16.7%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.1% · Q3 7.9% · Q4 5.4% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.1% |
13.9%
3.8 pts better
|
16.3%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 5.8% · Q3 5.3% · Q4 13.6% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.1% |
11.7%
7.4 pts worse
|
14.9%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 13.0% · Q3 27.1% · Q4 8.9% · 4Q avg 19.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
1.7%
1.5 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 7.7% · Q4 3.6% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.2% |
20.4%
11.2 pts better
|
19.8%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 15.6% · Q3 3.6% · Q4 3.5% · 4Q avg 9.2% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
5.6%
0.4 pts better
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.8% · Q3 7.6% · Q4 2.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 62.1% |
82.8%
20.7 pts worse
|
81.7%
19.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 47.1% · Q2 63.8% · Q3 69.5% · Q4 67.2% · 4Q avg 62.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
11.5%
2.3 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 8.6% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.6% |
79.5%
9.9 pts worse
|
79.7%
10.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.7% |
24.2%
10.5 pts worse
|
23.9%
10.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.7% · Observed 33.3% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-24 · Fire 2024-01-24
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-02-16 · Fire 2023-02-16
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-01-24
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-02-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-08
F · Potential for more than minimal harm
2023-02-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-08
Inspection history
Recent health citations
G · Actual harm
2025-09-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-03
E · Potential for more than minimal harm
2025-02-20
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-20
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-20
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-03-05
G · Actual harm
2024-01-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-14
D · Potential for more than minimal harm
2023-12-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-18
E · Potential for more than minimal harm
2023-02-16
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-03-08
E · Potential for more than minimal harm
2023-02-16
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-03-08
E · Potential for more than minimal harm
2023-02-16
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-03-08
D · Potential for more than minimal harm
2023-02-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-08
D · Potential for more than minimal harm
2023-02-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-08
D · Potential for more than minimal harm
2023-02-16
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-03-08
D · Potential for more than minimal harm
2023-02-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-03-08
Penalties and ownership
What sits behind the stars
Ownership
Nexcare Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Beardsley, Kevin
W-2 Managing Employee · Individual
Branscum, James
5% Or Greater Indirect Ownership Interest · Individual
Eisenberg, Leo
5% Or Greater Indirect Ownership Interest · Individual
Nexcare Health Systems, LLC
Operational/Managerial Control · Organization
Perry, Michael
Operational/Managerial Control · Individual
Robin Eisenberg 2014 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Sangster, Todd
Corporate Officer · Individual
Wronski, Frank
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Regency at Whitmore Lake
Whitmore Lake, MI
1-star overall rating with 1-star inspections with $235,995 in total fines with 21 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
WellBridge of Novi
Novi, MI
1-star overall rating with 1-star inspections with $145,575 in total fines with 15 recent health deficiencies
#3
Caretel Inns of Brighton
Brighton, MI
3-star overall rating with 2-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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