Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Medilodge Of Shoreline during CMS and state inspections, most recent first.
A resident with a ventral hernia, obesity, and type II diabetes developed abdominal pain, vomiting, and a distended abdomen with a protruding hernia. An LPN notified the physician and NP, who ordered one-time Pepcid and Pepto Bismol, but the MAR and chart did not show the orders were transcribed or administered. The resident continued in severe pain, was later sent to the hospital, and the DON confirmed the initial nurse did not follow through with the additional orders.
A facility failed to keep PASARR assessments current for four residents with dementia-related diagnoses and impaired cognition. Record review showed existing PASARR forms were not updated to reflect the residents' diagnoses, and no updated PASARR or 3878 forms were present. The SSC stated the PASARR updates were missed, and the DON said they were unaware the assessments were not up to date.
An LPN failed to ensure a resident consumed the full prescribed dose of Potassium and documented the MAR as if all medications were taken. The resident, who was cognitively intact and had orders for Potassium Chloride ER 20 mEq, was observed receiving only one of three tablets, while the nurse left before confirming ingestion. The UM, DON, and NP confirmed the resident often chose which meds to take and that staff were expected to observe swallowing, document partial doses accurately, and notify the provider when the full dose was not taken.
Expired medications were found in two of three medication carts reviewed. One cart contained Midodrine labeled for a resident with a use-by date past expiration, and another cart contained OTC sinus severe tablets with an expired date and no resident label. The UM and DON stated expired meds should not remain in the carts.
Failure to Provide Scheduled Showers: A resident with paraplegia, intact cognition, and dependence for ADLs did not receive or have documented completion of scheduled showers. The resident’s care plan called for one-person assist with bathing, but the shower record showed missed or unclear shower documentation, and the DON stated there was no documentation of refusals in the chart. When observed, the resident reported the last shower had been a week earlier and the DON could not explain why a scheduled shower was not documented as provided.
The facility did not hold the required quarterly Quality Assessment and Assurance (QAA) meetings for two out of four quarters, potentially affecting all 103 residents. The absence of sign-in sheets for March and June 2024 confirmed the meetings did not occur, as verified by the Nursing Home Administrator. This failure delayed the identification and resolution of issues, contrary to the facility's QAPI Plan requirements.
The facility failed to maintain a pest-free environment, with gnats observed in common areas and residents' rooms. Gnats were found on trash cans without liners, around medication carts, and swarming above residents' beds. Staff attributed the issue to food kept by residents and a specific incident involving fresh fruit brought in by a resident's family. The facility's pest control policy was not effectively implemented.
A resident with a new ostomy experienced frequent leaks and skin irritation due to inadequate colostomy care and documentation. The facility failed to document the condition of the ostomy site or notify the NP/MD of complications. The Wound Care Nurse was unaware of the issues, and the resident did not receive necessary education due to communication difficulties. An observation revealed excoriated skin, and the care plan was not adequately followed.
A resident with mild cognitive impairment was found with Nystatin powder and Hydrocortisone cream on their bedside table, contrary to facility policy. The resident explained that staff applied the medications and left them at the bedside. The DON confirmed that medications should not be stored at a resident's bedside.
A resident reported feeling intimidated by a CNA during care, who confronted them about a comment and allegedly disposed of their hygiene product. The facility's investigation confirmed the incident, revealing a breach of dignity policies, as the CNA used inappropriate language and engaged in an argument with the resident.
A facility failed to meet the communication needs of a resident who spoke Arabic, resulting in a deficiency. The resident's care plan lacked communication interventions, and staff were unaware of or did not use communication aids. The Social Service Director conducted assessments without a translator, contrary to the facility's policy on limited English proficiency. Family members were not involved in communication, and there was no documentation of translated documents or staff training.
A facility failed to provide and document appropriate indwelling catheter care for a resident admitted with a UTI and severe sepsis. The resident, who required assistance with mobility, had catheter care orders entered nearly two months post-admission. Interviews revealed the oversight was noticed later, indicating a lapse in following the facility's policy on catheter use.
A resident with tremors and a history of severe sepsis was observed eating meals without the required 1:1 assistance, despite the care plan and meal ticket indicating this need. The resident struggled to eat independently, resulting in food spillage, and attempted to drink from a regular cup instead of the prescribed two-handled cup. The facility failed to provide necessary services to maintain the resident's nutrition.
A medication administration error occurred when an LPN mistakenly placed Famotidine in a medication cup instead of the prescribed Furosemide for a resident. The error was identified during a surveyor's observation, and the incorrect medication was removed. The resident had been admitted with Urinary Tract Infection and Severe Sepsis with Septic Shock, and had intact cognition.
A resident with a recent UTI did not have their indwelling catheter changed, despite physician orders indicating it should be changed as needed for infection. The resident continued to experience symptoms post-antibiotics, and facility staff were unclear on the policy for catheter changes in such cases. The facility's policy did not address catheter changes following infections, leading to a deficiency in care.
The facility failed to provide and document showers for three residents as per their preferences and schedules. One resident received only two showers since admission, another experienced shift conflicts resulting in missed showers, and a third reported irregular showering. The DON acknowledged documentation issues due to staff access problems.
The facility failed to honor the preferences of two residents for getting out of bed, impacting their ability to participate in meals and activities. Both residents expressed frustration and were not assisted as per their preferences, despite having intact cognition and needing assistance with bed mobility and transfers.
The facility failed to float the heels of two residents as per physician orders, despite multiple observations and resident requests. Both residents had active orders to keep their heels floated to prevent pressure ulcers, but their heels were repeatedly observed resting on the mattress.
The facility failed to respond to a resident's call light in a timely manner. The resident waited for an hour and a half for assistance to be changed, despite multiple staff members passing by the activated call light. The facility's policy requires staff to respond to activated call lights and keep them on until the need is met, which was not followed in this case.
Failure to Transcribe and Administer Ordered Medications During Change in Condition
Penalty
Summary
The facility failed to transcribe and administer medications as ordered during a resident’s change in condition. The resident had diagnoses including ventral hernia without obstruction or gangrene, morbid obesity, and type II diabetes. During the early morning hours, the resident awoke with abdominal discomfort, reported one episode of vomiting after eating spaghetti, and later had a large loose bowel movement. Tylenol was given as needed, and the nurse documented that the abdomen was firm and distended with normal bowel sounds. The nurse notified the physician and NP, and the NP ordered Pepcid and Pepto Bismol one time and stated she would come to see the resident that morning. Later that morning, another nurse found the resident vocalizing pain, with the hernia protruding from the left lower quadrant of the abdomen and pain rated 10/10. The physician was notified and ordered the resident sent to the hospital. The resident’s chart did not show documentation that the NP’s one-time orders for Pepcid and Pepto Bismol were transcribed or administered. The resident’s progress notes also did not show monitoring of the resident’s pain status after Tylenol was given. Interview and record review showed the nurse who first assessed the resident wrote a note but did not follow through with the additional orders. The Director of Nursing confirmed the Tylenol was documented, but the one-time orders and documentation for Pepcid and Pepto Bismol could not be found. The Nursing Home Administrator stated the nurse did not transcribe the orders into the resident’s medical record. The facility policy required verbal orders to be documented with date, time, and signature, and required prompt physician notification when there was a change in condition.
Failed to Update PASARR Assessments for Four Residents
Penalty
Summary
The facility failed to complete annual PASARR assessments for four residents with mental health or cognitive diagnoses. R6 had diagnoses including vascular dementia, mood affective disorder, and adjustment disorder with disturbance of conduct, and had a BIMS score of 3/15 indicating severely impaired cognition. R28 and R32 were both readmitted with diagnoses including dementia; R28 had a BIMS score of 8/15 indicating moderately impaired cognition, and R32 had a BIMS score of 5/15 indicating severely impaired cognition. R61 was admitted with diagnoses including dementia and Alzheimer's disease and had a BIMS score of 3/15 indicating severely impaired cognition. Record review showed each resident had a PASARR (3877) assessment on file, but the assessments were not updated to reflect the residents' dementia diagnoses, and no updated PASARR or 3878 forms were found in the records for R6, R28, R32, or R61. The Social Services Coordinator stated the residents' PASARR updates were missed and not completed. The DON stated they were unaware the PASARR assessments were not up to date and expected residents to be assessed and updated as needed per policy.
Medication Administration Not Verified or Accurately Documented
Penalty
Summary
The facility failed to ensure that medication administration met professional standards of quality for one resident who was reviewed. The resident had a physician’s order dated 9/25/25 for Potassium Chloride ER 20 mEq, 3 tablets by mouth three times daily for supplement. The resident was admitted with diagnoses including Essential Hypertension, Lymphedema, Chronic Venous Insufficiency, and Peripheral Vascular Disease, and was cognitively intact. During observation on 1/7/26, an LPN prepared the resident’s medications and stated the resident usually only takes one of the three prescribed Potassium tablets, then placed only one tablet in the cup without offering the resident the full prescribed dose. The LPN handed the resident a cup containing several tablets, including a narcotic, and left the room while the resident was still taking medications. The LPN did not observe the resident consume the medications, yet documented on the MAR that the resident took the medications, including all 3 Potassium tablets, without noting that only one tablet was consumed or notifying the physician. Interviews with the UM and DON confirmed that staff are expected to observe the resident swallow the medication, document exactly what was taken when a dose is refused or partially taken, and notify the physician or NP when the full dose is not taken. The NP stated the physician and NP were aware of the resident’s medication non-compliance and that the resident often picked and chose what to take, but the MAR had been reviewed without realizing full doses were not always given even though they were documented as administered.
Expired Medications Found in Medication Carts
Penalty
Summary
The facility failed to remove expired medications from two of three medication carts reviewed. On 1/7/26, an observation of Station One, medication cart 2, found a bottle of Midodrine labeled for R17, filled on 11/1/24 with a use-by date of 11/1/25. Later that day, an observation of Station One, medication cart 1, found an over-the-counter brand of sinus severe tablets with an expiration date of 8/2024 and no identifying label for a specific resident. During interview, the Unit Manager stated the medication should have been in the medication carts because it was long past its expiration date, and the DON stated expired medications are to be removed from medication carts or medication storage areas and returned to pharmacy or discarded.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers for one resident, who was reviewed for ADLs and had paraplegia, intact cognition, and dependence on staff to complete daily activities. The resident’s MDS indicated partial/moderate assistance was needed for bathing, and the care plan identified an ADL self-care performance deficit with bathing interventions of one-person assist. The resident’s shower schedule was set for Monday and Thursday day shift, but the 30-day shower record showed missed or undocumented showers, including entries marked as response not required on some scheduled shower days and one scheduled shower day with no documented shower completion. During interview and record review, the DON stated the team reviews shower documentation in morning meetings and was not aware of the resident refusing showers, and she found no documentation of refusals in the medical record. The DON explained that if a resident refuses a shower, the aide should chart it in the task section, the nurse should reapproach the resident, and the outcome should be documented in a progress note. When the resident was observed, the call light was activated because it was a shower day and the resident reported the last shower had been a week earlier. The DON confirmed the resident was scheduled for morning showers on Monday and Thursday and was unsure why the Monday shower was not documented as given.
Failure to Hold Quarterly QAA Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) meetings were held quarterly, as required, for two out of four meetings. This deficiency potentially affected all 103 residents currently residing in the facility. During an interview and record review on October 17, 2024, it was discovered that there were no sign-in sheets for the QAA meetings in March and June 2024, indicating that these meetings did not occur. The Nursing Home Administrator confirmed the absence of these meetings. The facility's policy, as outlined in their QAPI Plan dated October 24, 2022, mandates that the QAA Committee communicate its activities to the governing body at least quarterly, with a formal meeting no less than annually. The failure to hold these meetings resulted in delayed identification and resolution of identified issues.
Facility Fails to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, resulting in the presence of gnats throughout common areas and residents' rooms. Observations included gnats on and inside trash cans without liners, flying around medication carts, and swarming above residents' beds. In one instance, a nightstand drawer was found partially open with spilled food items, which attracted a large number of gnats. Housekeepers and staff confirmed the presence of gnats in multiple rooms, attributing the issue to food kept by residents and a specific incident involving a resident's family bringing in fresh fruit. The pest control service report noted a garbage can filled with food debris, including milk and banana peels, without a bag, which contributed to the gnat problem. The facility's policy on pest control, dated January 2022, outlines measures to eradicate and contain common household pests, but the observations indicate a failure to adhere to these measures. The Director of Nursing acknowledged the issue and planned to follow up, but no corrective actions were detailed in the report.
Inadequate Colostomy Care and Documentation
Penalty
Summary
The facility failed to provide appropriate colostomy care for a resident, identified as R88, who had a new ostomy. R88 reported issues with the ostomy appliance not staying on, frequent leaks, and skin irritation. Despite these complaints, there was no documentation in R88's medical record regarding the leaking appliance, the condition of the skin at the ostomy site, or any notification to the Nurse Practitioner (NP) or Medical Doctor (MD) about these issues. The Wound Care Nurse (WCN) was unaware of the frequent leaks and did not document the condition of the ostomy site, nor was there any photographic evidence of the site upon admission. The WCN admitted that education was not provided to R88 due to communication difficulties. The NP was also unaware of the leaking appliance and the deteriorating skin condition, relying on the WCN to manage the situation. The Director of Nursing (DON) confirmed that documentation should include a description of the skin and surrounding area, and any complications should be reported to the NP/MD. An observation of R88's ostomy site revealed excoriated skin, and it was noted that the ostomy belt was missing upon admission and had to be reordered. The care plan for R88 included monitoring the skin integrity at the stoma site and providing education, which was not adequately followed.
Improper Medication Storage for a Resident
Penalty
Summary
The facility failed to properly store and secure medications for a resident, identified as R48, who was observed with Nystatin powder and Hydrocortisone cream on their bedside table. R48, who has a diagnosis of chronic obstructive pulmonary disease and mild cognitive impairment, explained that the facility staff applies the powder and cream and leaves them at the bedside. A review of R48's medical record showed an active order for Hydrocortisone ointment to be applied to specific areas for a rash, and a discontinued order for Nystatin powder for skin candidiasis. During an interview, the Director of Nursing stated that medications should not be kept at a resident's bedside.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to provide care in a dignified manner to a resident, identified as R49, during an incident involving two CNAs. R49 reported that while receiving care, CNA G confronted them about a comment they allegedly made, which R49 perceived as intimidating. During this confrontation, CNA G reportedly poured a hygiene product down the bathroom sink, an action that R49 found distressing. The incident was reported, and the CNAs involved were removed from providing care to R49. The facility's investigation confirmed the resident's report, and a review of CNA G's personal file revealed a previous performance improvement form citing inappropriate language and disposal of resident belongings. The facility's policy on promoting and maintaining resident dignity emphasizes treating residents with respect and protecting their personal possessions, which was not adhered to in this instance. CNA F, who was present during the incident, corroborated that CNA G used inappropriate language and engaged in a back-and-forth argument with R49, although they did not witness the disposal of the hygiene product.
Failure to Meet Communication Needs for Non-English Speaking Resident
Penalty
Summary
The facility failed to meet the communication needs of a resident who spoke Arabic and had a language barrier. The resident, who was admitted with diagnoses including Dysphagia and Adjustment Disorder with Anxiety, was observed unable to respond verbally and appeared confused. The staff, including a CNA and the Unit Manager, were not aware of or did not utilize a communication board, and the resident's care plan did not include interventions for communication assistance. The Social Service Director conducted assessments without a translator, relying instead on observation and gestures, and did not document the use of translation services or offer of an interpreter. The facility's policy on communicating with persons with limited English proficiency was not followed, as there was no evidence of a qualified interpreter being used or offered to the resident. Family members, who also did not speak English, were not involved in facilitating communication, and the facility did not provide documentation of translated vital documents or staff training on effective communication techniques. The lack of adherence to the policy and failure to provide appropriate communication support led to the deficiency.
Failure to Document Indwelling Catheter Care
Penalty
Summary
The facility failed to provide and document appropriate indwelling catheter care for a resident who had been admitted with a urinary tract infection and severe sepsis with septic shock. The resident, who had an intact cognition and required staff assistance with bed mobility and transfers, was observed with an indwelling catheter. However, the physician orders for catheter care were not entered until nearly two months after the resident's admission. Interviews with the Unit Manager and the Director of Nursing revealed that the catheter care orders were overlooked during the admission process and were only entered after the oversight was noticed. The facility's policy on the appropriate use of indwelling catheters requires that catheter use be in accordance with physician orders, including details such as the diagnosis, catheter size, and frequency of change. This oversight indicates a lapse in following the facility's policy and ensuring timely and appropriate catheter care for the resident.
Failure to Implement Nutritional Interventions for a Resident
Penalty
Summary
The facility failed to implement nutritional interventions for a resident, identified as R63, who required assistance with eating. Observations revealed that R63, who had visible tremors and was leaning to the side, was eating meals without the necessary 1:1 assistance. Despite the meal ticket indicating that R63 should have received help and used a two-handled cup with a lid, these interventions were not provided. R63 was observed struggling to eat independently, resulting in food falling onto the floor and their clothing, and attempting to drink from a regular cup instead of the prescribed two-handled cup. The resident, R63, had been admitted to the facility with diagnoses of a urinary tract infection and severe sepsis with septic shock. Despite having an intact cognition as indicated by a perfect score on the Brief Interview for Mental Status, R63 required staff assistance with bed mobility and transfers. The Registered Dietitian confirmed that the interventions were in place due to a decrease in intake and weight loss, and these were documented in the care plan and on the tray ticket. However, the facility's failure to adhere to these interventions was evident during multiple observations, highlighting a deficiency in providing necessary services to maintain the resident's nutrition.
Medication Administration Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during medication administration. On the morning of October 16, 2024, an LPN was observed administering medications to a resident. The physician's orders required the resident to receive Furosemide at 9:00 AM and Famotidine at 6:00 AM. However, the LPN mistakenly placed Famotidine in the medication cup and incorrectly marked it as Furosemide on the Medication Administration Record (MAR). Upon questioning by the surveyor, the LPN realized the error and removed the incorrect medication from the cup. The resident involved in the incident had been admitted to the facility with diagnoses of Urinary Tract Infection and Severe Sepsis with Septic Shock. The resident's cognitive status was intact, as indicated by a perfect score on the Brief Interview for Mental Status. The facility's policy on medication administration requires verification of the resident's name, medication name, form, dose, route, and time of administration, which was not adhered to in this instance.
Failure to Change Indwelling Catheter After UTI
Penalty
Summary
The facility failed to change an indwelling catheter for a resident who had a urinary tract infection (UTI). The resident, who was observed with an indwelling catheter hanging off their wheelchair, reported having a recent UTI and continued to experience symptoms despite completing a course of antibiotics. The resident's medical record indicated they were admitted with severe sepsis without septic shock and neuromuscular dysfunction of the bladder. The physician's orders specified that the catheter should be changed as needed for signs of infection or if the closed system was compromised. However, a review of the Medication Administration Record (MAR) for August, September, and October showed no documentation of the catheter being changed since the resident's admission. Interviews with facility staff revealed a lack of clarity and adherence to the policy regarding catheter changes in the context of infections. The Infection Control Nurse believed the catheter should have been changed when the urinalysis sample was collected, while the Unit Manager was unsure about the policy. The Director of Nursing stated that catheters were only changed if there was sediment or clogging, not routinely following a UTI. The facility's policy on the appropriate use of indwelling catheters did not address the need for changing catheters in the event of infections, contributing to the oversight in care for the resident.
Failure to Provide and Document Scheduled Showers
Penalty
Summary
The facility failed to document and provide showers according to resident preferences and schedules for three residents. Resident 902 reported receiving only two showers since admission, despite being scheduled for showers on Mondays and Thursdays. The resident expressed a preference for showers over bed baths and felt that staff were reluctant to assist due to their size. Documentation confirmed that several scheduled showers were missed in the past month. Resident 903 also reported not receiving showers as scheduled, citing conflicts between shifts over responsibility for showering. The medical record showed no documented showers in the last 30 days, and the facility did not provide requested documentation during the survey. Resident 904 mentioned irregular showering, with the last shower occurring about a week and a half prior. The resident's medical record indicated a need for two-person assistance for bathing, but the facility failed to provide documentation of showers upon request. The Director of Nursing acknowledged issues with staff not documenting showers due to access problems, instructing them to report such issues to management. The facility's policy on Activities of Daily Living requires necessary services to maintain personal hygiene, which was not adhered to in these cases.
Failure to Honor Residents' Preferences for Getting Out of Bed
Penalty
Summary
The facility failed to honor the residents' preferences for getting out of bed, impacting two residents. Resident R803 expressed a preference to be out of bed before breakfast and to be up for all meals, as well as to participate in activities like bingo. However, on multiple occasions, R803 was observed still in bed during meal times and was not assisted out of bed as per their preference. The CNA acknowledged that R803 was supposed to be up before breakfast but cited facility issues as the reason for the delay. R803's medical record indicated an intact cognition and a need for assistance with bed mobility and transfers. Resident R806 was also affected, as they were heard crying and expressed frustration over not being assisted out of bed for two days, which prevented them from attending activities. R806 mentioned being told that the facility was short-staffed. The Activities Director assured R806 that they would be assisted out of bed that day. R806's medical record also indicated an intact cognition and a need for assistance with bed mobility and transfers. The Nursing Home Administrator stated that it is the facility's policy to accommodate residents' preferences for getting up, but this was not adhered to in these cases.
Failure to Float Heels as Per Physician Orders
Penalty
Summary
The facility failed to adhere to physician orders to float the heels of two residents, R802 and R803, to prevent pressure ulcers. Observations on multiple occasions revealed that R802's heels were resting on the mattress without any pillow support, despite physician orders and care plan interventions to keep the heels floated. R802 was admitted with diagnoses of Diabetes and Dysphagia and had an intact cognition with a Brief Interview for Mental Status score of 15/15. The resident required assistance with bed mobility and transfers, and the physician order to float the heels was active since 10/23/2023. Similarly, R803's heels were observed resting on the mattress during multiple checks. R803 reported that they had requested staff to float their heels the previous night, but the staff did not comply. R803 was admitted with diagnoses of Muscle Wasting and Atrophy and Diabetes, also with an intact cognition and a Brief Interview for Mental Status score of 15/15. The resident required assistance with bed mobility and transfers, and the physician order to float the heels was active since 5/12/2023. The Unit Manager confirmed that the heels should have been floated as per the physician orders.
Failure to Respond to Call Light in a Timely Manner
Penalty
Summary
The facility failed to answer a call light and provide timely assistance to a resident (R805). On 4/23/2024, R805's call light was observed activated at 1:50 PM and remained on until 2:09 PM, despite multiple staff members passing by. R805 reported waiting for an hour and a half to be changed. CNA B eventually entered the room at 2:10 PM, turned off the call light, and stated that R805 required a two-person assist, necessitating finding another staff member. Care was finally provided at 2:20 PM. R805 had medical diagnoses of muscle weakness and major depressive disorder and required assistance with bed mobility and transfers. The facility's policy mandates that any staff member who sees or hears an activated call light is responsible for responding, and the light should remain on until the need is met. However, this policy was not followed in this instance.
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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 Sterling Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeside Manor Nursing And Rehabilitation Center | 0.8 mi | — | 12 | 0 |
| Shelby Health And Rehabilitation Center | 1.5 mi | ★★★★★ | 10 | 0 |
| Shelby Crossing Health Campus | 1.7 mi | ★★★★★ | 0 | 0 |
| Harmony Village Of Clinton | 2.8 mi | ★★★★★ | 1 | 0 |
| Regency Manor Nursing & Rehabilitation Center | 3.2 mi | ★★★★★ | 9 | 0 |
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