Below 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 Medilodge Of Sterling Heights during CMS and state inspections, most recent first.
A facility failed to ensure meals were palatable and served at the preferred temperature for six residents. Residents reported food that was cold, overcooked, tough, greasy, soggy, or otherwise unpleasant, and one resident said staff refused to reheat meals. Food committee minutes documented ongoing complaints, and surveyors observed hot items on lunch carts at low temperatures, with a tray taste-tested as lukewarm and negatively affecting palatability.
Kitchen sanitation, food storage, and pest control deficiencies: An ice machine area had a leak, damp flooring, and a black mold-like substance on the floor tiles. The walk-in cooler floor was soiled and sticky, and undated ready-to-eat foods were found. In dry storage, dented cans were mixed with active stock, food debris was on containers and boxes, and a black spotted mold-like substance was seen on overhead duct work above canned goods. The cart washing area had cracked tiles, stagnant water, and gnats.
A resident’s room was observed with a wheelchair seat covered by a folded sheet stained with apparent stool residue, a strong urine odor, and a large puddle of dried urine on the floor between the bed and wall. The soiled sheet remained in place across multiple observations, and the DON stated the wheelchair and urine puddle should have been identified and cleaned in a timelier manner.
PICC line dressings were not maintained as required for two residents receiving IV therapy. One resident’s dressing was soiled, peeling away from the skin, and dated weeks earlier, while another resident’s PICC dressing was observed without a date. The DON and an LPN described dressing-change practices, and the facility policy required transparent dressings to be changed at set intervals and immediately if compromised.
Medication Storage and Dating Deficiencies: The facility failed to ensure multiple meds and biologicals were properly labeled and dated in several med carts. Surveyors found an expired meclizine bottle, inhalers without resident identifiers or open dates, undated latanoprost, Humalog, glargine insulin pens, and undated blood glucose test strips. The DON stated carts are checked daily by nurses and unit managers once or twice a week, and the facility policy required meds to be stored per manufacturer recommendations.
Sanitary Tube Feeding Pole Not Maintained: A resident with a gastrostomy and severely impaired cognition was observed with a tube feeding pole and base caked with a dried beige substance on repeated observations. The condition remained unchanged over multiple days, and the DON acknowledged the pole should have been kept clean and that any nursing or housekeeping staff noticing the residue were expected to clean it.
A resident with limited mobility and multiple chronic conditions did not consistently receive restorative therapy services as ordered, with only partial documentation of therapy sessions and missed opportunities for care. Staff interviews confirmed both missed treatments and incomplete documentation, contrary to facility policy.
A resident experienced ongoing discomfort due to an inadequate mattress and reported the issue to multiple staff members over several months. Despite these reports, no documentation or maintenance work order was submitted, and the mattress was not replaced, even though other mattress replacements were processed for different residents during the same period.
A resident with significant mobility limitations and a care plan requiring two-person assistance for bed mobility fell from bed when a hospice aide provided care alone, contrary to the documented intervention. Facility records and staff interviews confirmed the care plan was not followed, resulting in the resident's fall.
The facility failed to serve food in a palatable manner and at preferred temperatures for several residents, leading to dissatisfaction. Residents reported the food as cold, unappetizing, and sometimes difficult to chew. A lunch tray was found to have food items served at lukewarm temperatures, and group interviews highlighted food quality as a significant concern. The facility's policy on food preparation and serving temperatures was not consistently met.
The facility's kitchen dish machine area was not maintained in a clean manner, leading to a gnat infestation. Numerous gnats were observed due to wet, murky standing water and black slimy substances on pipes. Pest control reports from August 2024 to January 2025 highlighted heavy gnat activity due to poor cleanliness, particularly around the dish tank, sinks, corners, and drains.
The facility failed to ensure call lights were within reach for five residents, leading to a deficiency in call light accessibility. Observations showed call lights on the floor and out of reach, despite staff knowing the proper placement requirements. Residents had various medical conditions and required different levels of assistance, yet the issue persisted across multiple observations and interviews.
A facility failed to promptly investigate an abuse allegation involving a resident with severe cognitive impairment. The incident, where a staff member allegedly mocked the resident, was reported by a witness but not investigated until 13 days later. The delay and inconsistency in witness statements indicate a deficiency in following the facility's abuse policy.
The facility failed to complete an annual PASARR for two residents. One resident with severe cognitive impairment had no level II PASARR request, while another resident with intact cognition had no updated PASARR available. The facility's policy requires coordination with the PASARR program, which was not followed.
A resident with PTSD and Major Depressive Disorder was admitted to the facility, but the care plan failed to address the PTSD diagnosis and known triggers. Despite the resident's intact cognition and acknowledgment of PTSD, the mood/behavior care plan lacked necessary details. Interviews with staff revealed communication lapses, as the PTSD diagnosis was not included in the care plan during the behavior meeting, contrary to facility policy.
The facility failed to provide timely ADL assistance to two residents. One resident experienced delays in receiving care, including being left on a bedpan for two hours. Another resident, who requires 1:1 feeding assistance, was observed eating without help despite having impaired cognition and shaking hands. The facility's policy mandates necessary services for residents unable to perform ADLs.
A resident with Down's syndrome, Schizophrenia, and Chronic kidney disease expressed concerns about long toenails causing discomfort. Despite having intact cognition, the resident's medical records lacked a current podiatry consultation. Facility staff acknowledged the need for nail care, but the social services team was still establishing connections with ancillary services, resulting in a deficiency in timely podiatry care.
A resident with quadriplegia and gastrostomy was observed with an unlabeled and undated tube feeding bottle. An LPN confirmed that the tube feeding is set up during the evening shift and should be labeled. The DON also stated that the tube feeding should be labeled and dated when set up. However, the facility's policy on Feeding Tubes did not address labeling and dating requirements.
The facility failed to discard expired medications from a medication cart, as observed by an LPN. Two expired medications, Glucosamine Chondroitin and Oyster Shell Calcium, were found in the cart. The DON confirmed that expired medications should be removed, but the facility did not provide a Medication Storage policy.
The facility failed to maintain resident equipment in a clean and safe condition, affecting three residents with severe cognitive impairments. Observations revealed issues with a bedside dresser and overbed table, and the Maintenance Director found no submitted orders for repair or cleaning. The facility's Preventative Maintenance Program policy was not effectively implemented, as no maintenance requests were documented for the observed issues.
A facility failed to conduct weekly skin checks for a resident, leading to gangrene in the right great toe and hospitalization. The resident, with multiple health conditions, was at risk for impaired skin integrity, but an eight-week gap in assessments allowed the condition to worsen. The issue was discovered by a family member, and the facility's DON acknowledged the lapse in care.
The facility failed to provide adequate incontinence care, repositioning, and hydration for three dependent residents. Two residents were left without water and timely incontinence care, while another was found in a soiled state for hours without intervention. Despite staff presence, necessary care was not provided, leading to deficiencies in adherence to care plans and facility policies.
The facility failed to ensure a homelike environment in resident rooms and common areas, with issues such as non-functional lights, exposed wires, and cluttered shower rooms. Observations revealed safety hazards like sharp metal objects in hallways and inadequate maintenance of resident rooms, including missing light covers and rusting sink repairs. Maintenance logs showed unresolved issues, and interviews indicated delays in providing necessary items to residents.
A resident with a history of falls and moderate cognitive impairment experienced nine falls without adequate interventions being implemented in their care plan. Despite multiple incidents, the facility failed to consistently update the care plan to prevent further falls, contrary to their fall prevention policy.
The facility failed to serve food in a palatable manner and at the preferred temperature for three residents, leading to dissatisfaction during meals. A complaint was submitted, and a surveyor's taste test revealed issues with food temperature and flavor. Interviews with the Dietary Manager and residents confirmed these issues, despite the facility's policy stating that food should be palatable and served at an appetizing temperature.
The facility failed to maintain adequate lighting in the East Dining Room, as observed by surveyors and reported by a resident. Five lights were not functioning, and attempts to operate them were unsuccessful. The NHA was unaware of the issue until informed by the Activities Director, despite the facility's policy requiring maintenance requests to be documented in an electronic system.
The facility failed to maintain sanitary conditions of a steam table in the East Dining Room, where loose crusted material and mold were observed. The Nursing Home Administrator acknowledged the expectation for cleanliness, and the facility's cleaning policy highlights the importance of removing debris and bacteria.
The facility failed to maintain a clean and comfortable environment for two residents, leading to feelings of anger and frustration. A complaint revealed bugs and a black substance leaking from the air conditioner in their rooms. Despite reporting the issue, it persisted for months without resolution. Housekeeping confirmed the presence of bugs and the unsuccessful removal of the black substance, which was reported to maintenance. The Maintenance Director was unaware of the issues, and pest control had not been conducted. Facility policies on maintaining a safe environment were not followed.
The facility failed to notify the guardian of a resident's transfer to the hospital. The resident, with severe cognitive impairment and multiple diagnoses, required immediate medical intervention and was transferred via EMS. Despite the facility's policy and expectations, the responsible party was not informed of the change in the resident's condition.
Food Served at Improper Temperature and Poor Palatability
Penalty
Summary
The facility failed to ensure that food was served in a palatable manner and at the preferred temperature for six residents reviewed for food palatability. During interviews, residents reported repeated concerns that meals were cold, overcooked, tough, greasy, soggy, or otherwise unappetizing. One resident stated the food was always cold, overcooked, and tough and said staff refused to reheat it when asked. Another resident reported the food was horrible and that cold water was not being passed on weekends. Additional residents described the food as nasty, terrible, or always cold, and one resident with schizoaffective disorder, bipolar type, and dementia grimaced and stuck out their tongue when interviewed about the food. Record review showed the affected residents had diagnoses including fractures and multiple trauma, pulmonary embolism, end stage renal disease, type 2 diabetes, and dementia, and several had intact cognition while requiring assistance with activities of daily living. Facility food committee meeting minutes from January 2026 through April 2026 documented ongoing resident complaints about chicken salad palatability, dry meat and fish, greasy grilled cheese sandwiches, soggy vegetables, and hard potatoes. Surveyor observations and temperature checks found hot food items on a lunch cart at low temperatures, including spaghetti with meat sauce at 106.9 degrees Fahrenheit and parmesan roasted cauliflower at 98.0 degrees Fahrenheit, as well as country fried steak at 117 degrees Fahrenheit, diced potatoes at 106 degrees Fahrenheit, and cooked carrots at 103 degrees Fahrenheit. The surveyor also taste tested a lunch tray and found the food lukewarm, which negatively impacted palatability.
Kitchen sanitation, food storage, and pest control deficiencies
Penalty
Summary
Food service safety standards were not followed in multiple areas of the kitchen and food storage spaces. During observation, the ice machine in the room next to the conference room had a leak behind it, the floor was damp, and there was a black mold-like substance on the floor tiles. In the walk-in cooler, the floor was soiled and sticky, and there were undated pans of cut pineapple chunks, mixed vegetables, and chopped salad. When asked, the Manager-in-Training confirmed the items should have been dated and stated they would be discarded. In the dry storage room, active stock included a dented can of shredded sauerkraut and two dented cans of pumpkin, and the Manager-in-Training confirmed they should have been removed. Food debris was observed on top of several food containers and boxes, and a black spotted mold-like substance was seen on the overhead duct work directly above the rack of canned food goods. At the cart washing area, cracked and broken floor tiles were observed with standing stagnant water pooled under loose tiles and in missing tile wells, and several gnats were flying in the area. The Dietary Manager stated the broken tiles had been reported to Maintenance but gave no explanation for the standing water.
Soiled wheelchair and urine odor left in resident room
Penalty
Summary
The facility failed to maintain a clean, comfortable, homelike environment for one resident. On 04/12/2026, the resident was observed in their room sitting in a wheelchair and later transferred to bed. During observation, the resident’s wheelchair had a folded bed sheet on the seat cushion with a large stain that appeared to be liquid brown stool residue. The resident’s record showed admission on 11/04/24 with diagnoses including adjustment disorder with depressed mood and other specified disorder of the brain, and the MDS indicated intact cognition and a need for encouragement and assistance with self-care activities. On 04/13/2026, the soiled sheet remained on the wheelchair seat cushion, a strong urine odor was present in the room, and the resident did not respond to verbal attempts to interview. Later observations showed the sheet still in place with part of the stool residue visible, the urine odor continuing, and a large puddle of dried urine on the far side of the bed between the bed and the wall. When the DON observed the room, the soiled wheelchair and urine puddle had still not been removed or cleaned in a timely manner, and the DON stated that these conditions should have been identified and addressed sooner.
PICC Line Dressings Not Changed or Dated Timely
Penalty
Summary
The facility failed to ensure timely dressing changes and dating for PICC line IV sites for two residents receiving IV therapy. On 04/12/2026, R169 was observed seated on the bed with a right upper arm PICC line used for daily IV antibiotics. The transparent dressing over the insertion site was soiled black around the edges, peeling away from the skin at the lower inside edge, and the resident was able to lift the dressing with their fingers. The dressing was dated 03/23/26. The record review noted the resident had been admitted to the facility and reported the PICC line had been inserted and dated at the hospital. On 04/14/2026, R171 was observed in the hallway with a PICC line in the left upper arm. The smaller transparent dressing over the insertion site was not dated. An LPN stated dressings are dated when changed. The facility policy titled, Dressing Change for Vascular Access Devices, dated August 2021, stated central venous access device and midline dressings are changed at established intervals and immediately if the dressing is compromised, with transparent semi-permeable membrane dressings changed every seven days and PRN, and immediately if non-occlusive or soiled.
Medication Storage and Dating Deficiencies
Penalty
Summary
The facility failed to ensure biologicals were dated when opened and expired medications were discarded in five of six medication carts. During observations with nursing staff, an over-the-counter meclizine bottle in the 400 hall front medication cart had a date opened of 08/10/25 and an expiration date of 01/2026. In the 100 hall medication cart, an Anoro inhaler for one resident did not have a resident identifier on it. In the 500 hall medication cart, an Advair 250/50 inhaler for one resident was not labeled with the name and date opened, and a Trelegy inhaler was not dated when opened. In the 600 hall medication cart, a latanoprost eye drop vial for one resident was not dated when opened, two Humalog insulins for another resident were not dated when opened, and the blood glucose test strips were not dated when opened. In the 400 hall back cart, two opened glargine insulin pens for one resident, and additional glargine insulin pens for two other residents, were not dated when opened, and the blood glucose test strips were not dated when opened. The DON stated on interview that medication carts are checked daily by nurses and unit managers once or twice a week, and the facility policy required medications to be stored according to manufacturer recommendations.
Sanitary Tube Feeding Pole Not Maintained
Penalty
Summary
The facility failed to maintain a sanitary tube feeding pole for one resident, R191, who was reviewed for environmental concerns. On 04/12/2026, R191 was observed in bed and was not responsive to verbal greetings. The resident had a gastrostomy status requiring nutrition via tube feeding, and the MDS indicated the resident required total assistance with self-care and had severely impaired cognition. At that time, the resident's tube feeding pole and the base of the pole were caked with a dried beige substance. On 04/14/2026, R191 was again observed in bed and was alert enough to acknowledge the surveyor with head and eye movements but was unable to answer interview questions. The tube feeding pole remained in the same condition with the dried beige substance still present. Later that day, the DON observed the build-up on the base of the tube feeding pole and stated the pole was expected to be kept clean and not left in that condition, and that any staff noticing the residue would be expected to clean it whether they were nursing or housekeeping staff. The facility policy stated housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly, and comfortable environment, and that sanitary included keeping resident care equipment clean and properly stored.
Failure to Provide and Document Ordered Restorative Therapy Services
Penalty
Summary
A deficiency occurred when the facility failed to provide restorative therapy services as ordered for a resident with diagnoses including spinal stenosis, multiple sclerosis, and fibromyalgia. The resident, who was alert and oriented and required extensive assistance with bed mobility and transfers, was observed lying in bed and confirmed not receiving consistent restorative therapy during the week. Physician orders specified skilled restorative nursing three times a week for 12 weeks, focusing on active range of motion (ROM) exercises for both upper and lower extremities. However, a review of the clinical record over a 14-day period showed that restorative therapy was only documented as provided on three out of six possible occasions. Further investigation revealed discrepancies in documentation, as a CNA reported providing restorative therapy on additional dates that were not recorded in the medical record. The Assistant Director of Nursing acknowledged the lack of accurate documentation and stated that the restorative program was under review. Facility policy requires that implementation of restorative nursing programs be documented in the delivery record or electronic medical record, but this was not consistently done for the resident in question.
Failure to Timely Replace Uncomfortable Mattress After Resident Complaints
Penalty
Summary
A deficiency was identified when a resident reported having an uncomfortable mattress that felt as though it had a hole and caused them to feel the bed frame. The resident stated this issue had persisted since their admission approximately six months prior and that they had informed various staff members about the problem during this time. Despite these reports, the mattress was not replaced, and the resident continued to experience discomfort. Observations confirmed the mattress had a visible wrinkle and a compressed, softer center, supporting the resident's complaint. Interviews with staff, including a CNA and an LPN, confirmed that the resident had repeatedly voiced concerns about the mattress over several months. However, there was no documentation in the resident's progress notes regarding these complaints, and a review of the facility's maintenance reporting system (TELS) showed no work order had been submitted for a mattress replacement for this resident. Administrative staff confirmed that all staff are trained to enter work orders into TELS, and other mattress replacements had been processed for different residents during the same period. Maintenance staff also indicated that no work order had been received for this issue.
Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with diagnoses of Primary Generalized Osteoarthritis, Spinal Stenosis, and Muscle Weakness, who was receiving hospice services, experienced a fall from their bed during care. The resident reported that the hospice aide was providing care alone and, while turning the resident in bed, the resident rolled off onto the floor. The resident's care plan specifically required two staff members to assist with bed mobility due to their fall risk, an intervention that was documented and in place prior to the incident. Facility records, including the incident/accident report and progress notes, confirmed that the hospice aide provided care without the required second staff member. The Director of Nursing acknowledged awareness of the incident and stated that the expectation was for care to be provided with two-person assistance, as outlined in the resident's care plan. The facility's policy also required care plans to be developed and implemented based on fall risk assessments.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to ensure that food was served in a palatable manner and at the preferred temperature for several residents. Multiple residents, including those with intact cognition and various medical conditions such as COPD, osteomyelitis, and heart failure, reported dissatisfaction with the food quality. They described the food as cold, unappetizing, and sometimes difficult to chew. Specific instances included a resident noting that the food was better when surveyors were present, and another resident expressing that the food was cold and sometimes burnt. During the survey, a lunch tray was temperature checked, revealing that the food items were served at temperatures below what might be considered hot, with the chicken at 119.8°F, Brussels sprouts at 121.3°F, and rice pilaf at 122.1°F. The survey team also taste-tested the food and found it to be lukewarm and lacking flavor. The facility's dietary manager and corporate manager indicated that food temperatures were based on resident preferences, but no specific temperature guidelines were provided. A group interview with seven residents highlighted that food quality was a significant concern, with reports of the food being mostly warm rather than hot. The facility's food committee notes indicated mixed feedback, with 60% of residents finding the food tasty, but 35% reporting that it was not hot enough. The facility's policy stated that food should be prepared to conserve nutritive value, flavor, and appearance, and served at a safe and appetizing temperature, but the observations and resident feedback suggest these standards were not consistently met.
Gnat Infestation Due to Poor Kitchen Cleanliness
Penalty
Summary
The facility failed to maintain the dish machine area in the kitchen in a clean manner, resulting in the presence of gnats. On March 10, 2025, numerous gnats were observed underneath the dish machine tank and drainboard, where the flooring was wet with murky standing water, and the pipes were coated with a black slimy substance. The Dietary Manager was unable to provide an explanation for the presence of gnats. Pest control service reports from August 2024 to January 2025 consistently noted heavy gnat activity due to poor cleanliness in the kitchen, particularly around and underneath the dish tank, sinks, corners, and drains. According to the 2017 FDA Food Code section 6-501.111, premises should be maintained free of insects, rodents, and other pests by eliminating harborage conditions.
Deficiency in Call Light Accessibility
Penalty
Summary
The facility failed to ensure that call lights were within reach for five residents, leading to a deficiency in call light accessibility. Observations revealed that residents' call lights were often found on the floor and out of reach, despite staff being aware of the proper placement requirements. For instance, Resident 612's call light was observed on the floor, and staff confirmed it should be within hand reach. Similarly, Resident 613's call light was repeatedly found on the floor, even after staff entered and exited the room. Interviews with staff, including a unit manager and the administrator, confirmed that call lights should be accessible to residents. The residents involved had various medical conditions, such as end-stage renal disease, type 2 diabetes, osteomyelitis, cerebral infarction, sepsis, respiratory failure, hemiplegia, muscle weakness, and dysphagia. Some residents had intact cognition, while others had impaired cognition, requiring different levels of assistance with activities of daily living. Despite these needs, the facility's failure to ensure call light accessibility was consistent across multiple observations and interviews, indicating a systemic issue in maintaining proper call light placement.
Delayed Investigation of Abuse Allegation
Penalty
Summary
The facility failed to timely complete an investigation for an allegation of abuse involving a resident with severe cognitive impairment. The incident in question occurred when a staff member allegedly mocked the resident, leading to the resident becoming visibly upset and crying. The Maintenance Director witnessed the incident and reported it to the Nursing Home Administrator. However, the investigation was not initiated until 13 days after the incident, and witness statements were not obtained until the same day the investigation began. The facility's policy requires immediate investigation of any allegations of abuse, neglect, or exploitation, but this protocol was not followed. The delay in obtaining witness statements and the inconsistency in the Maintenance Director's account of the incident highlight deficiencies in the facility's response to the allegation. The Nursing Home Administrator considered the incident a customer service concern, which may have contributed to the delay in addressing the issue according to the facility's abuse policy.
Failure to Complete Annual PASARR for Two Residents
Penalty
Summary
The facility failed to complete an annual PASARR (Preadmission Screen and Resident Review) for two residents, R70 and R139, out of six residents reviewed for PASARR screening. R70 was admitted with diagnoses including dysphagia, intellectual disabilities, and functional quadriplegia, and had a severe cognitive impairment as indicated by a BIMS score of 00. The medical record for R70 showed a PASARR dated 11/27/24, but there was no request for a level II PASARR, which is required for residents with mental illness or intellectual disabilities. R139, who was observed in bed watching television and expressed a desire to meet with a social worker regarding a change in guardianship, was admitted with diagnoses including adjustment disorder with anxiety and depressed mood, bipolar disorder, and chronic respiratory failure with hypoxia. R139 had an intact cognition as indicated by a BIMS score of 15. The medical record for R139 showed a PASARR dated 7/08/24 with a hospital exemption for 30 days, but no updated PASARR was completed or available at the time of the survey. The facility's policy requires coordination with the PASARR program to avoid duplicative testing and mandates preadmission screening for all individuals with mental illness or intellectual disabilities, which was not adhered to in these cases.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing Post-Traumatic Stress Disorder (PTSD) for a resident, identified as R62, who was admitted with diagnoses of Major Depressive Disorder and PTSD. The resident's medical record and the most recent Minimum Data Assessment (MDS) indicated an intact cognition with a score of 15/15. Despite the resident's acknowledgment of having PTSD and experiencing triggers, the mood/behavior care plan did not include the PTSD diagnosis or known triggers. Interviews with facility staff revealed lapses in communication and documentation. The Social Worker (SW) stated that the PTSD diagnosis and known triggers should have been included in the mood care plan upon the resident's admission. The Director of Nursing (DON) acknowledged that the PTSD diagnosis was not communicated during the behavior meeting, which resulted in the care plan not being developed as required. The facility's policy on Comprehensive Care Plans mandates that the care planning process should assess the resident's strengths and needs, incorporating personal and cultural preferences, and should be trauma-informed, which was not adhered to in this case.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to provide timely assistance for two residents in need of help with Activities of Daily Living (ADLs). Resident R24 reported that over a weekend, they requested ADL care at 6:15 AM, but did not receive assistance until 9:45 AM. On another occasion, they activated the call light at 7:00 PM and did not receive care until 9:30 PM. R24's medical records indicate they require assistance due to muscle weakness and limited mobility. The facility's concern forms documented multiple instances of delayed care, including an incident where R24 was left on a bedpan for two hours during the midnight shift. The Director of Nursing acknowledged issues with the midnight shift and stated that residents should be checked on hourly. Resident R154 was observed struggling to eat due to shaking hands and reported not receiving assistance with meals, despite having a physician's order for 1:1 feeding assistance. R154's medical records show they have impaired cognition and require assistance with eating. A nutrition note indicated that R154 benefits from supervision or assistance with meals. The Assistant Director of Nursing stated that R154 should receive help with meal setup and cueing, but observations showed R154 eating without assistance. The facility's policy on ADLs states that residents unable to perform these activities should receive necessary services to maintain good nutrition and hygiene.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to provide timely podiatry care for a resident, identified as R201, who expressed concerns about their toenails being too long and causing discomfort. During an observation, R201's toenails were noted to extend past the tips of their toes. The resident, who has a diagnosis of Down's syndrome, Schizophrenia, and Chronic kidney disease, could not recall their last podiatry visit. A review of R201's medical records did not show a current podiatry consultation, despite the resident having intact cognition as indicated by a BIMS score of 14. Interviews with facility staff revealed that R201 was on a list to be seen by podiatry, but the social services team was new and still working to establish connections with ancillary services. The Director of Nursing confirmed the need for R201's toenails to be cut. The facility's policy on nail care, revised in August 2024, requires assessments of residents' nails upon admission and readmission, and mandates reporting unusual nail conditions to a physician. However, this policy was not effectively implemented for R201, leading to the deficiency.
Failure to Label and Date Tube Feeding Bottle
Penalty
Summary
The facility failed to label and date a tube feeding bottle for a resident, identified as R75, who was observed on 3/11/2025 with an unlabeled and undated tube feeding bottle while laying in bed. Licensed Practical Nurse (LPN) A confirmed that the tube feeding is set up during the evening shift and acknowledged that it should be labeled. R75 was admitted with diagnoses of Quadriplegia and Gastrostomy and required staff assistance with bed mobility and transfers. The resident's recent Minimum Data Set assessment indicated a Brief Interview for Mental Status score of 99, showing they were unable to complete the assessment. The Director of Nursing (DON) also confirmed that the tube feeding should be labeled and dated when set up. However, a review of the facility's policy on Feeding Tubes revealed it did not address the requirement for labeling and dating.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure that medications were discarded when expired, as observed during a survey of one of the medication carts. On March 12, 2025, at 2:07 PM, an LPN identified two expired stock medications in the top drawer of Unit 100's lower numbered medication cart. The medications included Glucosamine Chondroitin, which had an open date of October 1, 2024, and a stamped expiration date of January 2025, and Oyster Shell Calcium 500mg, with an open date of September 25, 2024, and a stamped expiration date of August 2024. Later that day, at 4:15 PM, the DON confirmed that expired medications should be removed from use. Despite a request, the facility did not provide a policy for Medication Storage by the end of the survey.
Deficiency in Maintenance of Resident Equipment
Penalty
Summary
The facility failed to maintain resident equipment in a clean and safe condition, affecting three residents with severe cognitive impairments. Observations revealed that a bedside dresser for one resident had a two-inch gap between drawers, while another resident's overbed table was stained with dark circular marks. Additionally, a third resident's bedside dresser was stained, rough, and had uneven edges. These conditions were noted during observations conducted on March 10, 2025. The Maintenance Director reviewed the maintenance system and found no submitted orders for the repair or cleaning of the affected equipment. The facility's Preventative Maintenance Program policy, last reviewed in February 2022, requires the Maintenance Director to maintain a schedule of maintenance services to ensure equipment is safe and operable. However, the policy's implementation was lacking, as no maintenance requests were documented for the issues observed, indicating a failure in the facility's maintenance reporting and response system.
Failure to Conduct Weekly Skin Checks Leads to Gangrene
Penalty
Summary
The facility failed to complete weekly skin checks for a resident, resulting in the development of gangrene in the right great toe, right foot pain, and subsequent hospitalization. The resident, who had diagnoses including osteoarthritis, gout, adult failure to thrive, and end-stage renal disease requiring dialysis, was at risk for impaired skin integrity. The care plan for the resident included weekly skin inspections, but there was an eight-week gap between assessments, during which the condition of the resident's right foot deteriorated. The deficiency was identified when a family member visited the resident and discovered the gangrenous condition of the toe. The facility's Director of Nursing acknowledged the lapse in assessments and recognized the deficient practice. The resident was hospitalized for gangrene and sepsis, likely due to the gangrene, and continued to experience right foot pain even after returning to the facility.
Deficiencies in Resident Care: Incontinence, Repositioning, and Hydration
Penalty
Summary
The facility failed to provide adequate incontinence care, repositioning, and hydration for three dependent residents, leading to deficiencies in their care. Resident R703 and R707 were observed without water cups and reported not receiving timely incontinence care. R703 expressed concerns about not being turned as required, and both residents were left without water between meals, despite the availability of a water cart nearby. Staff were present in the hallway but did not address these needs, leaving the residents without necessary care for extended periods. Resident R706 was found in a soiled state, with a visible brown ring on the bed and gown, indicating a lack of timely incontinence care. Despite the presence of staff, R706 remained in the same position for several hours, with no intervention to change or reposition them. The resident's care plan indicated a need for assistance with toileting due to neuromuscular dysfunction, yet staff failed to provide the necessary care, leaving R706 in an unhygienic condition. The Director of Nursing acknowledged the need for repositioning, incontinence care, and hydration for dependent residents, confirming that no residents in the facility were fully independent. The facility's policies on Activities of Daily Living and Hydration were not adhered to, resulting in the observed deficiencies. The lack of staff intervention and adherence to care plans contributed to the inadequate care provided to these residents.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment in resident rooms, common areas, and shower rooms on two nursing units. Observations revealed numerous deficiencies, including non-functional bathroom lights, unattached sink piping, and a burnt outlet. Sharp metal objects were found protruding from the hallway floor, posing a safety hazard. Resident rooms were observed with multiple white spackle patches on the walls, missing towel dispensers, and broken or missing light fixtures. Additionally, some rooms had exposed wires, rusting sink repairs, and missing light covers. Common areas and shower rooms were also found to be in disrepair and cluttered. The main hallway had a loose metal disc with bent edges, and baseboards were peeling away from the walls. Shower rooms contained various stored items, such as laundry bin frames and used foam wedges, and were not maintained in a clean state. Toilets in these areas had brown water stains, dead flies, and missing cabinet parts. The maintenance logs indicated unresolved issues, such as non-working lights and heating problems, which were reported but not promptly addressed. Interviews with residents and staff highlighted further issues, such as the delayed provision of necessary items like toilet seats and televisions upon admission. The facility's policies on maintaining a safe and homelike environment were not effectively implemented, as evidenced by the numerous maintenance and cleanliness issues observed. The administrator acknowledged that room readiness checks should be conducted by admissions, maintenance, and housekeeping staff before resident placement, but these checks were evidently insufficient or not performed.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to develop and implement effective actions to prevent repeated falls for a resident, resulting in nine falls without appropriate goals and interventions to prevent further incidents. The resident, who was admitted after sustaining a fractured left wrist and left femur, had a history of dementia, heart disease, difficulty walking, cognitive communication deficit, and muscle weakness, with a BIMS score indicating moderate cognitive impairment. Despite experiencing multiple falls on various dates, the care plan was not adequately updated to address the resident's needs. A fall pad was only added to the care plan after a fall on 6/12/2024, and the care plan was revised again on 7/16/2024, 15 days after another fall, without interventions being put in place after the other falls. The facility's policy on fall prevention required reviewing and updating the care plan after any fall, which was not consistently followed.
Failure to Serve Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to serve food in a palatable manner and at the preferred temperature for three residents, resulting in dissatisfaction during meals. A complaint was submitted to the state agency, stating that the food was terrible, and residents had to spend their own money on food, which they could not afford. During a surveyor's taste test of a random lunch meal, it was found that the cheeseburger and fries were only warm, the slaw lacked flavor, and the pickle spear was soggy, negatively impacting the meal's palatability. Interviews with the Dietary Manager and residents confirmed the issues with food temperature and palatability. The Dietary Manager acknowledged that hot food should be hot and cold food should be cold but could not explain why the last tray served was not warmer. Residents expressed dissatisfaction with the food, describing it as terrible. The facility's policy on food palatability, revised in 2017, stated that food should be palatable and served at an appetizing temperature, which was not adhered to in this instance.
Inadequate Lighting in Dining Room
Penalty
Summary
The facility failed to maintain adequate lighting in the East Dining Room, one of two dining rooms reviewed for a homelike environment. During an interview, a resident mentioned that the lights in the East Dining Room had been out for some time, and staff were aware but frustrated with the maintenance issues. An observation confirmed that five lights were not illuminated, and attempts to operate the switches with the Activities Director were unsuccessful. The Nursing Home Administrator was unaware of the issue until notified by the Activities Director and indicated that maintenance requests should be submitted through the electronic maintenance request system. The facility's Preventative Maintenance Program policy requires documentation of all tasks in the electronic maintenance request system to ensure a safe and comfortable environment.
Unsanitary Steam Table Conditions
Penalty
Summary
The facility failed to maintain a sanitary condition of the steam tables in the East Dining Room, specifically the third steam table with a small hood. During an observation, loose crusted material and mold were noted on this steam table. When the material was touched, it fell onto the area where food would be placed during use. This observation was made in the presence of the Nursing Home Administrator, who acknowledged that the steam table hoods should be clean and free of mold and materials that could contaminate food. The facility's cleaning policy, provided by a cleaning company, emphasizes the importance of cleaning and sanitizing to maintain a safe operation for residents, stating that cleaning removes visible debris and sanitizing removes most harmful bacteria.
Failure to Maintain a Clean and Comfortable Environment
Penalty
Summary
The facility failed to provide a clean and comfortable environment for two residents, resulting in feelings of anger and frustration. A complaint was submitted to the state agency regarding bugs and a black substance leaking from the air conditioner in the residents' rooms. During an interview, one resident expressed their upset and anger over the situation, which had been ongoing for two to three months without resolution. The surveyor observed a dried blackish substance on the rug under the air conditioner and a small black bug on the resident's bedding. Housekeeping aides confirmed the presence of bugs and the unsuccessful attempt to remove the black substance from the carpet, which was reported to maintenance. The Maintenance Director was unaware of the environmental issues and indicated that bug spray had been used, but a pest control contractor had not inspected or treated the room. The account manager for environmental services, who was filling in for the facility manager, stated that if a stain could not be removed, they would consult with the Administrator and Maintenance Director about further actions. The Nursing Home Administrator indicated that rooms should be deep cleaned on a schedule and that pest control was expected soon. The facility's policies on maintaining a safe and homelike environment and pest control were reviewed, highlighting the failure to adhere to these guidelines.
Failure to Notify Guardian of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the guardian of a resident's transfer to the hospital. The resident, who was admitted with diagnoses of Vascular Dementia, Acute Kidney Failure, and Hypertension, had a severe cognitive impairment as indicated by a BIMS score of 0. On the date of the incident, the resident was found to be tachypneic and required immediate oxygen administration. Despite the medical intervention and the decision to transfer the resident to the hospital via EMS, the responsible party was not notified of the change in the resident's condition as required by the facility's policy. Interviews with the Assistant Director of Nursing (ADON) and the Nursing Home Administrator (NHA) confirmed that it was the facility's expectation to notify the responsible party or family members as soon as possible about any change in condition. A review of the facility's policy on Notification of Changes, revised on 1/01/22, also supported this requirement. However, the failure to inform the guardian of the resident's transfer to the hospital resulted in a deficiency in adhering to the policy and ensuring the guardian was aware of the resident's condition.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 976 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Optalis Health And Rehabilitation Of Sterling Heig | 1.6 mi | ★★★★★ | 2 | 0 |
| Fraser Villa | 1.7 mi | ★★★★★ | 7 | 0 |
| Harmony Village Of Clinton | 2.7 mi | ★★★★★ | 1 | 0 |
| Windemere Park Health And Rehabilitation Center | 2.9 mi | ★★★★★ | 2 | 0 |
| Autumn Woods Residential Health | 3.1 mi | ★★★★★ | 28 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.