Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Optalis Health And Rehabilitation Of Sterling Heig during CMS and state inspections, most recent first.
A resident with impaired cognition, cervical fracture, and muscle wasting was care planned and coded on the MDS as dependent for bed mobility and requiring a two-person assist. Despite this, a CNA provided perineal care alone and repositioned the resident, during which the resident moved and rolled out of bed. The resident subsequently complained of right leg pain and was later found to have a right femur fracture requiring surgery. The DOR confirmed the ongoing need for two-person assistance for safety, and the DON stated the expectation that two staff be present when a resident is care planned as a two-person assist, which did not occur in this incident.
A resident with Alzheimer's disease, severe cognitive impairment, restlessness, agitation, and aggression toward staff was admitted on a scheduled antipsychotic (Olanzapine) with physician orders for a psych consult related to aggressive behaviors. However, consent for psychiatric services was not obtained until about three months after admission, and no psych visit notes were available in the record or provided to surveyors. Social work staff reported that the standard process is to obtain psych consent at admission for residents on regular antipsychotics and to send a referral, but they could not explain why this was not done. This was inconsistent with the facility’s Behavioral Health and Management policy requiring necessary behavioral health care and services in accordance with the resident’s plan of care.
Surveyors identified several deficiencies in food service safety, including mold-like buildup and leaking equipment in the kitchen, undated and expired food items in storage, dishwashing equipment failing to reach required sanitization temperatures, expired ice machine filters, and a staff member failing to perform hand hygiene before handling food. These issues were confirmed by facility staff and were not in accordance with professional standards.
The facility did not keep the exterior dumpster area clean, as the ground was observed to be soiled with grease, sludge, and a milky liquid, along with a foul odor. Staff interviews confirmed that maintenance was responsible for cleaning the area, which had not been cleaned recently.
Surveyors identified that the facility did not maintain an active water management program, with required team members uninvolved and key monitoring activities, such as disinfectant checks and fixture flushing, not completed or documented. Additionally, staff failed to use required PPE, specifically gowns, during high-contact care for a resident on Enhanced Barrier Precautions, and did not perform hand hygiene during medication administration. The facility also lacked documentation of monthly infection control surveillance as required by policy.
Several residents with intact cognition reported that food was frequently cold and unpalatable, a concern also reflected in resident council meeting minutes. Food temperature testing confirmed that meals were served below the preferred temperature, and the use of foam containers due to a broken dishwasher contributed to the issue. The dietary manager and survey team acknowledged that the food was cold and not appetizing, failing to meet facility standards.
A resident with severe cognitive and physical impairments was initially placed on Contact Isolation for C. difficile and later required Enhanced Barrier Precautions (EBP) due to tube feeding. The care plan was not updated to reflect the change from Contact Isolation to EBP, despite physician orders and ongoing EBP signage, resulting in the care plan containing outdated information.
Three dependent residents with severe cognitive and physical impairments were not provided timely assistance with ADLs, including repositioning and brief changes, and did not have consistent access to their call lights. Observations showed residents left in bed for extended periods, call lights placed out of reach, and care needs unmet despite facility policy and staff awareness of required standards.
Two residents with severe cognitive impairment and high dependency were not provided with meaningful activities, despite documented preferences and care plans indicating the importance of such engagement. Both were observed in bed without any form of stimulation, and activity records showed no evidence of independent, intellectual, physical, social, or spiritual activities being offered or documented. Facility staff confirmed the lack of activity provision and documentation, contrary to facility policy.
A resident with a history of paraplegia and hypertension experienced ongoing post-menopausal vaginal bleeding, which was repeatedly documented by staff and reported by the resident. Despite recommendations for GYN follow-up, delays in arranging specialist care occurred due to transportation issues, scheduling difficulties, and unclear staff responsibilities. The resident's symptoms persisted and worsened over several months before a diagnosis of endometrial carcinoma was made following a delayed surgical procedure.
A resident requiring one to two-person assist for transfers and bed mobility fell from bed during incontinence care when a CNA, working alone, rolled the resident away from herself, resulting in injury and prolonged time on the floor. The facility's policy did not address fall prevention interventions.
A resident with severe cognitive impairment and total dependence on staff was observed receiving tube feeding at a rate lower than the physician-ordered amount, with no documentation to support the change. The tube feeding formula bag in use was also not changed within the required 24-hour period, contrary to facility policy. Nursing staff and the DON confirmed the expectation to follow physician orders and change bags as directed.
A resident with a history of cerebral infarction, hypertension, and muscle weakness was found with a medication cup containing two pills left on their overbed table, with no awareness of how long the medications had been there. An LPN had provided the medications but did not ensure they were taken, and there was no assessment for self-administration in the medical record. The DON confirmed that medications should not be left at the bedside, and the facility's policy did not address this issue.
Two CNAs did not have documentation of completing the required 12 hours of annual in-service training, including dementia care and abuse prevention. The facility's records were incomplete, and the staffing policy did not address the annual training requirement.
A resident with impaired cognition and severe malnutrition was admitted without pressure ulcers and placed on preventative measures. Later, an open area was discovered on the coccyx and groin, but the wound was not timely assessed, staged, or measured by the wound care team or licensed nurse, as required by facility policy. The wound care nurse awaited the weekly visit from the wound care nurse practitioner, who did not assess the wound before the resident's hospital transfer.
A resident who required extensive assistance for incontinence care experienced a delay of approximately one hour in being changed after having a soiled brief. The resident, who was cognitively intact, documented the incident and reported similar past issues. A grievance was filed by the resident's representative, and the CNA involved received a written warning for failing to complete the assigned task. The facility's policy required timely assistance based on resident needs, which was not followed.
A resident at high risk for pressure ulcers developed a Stage III ulcer due to the facility's failure to implement timely and effective preventative measures. Despite being identified as very high risk, the facility did not consistently follow prescribed skin care treatments, and necessary pressure-reducing support surfaces were not provided until after the ulcer worsened. Interviews with staff highlighted a lack of adequate preventative measures and support surfaces, and the facility's guidelines did not address necessary interventions.
The facility failed to provide and document adequate assistance with ADLs for two dependent residents. One resident with dementia and other health issues received minimal bathing assistance, while another with multiple sclerosis reported not knowing their shower schedule and expressed hygiene concerns. Both residents require significant assistance, and the facility acknowledged the need for improvement in documentation.
The facility failed to ensure safe food storage and maintain sanitary conditions in the kitchen. Observations included improperly cooled pork roasts, raw meat stored next to cooked meat, a soiled microwave, and expired food items in nourishment room refrigerators. The Certified Dietary Manager confirmed these issues.
A resident with Parkinson's Disease and Dementia had a peripheral intravenous line (PIV) that was not labeled, dated, or removed after completing IV therapy. The resident expressed discomfort and requested its removal. The facility's policy required the PIV to be removed if not used for 24 hours and the dressing to be labeled, which was not followed.
The facility failed to identify and document targeted behaviors, non-pharmacological interventions, and monitor side effects of a prescribed psychotropic medication for a resident. The resident was excessively sedated, often lethargic, and not consuming meals, with inadequate documentation and attempts of non-pharmacological interventions prior to medication increases.
The facility failed to store medication securely and monitor refrigerator temperatures properly. Unlocked medication carts were observed on multiple occasions, and temperature logs for a medication refrigerator were found to be incomplete for several dates. The facility's policies on medication storage and temperature monitoring were not adhered to.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to follow the resident’s care plan requiring two-person assistance for bed mobility, which resulted in a fall and subsequent right femur fracture. The resident was admitted with cervical fracture and muscle wasting/atrophy and had a BIMS score of 3/15, indicating impaired cognition. The most recent MDS documented the resident as dependent for bed mobility, and the ADL care plan dated 11/14/2025 specified a two-person assist for bed mobility. The Director of Rehabilitation confirmed that this resident required two staff during care for safety and remained a two-person assist for bed mobility. On 12/31/2025, during perineal care, a CNA provided care alone and repositioned the resident toward themselves. During this care, the resident, described by the LPN as very antsy, moved and rolled out of bed. An incident report documented that the resident complained of right leg pain, could not move the right lower leg, and was assisted back to bed by two staff, with vital signs taken and a STAT X-ray ordered. A subsequent physician readmission note dated 1/15/2026 documented that the resident was sent back to the hospital for possible trauma and was found to have a right femur fracture requiring surgery in the OR. The DON stated that the expectation is that when a resident is care planned as a two-person assist, there should be two people in the room, indicating that this expectation was not met at the time of the fall.
Failure to Timely Initiate Psychiatric Services for Resident on Antipsychotic Therapy
Penalty
Summary
The facility failed to provide necessary behavioral health care and services by not timely initiating psychiatric services for a resident admitted with significant behavioral and cognitive issues. The resident was admitted with Alzheimer's disease, restlessness, and agitation, and had a Brief Interview for Mental Status score of 0/15, indicating severely impaired cognition. The resident required staff assistance with bed mobility and transfers. Physician orders at admission included scheduled Olanzapine 5 mg orally every 12 hours as an antipsychotic and a psychiatric consult related to aggression toward staff, including throwing water at staff and refusing care, with consult start dates documented as 9/9/2024 and 10/13/2024. Despite these orders and the resident’s behavioral concerns, the medical record showed that consent to receive psychiatric services was not obtained until 12/12/2024, approximately three months after admission. No psychiatric visit notes were available in the record and were not provided to surveyors upon request. Social work staff interviewed during the survey stated that the usual process is to obtain consent for psychiatric services upon admission for residents on regular antipsychotic medications and to send a referral to the psychiatric provider, but they were unable to explain why this did not occur for this resident. The facility’s Behavioral Health and Management policy states that it is the policy of the facility to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents in accordance with their plan of care, which was not followed in this case.
Multiple Food Service Safety and Sanitation Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in food service safety and sanitation within the facility's kitchen. There was a buildup of a black, mold-like substance on the backsplash of the dish machine, and the faucet assembly for the hose sprayer was leaking water. In the walk-in cooler, opened containers of ranch and Greek dressing were found undated, and a container of cut carrots and celery was dated beyond the acceptable range and appeared dried out. The Dietary Manager confirmed that the dressings should have been dated and the vegetables discarded. The dish machine was tested and found not to reach the required sanitization temperature, with the Dietary Manager acknowledging ongoing issues and a pending replacement. Additionally, ice machine filters in several locations were observed with expired dates, and the Maintenance Supervisor confirmed they were overdue for replacement. Further, a dietary staff member was observed entering the kitchen and beginning work on the lunch trayline without performing required handwashing. The Dietary Manager confirmed that handwashing should have occurred before handling food items. These observations were all in direct violation of specific sections of the 2022 FDA Food Code regarding cleanliness, equipment maintenance, food labeling and dating, temperature requirements for dishwashing, and hand hygiene.
Improper Maintenance of Exterior Dumpster Area
Penalty
Summary
The facility failed to maintain the exterior trash refuse area in a clean and sanitary condition. During observation, the ground around both dumpsters was found to be soiled with grease and sludge, and a milky liquid was pooled on the ground, accompanied by a foul, sour odor. The Dietary Manager indicated that Maintenance was responsible for cleaning the dumpster area, while the Maintenance Supervisor stated that the area is typically cleaned monthly and acknowledged it was likely due for cleaning again. These findings were confirmed through observation, staff interviews, and reference to the 2022 FDA Food Code requirements for refuse area maintenance. No specific residents were directly involved or affected at the time of the deficiency, but the condition of the refuse area had the potential to impact all residents, staff, and visitors.
Deficiencies in Water Management and Infection Control Practices
Penalty
Summary
The facility failed to maintain an active and ongoing Water Management Program Plan (WMPP) to reduce the risk of Legionella and other opportunistic pathogens in the plumbing system. The WMPP required the establishment of a Water Management Team, including the Administrator, Maintenance Director, and Infection Preventionist, to implement policies, monitor performance, and review the program annually. However, interviews revealed that the Infection Preventionist and Administrator were not actively involved, with responsibilities deferred entirely to the Maintenance Supervisor. The plan had not been updated since 4/29/23, and required monitoring activities such as Point of Use Residual Disinfectant checks and fixture flushing logs were not being completed or documented, as confirmed by the Maintenance Supervisor. The facility also failed to ensure proper use of Personal Protective Equipment (PPE) during isolation precautions and did not complete departmental infection control surveillance. Observations showed that staff providing care to a resident on Enhanced Barrier Precautions (EBP) wore only gloves, not gowns as required by signage and physician orders, during high-contact activities such as bathing, brief changes, and PEG tube care. Additionally, a nurse was observed failing to perform hand hygiene during a medication pass. The Infection Control Preventionist confirmed that the required PPE was not used and that there was no documentation of monthly departmental infection control surveillance. The resident involved in the PPE deficiency had significant medical needs, including non-traumatic brain dysfunction, stroke, high blood pressure, severely impaired cognition, impaired range of motion, and total dependence on staff for activities of daily living. The resident was on EBP due to a PEG tube and had previously been on contact precautions for a stool-borne pathogen. The facility's infection surveillance policy required monthly data analysis and presentation to the QAPI committee, but no such documentation was available at the time of the survey.
Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
The facility failed to ensure that food was served in a palatable manner and at a safe, appetizing temperature for several residents. Multiple residents with intact cognition reported that the food did not taste good and was frequently cold when served. These concerns were echoed by five residents during a group interview and were also documented in resident council meeting minutes over several months, which noted that meals were cold and the overall quality of food needed improvement. Specific residents interviewed had medical conditions such as cellulitis, heart disease, fracture of the right lower leg, muscle weakness, spondylolisthesis, heart failure, and depressive disorder. During an observation, a breakfast tray was tested for temperature and found to be below the preferred standard, with pancakes at 105°F and turkey sausage at 103°F, while the dietary manager indicated the desired temperature was 130°F or greater. The food was served in white foam containers due to a broken dishwasher, and the dietary manager acknowledged that these containers did not maintain food temperature well. Survey team members confirmed that the food tasted cold, which negatively impacted its palatability. The administrator confirmed that the expectation was for food to meet all temperature standards.
Failure to Update Care Plan Following Change in Isolation Precautions
Penalty
Summary
A resident with diagnoses including non-traumatic brain dysfunction, stroke, and high blood pressure was admitted to the facility and assessed as having severely impaired cognition, impaired range of motion, and total dependence on staff for all activities of daily living. The resident was initially placed on Contact Isolation Precautions for C. difficile shortly after admission, and later, a physician's order directed that Enhanced Barrier Precautions (EBP) be implemented every shift due to tube feeding. Despite these changes, the resident's care plan, last revised on the date of the initial isolation, was not updated to reflect the new EBP order. Observations during the survey confirmed that EBP signage was present on the resident's door, and interviews with the Infection Preventionist and DON revealed that the care plan should have been updated immediately to reflect the change from Contact Isolation to EBP. The care plan continued to reference the discontinued C. difficile precautions and did not include the current EBP requirements, indicating a failure to revise the care plan in accordance with the resident's updated care needs and physician's orders.
Failure to Provide Timely ADL Care and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to provide timely care and assistance with activities of daily living (ADLs), including repositioning, brief changes, and ensuring call light accessibility, for three dependent residents. Observations revealed that residents with severe cognitive impairment and physical limitations, such as those with diagnoses of non-traumatic brain dysfunction, stroke, high blood pressure, Alzheimer's, anxiety, depression, and dementia, were left in bed for extended periods without being repositioned or assisted out of bed. In multiple instances, residents' call lights were found out of reach, placed in closed drawers, and not accessible to the residents, despite facility policy requiring call lights to be within reach and functioning. One resident was observed multiple times over several days lying supine in bed, dressed in a hospital gown, with their breakfast tray untouched and the call light inaccessible. The resident expressed a desire to be out of bed but was not observed to have been assisted with transfers or repositioning, and staff confirmed the resident required a Hoyer lift and two-person assistance. Another resident was observed with long, dirty fingernails, a saturated brief, and reported not having been changed or repositioned recently. Staff interviews confirmed knowledge of the facility's two-hour repositioning and brief change policy, but observations indicated these standards were not consistently met. Additionally, a third resident was observed repeatedly activating their call light to request a brief change, but staff deactivated the call light without providing care and left the room. Agency staff admitted to not knowing the call light policy. Resident council meeting minutes documented ongoing concerns about untimely call light responses and lack of care. Interviews with nursing leadership confirmed expectations for timely call light response and care provision, but these were not consistently followed as evidenced by the observations and resident reports.
Failure to Provide Meaningful Activities for Dependent Residents
Penalty
Summary
The facility failed to provide appropriate and meaningful activities for two residents with severe cognitive impairment and high dependency for activities of daily living. Both residents were observed in their rooms, in bed, without any form of engagement such as television, music, or other devices during multiple days and times. Record reviews indicated that both residents had documented preferences for activities such as listening to music, keeping up on the news, participating in group activities, and going outside. Care plans for both residents included encouragement to attend activities of their choice and assistance with attending special events or going off the unit. However, activity task documentation showed no evidence that any independent, intellectual, physical, social, or spiritual activities were provided to either resident during the reviewed period. Interviews with the Activities Director confirmed that room visits are intended for residents who are bedbound or do not leave their rooms, but there was no documentation of any such activities for the two residents in question. The Director of Nursing also confirmed that care activities should be provided and documented. Facility policies require an ongoing program of activities to meet the interests, choices, and preferences of each resident, supporting their physical, mental, and psychosocial well-being, as well as their right to participate in activities programs of their choice. Despite these policies, the facility did not provide or document activities for the two residents reviewed.
Failure to Provide Timely Gynecological Care for Resident with Abnormal Uterine Bleeding
Penalty
Summary
A deficiency occurred when the facility failed to provide timely gynecological care for a resident experiencing post-menopausal vaginal bleeding. The resident, who had a history of paraplegia, adjustment disorder, and hypertension, reported intermittent vaginal bleeding beginning in June 2024. Despite multiple progress notes documenting the resident's ongoing symptoms and requests for gynecological evaluation, there were significant delays in arranging appropriate specialist care. The initial assessment by the facility's nurse practitioner ruled out a urinary tract infection, but no further investigation was pursued for several months, even as the resident's symptoms persisted and sometimes worsened to heavy and painful bleeding. The resident's medical record showed repeated documentation of abnormal uterine bleeding, with recommendations for gynecological follow-up made by both the primary care provider and facility staff. However, logistical challenges, such as the need for stretcher transportation and difficulties in scheduling with a gynecologist who could accommodate the resident's bedbound status, led to multiple missed and rescheduled appointments. Interviews with staff revealed a lack of clarity regarding responsibility for scheduling these appointments, with the unit clerk unaware of the need for gynecological care until several months after the initial symptoms were reported. Social work staff indicated their role was limited to ancillary services, and the director of nursing was not familiar with the concern. Throughout this period, the resident continued to experience vaginal bleeding, which was observed by direct care staff and reported to nursing. The resident ultimately received a diagnosis of mixed high-grade endometrial carcinoma after a significant delay, following a surgical procedure performed under anesthesia. The facility's failure to ensure timely specialist evaluation and coordination of care, despite ongoing symptoms and repeated documentation of the need for follow-up, resulted in a delay in diagnosis and treatment of a serious medical condition.
Failure to Prevent Resident Fall During Incontinence Care
Penalty
Summary
A deficiency occurred when a resident with a history of nontraumatic intracerebral hemorrhage, diabetes, and heart failure, who was cognitively intact and required assistance from one to two staff for transfers and bed mobility, sustained a fall during incontinence care. The resident was being assisted by a single CNA, despite requiring up to two-person assistance, and the CNA rolled the resident away from herself, resulting in the resident falling out of bed onto the floor. The resident reported pain to the right upper and lower extremities and remained on the floor for approximately 30-45 minutes while staff located a mechanical lift to return them to bed. Documentation and interviews confirmed that the CNA was working alone and did not follow proper transfer technique, which was acknowledged by both the ADON and DON. Further review revealed that the facility's provided policy, titled "Accident and Incident Report," did not address fall interventions or prevention measures. The incident was witnessed by staff who responded to a loud noise and found the resident on the floor. The resident expressed concerns about the adequacy of assistance during transfers and bed mobility, and the lack of a comprehensive fall prevention policy contributed to the failure to prevent the accident.
Failure to Properly Label, Date, and Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to properly label, date, and administer tube feeding as ordered for a resident with significant medical needs. The resident, who had diagnoses including non-traumatic brain dysfunction, stroke, and high blood pressure, was assessed as having severely impaired cognition and was dependent on staff for all activities of daily living, including eating. Observations over two days showed the resident receiving tube feeding at a rate of 40 ml/hr, while the physician's order specified a rate of 45 ml/hr. There was no documentation in the progress notes or orders to justify the deviation from the prescribed rate. Additionally, the tube feeding formula bag in use was observed to be dated from the previous day, exceeding the facility's policy to change the bag every 24 hours. Interviews with nursing staff and the DON confirmed that the policy requires tube feeding bags to be changed and dated every 24 hours and that physician orders should be followed precisely. The facility's own policy also mandates that tube feedings be administered according to current clinical standards and physician orders, including specific instructions for feeding type, rate, and bag changes.
Medications Left Unattended at Bedside
Penalty
Summary
A deficiency occurred when a medication cup containing two pills was observed on a resident's overbed table, with the resident unaware of their presence or how long they had been there. The resident, who was cognitively intact and required minimal assistance for activities of daily living, had been admitted with diagnoses including cerebral infarction, hypertension, and muscle weakness. There was no assessment in the medical record for the resident's ability to self-administer medications. The assigned LPN reported having provided the medications to the resident while attending to the resident's roommate but did not ensure the medications were taken at that time. The LPN was unaware of why the medications had not been taken and only observed the resident take them after being prompted. The facility's Director of Nursing confirmed that medications should not be left at the bedside and that nurses are expected to watch residents take their medications. The facility's policy on medication storage did not address the issue of medications being left at the bedside.
Failure to Ensure Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs) completed the required 12 hours of annual in-service training, including education in dementia care and abuse prevention. Documentation for one CNA only included a skills competency checklist, which did not specify the number of training hours or confirm that dementia management and abuse prevention topics were covered. No training documentation was provided for the second CNA by the end of the survey. The facility relies on a vendor to provide training for agency CNAs through an app, and ongoing education is reportedly provided during work shifts. Additionally, a review of the facility's staffing policy revealed it did not address the requirement for 12 hours of annual in-service training for CNAs.
Failure to Timely Assess and Document Pressure Ulcer
Penalty
Summary
A resident with severe protein-calorie malnutrition and impaired cognition was admitted to the facility without any open pressure ulcers, as confirmed by an initial skin assessment conducted by the wound care team. Preventative measures, including a pressure-reducing mattress and repositioning protocols, were implemented due to the resident's decreased mobility. However, the resident later developed an open area on the coccyx and groin, which was first identified by a CNA and subsequently treated by nursing staff with cleansing, application of Medihoney, and a foam dressing. The medical doctor was notified, and a wound care consult was requested. Despite the development of the pressure ulcer, there was no evidence in the medical record that the wound was timely assessed, staged, or measured by the wound care team or licensed nurse, as required by facility policy. The wound care nurse stated that they were waiting for the wound care nurse practitioner, who visits weekly, but the practitioner did not assess the wound before the resident was transferred to the hospital. Wound care notes were requested but not provided by the end of the survey.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as R702, who was cognitively intact and required extensive assistance from two persons for incontinence care. On a specific day, R702 experienced a delay in being changed after having a soiled brief. The resident reported waiting approximately one hour before being attended to by their assigned CNA, despite being told they would be changed sooner. This delay was documented by the resident in a notepad, which included dates, assigned staff, and wait times for care. The resident also expressed that they had experienced similar issues in the past and had attempted to plan their bowel movements around staff shifts due to long call light wait times. The incident was further corroborated by a grievance filed by the resident's representative, expressing concerns about the timeliness of incontinence care. The facility's records showed that the CNA involved received a written warning for failing to complete the assigned task and for carelessness in performing their job duties. The Director of Nursing acknowledged the incident but did not provide additional comments. The facility's policy on incontinence care stated that residents should receive assistance based on their requests or needs, which was not adhered to in this case.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to implement timely and effective interventions to prevent the development of a pressure ulcer for a resident identified as R701. Initially admitted without skin integrity issues, R701 had multiple diagnoses, including Vascular Dementia and Acute Kidney Disorder, and required extensive assistance for mobility and toileting. After a hospital transfer, R701 returned with a Stage II pressure ulcer, which later healed. However, the resident was at very high risk for pressure ulcers, as indicated by the Braden Scale, and the facility's treatment records showed lapses in the prescribed skin care regimen. Despite the high risk, the facility did not consistently follow the physician's orders for skin care, as evidenced by missed treatments on several dates. Additionally, the facility's documentation failed to identify any skin abnormalities in weekly evaluations, even as the resident's condition deteriorated to a Stage III pressure ulcer. The facility's interventions, such as the use of a custom care mattress, were not sufficient, and a low air loss mattress was not provided until after the ulcer worsened. Interviews with facility staff, including the Wound Care Nurse and Director of Nursing, revealed a lack of adequate preventative measures and support surfaces for R701. The facility's Skin and Wound Guidelines did not address the implementation of preventative interventions, contributing to the deficiency. The resident's care plan and physician orders were not updated to include necessary pressure-reducing support surfaces until the pressure ulcer had progressed to a more severe stage.
Failure to Provide and Document ADLs for Dependent Residents
Penalty
Summary
The facility failed to document and provide adequate assistance with Activities of Daily Living (ADLs) for two dependent residents, R902 and R903. R902, who has diagnoses including Dementia, Diabetes, and Heart Failure, was observed to have received only a bed bath on one occasion and a shower on another within a 30-day period, with other dates marked as Not Applicable. The resident's family expressed concerns about the lack of showers and assistance in getting out of bed. R902 is significantly cognitively impaired and requires 1-2-person assistance for bed mobility, transfers, and toileting. Similarly, R903, who has Multiple Sclerosis, Hypotension, and Bi-Polar Disorder, reported being unaware of their shower schedule and expressed concern about personal hygiene. A review of R903's records showed no documentation of showers or resident refusals, with all entries marked as Not Applicable. R903 also has significantly impaired cognition and requires assistance for transfers, toilet use, and personal hygiene. The Director of Nursing and a corporate employee acknowledged the need for improvement in documentation after reviewing the electronic medical records.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was safely stored and maintained sanitary conditions in the kitchen, as observed during an initial tour. In the walk-in cooler, two foil-covered pans with cooked whole pork roasts dated 5/13 were found with internal temperatures between 56-58 degrees Fahrenheit, which did not comply with the FDA Food Code requirements for cooling potentially hazardous food. The Certified Dietary Manager (CDM) was unable to locate the cooling logs used by kitchen staff. Additionally, raw ground beef was stored next to cooked beef patties and chopped beef, and a box of raw bacon was stored directly above the cooked beef, which violates the FDA Food Code's guidelines for preventing cross-contamination of food items. The CDM confirmed these storage issues during the inspection. Furthermore, the second-floor kitchenette had a microwave with dried, encrusted food debris, and the nourishment room refrigerators contained undated and expired food items, including containers with unknown substances and food items dated as far back as 4/7, which were not discarded as per the facility's Outside Food Policy dated 10/2/23.
Failure to Label, Date, and Remove Peripheral Intravenous Line
Penalty
Summary
The facility failed to label, date, and remove a peripheral intravenous line (PIV) for a resident who had completed their IV therapy. On 5/14/2024, the resident was observed with a PIV in their left wrist that was not labeled or dated, and an IV pump was present in the room. The resident, who had Parkinson's Disease and Dementia, stated they were not receiving any fluids through the PIV and expressed discomfort, requesting its removal. The medical record indicated that the resident had completed their IV therapy on 5/8/2024, but the PIV was still in place as of 5/14/2024. An interview with the Infection Control Preventionist (ICP) revealed that the PIV might have been left in due to the resident's hypotension, but the dressing should have been labeled and dated. The facility's policy on catheter insertion and care stated that the peripheral catheter should be removed if it has not been used for 24 hours or if the therapy is discontinued, and the dressing should be labeled with the date, time, and initials. The failure to follow these policies led to the deficiency observed during the survey.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to identify and document targeted behaviors, non-pharmacological interventions for behaviors, and monitor side effects of a prescribed psychotropic medication for one resident. The resident, who was admitted with diagnoses including Cerebral Infarction, Adjustment Disorder, Diabetes Type II, and Hypertension, was observed to be excessively sleeping and not consuming meals. Despite being severely cognitively impaired and requiring assistance for bed mobility and transfers, the resident's excessive sedation was not adequately addressed or documented in their care plan. The resident was prescribed Quetiapine upon discharge from the hospital, with the dosage being increased twice within a short period. Despite recommendations from a Medication Regimen Review to consider discontinuation or adding a supporting diagnosis, the resident continued to receive the medication. Observations and interviews with staff indicated that the resident was often lethargic, drowsy, and unresponsive, with multiple instances of the resident not participating in therapy and refusing meals. Interviews with the Nurse Practitioner and Director of Nursing revealed that non-pharmacological interventions were not adequately attempted or documented prior to the medication increases. The resident's care plan included interventions for psychotropic medication use, but there was no evidence of targeted or documented non-pharmacological attempts for behavior management. The facility's policy for unnecessary medications was not provided by the end of the survey.
Medication Storage and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to store medication in a safe and secure manner for two of the nine medication/treatment carts. On multiple occasions, medication carts were observed to be unlocked and unattended, allowing residents and staff to pass by them. Specifically, on 5/14/24, a treatment cart near room 152 was found unlocked, and on 5/15/24, a medication cart on the second floor was also observed to be unlocked. The unit manager, LPN C, was informed about the unlocked cart and instructed the assigned nurse to ensure it was locked. The Nursing Home Administrator confirmed that the facility's expectation is to lock the medication cart when not in use. The facility's policy on medication and treatment storage mandates that all medications and biologicals be stored in locked compartments under proper temperature controls, which was not adhered to in these instances. The facility also failed to monitor the temperatures of a medication refrigerator that stored drugs and biologicals. During an observation on 5/16/24, the One [NAME] Unit medication refrigerator's temperature log was found to have incomplete documentation for several dates in February, March, April, and May 2024. LPN B explained that the day shift nurse is responsible for completing the temperature log on the day shift, and the afternoon nurse is responsible for its completion on the afternoon shift. Both the Nursing Home Administrator and the Director of Nursing confirmed that the expectation is for the temperature logs to be completed daily. The facility's policy requires that logs be kept on each refrigerator and temperature levels be recorded daily by the charge nurse or other designee, which was not followed in this case.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 986 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) |
|---|---|---|---|---|
| Medilodge Of Sterling Heights | 1.6 mi | ★★★★★ | 13 | 0 |
| Harmony Village Of Clinton | 2.1 mi | ★★★★★ | 1 | 0 |
| Fraser Villa | 2.9 mi | ★★★★★ | 7 | 0 |
| Lakeside Manor Nursing And Rehabilitation Center | 3.1 mi | — | 12 | 0 |
| Medilodge Of Shoreline | 3.2 mi | ★★★★★ | 8 | 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.