Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Sterling during CMS and state inspections, most recent first.
Improper Sling Size Used During Mechanical Lift Transfers: A resident who was totally dependent for ADLs and required a mechanical lift for all transfers was moved three times using a sling that was too large instead of the green sling specified in the care plan. During the transfers, the resident's lower back and bottom hung out of the sling opening, and he later stated he felt like he was going to fall and that his lower back hurt.
Failure to Maintain Resident Dignity: A resident with a Foley catheter was observed without a privacy bag covering the drainage bag during transfers and while in bed, and a strong urine odor was noted in the room. Another resident with severe cognitive impairment and extensive toileting assistance needs was left calling for help after a bowel movement while multiple CNAs and a nurse walked past without acknowledging the resident, and a strong bowel movement odor was present.
Insulin Pen Not Held Long Enough: An LPN administered Lantus SoloStar insulin to a resident and held the pen in place for only five seconds, including the time the injection button was depressed, rather than the manufacturer-recommended 10 seconds. The LPN stated the pen should be held in place for five seconds, and the Administrator was informed of the concern that the resident may not have received the full dose.
Failure to follow up on abnormal antiseizure lab results. A severely cognitively impaired resident with epilepsy, Alzheimer’s disease, and a history of seizure-related falls was receiving Keppra and Depakote with ordered therapeutic drug monitoring. After seizure/fall events, a Keppra level was ordered, but an elevated Keppra result was not redrawn or dose-adjusted, there were no notes showing the HCP was notified, and a later Keppra result remained pending in the EMR without documented follow-up.
Failure to Use EBP and Hand Hygiene After Glove Removal: Staff did not use gowns for EBP during high-contact care for a resident with a Foley catheter, and multiple CNAs/Shower Aide did not wash hands after removing soiled gloves. The resident was dependent for ADLs, incontinent, and required mechanical lift transfers; care observed included transfer, peri care, catheter care, and bed making while EBP supplies were available in the room.
A facility failed to ensure nurse staffing information was posted in a clear and prominent place readily accessible to residents and visitors for all residents. Surveyors could not locate the staffing information during multiple observations, and the Administrator later retrieved a clipboard from a wall bin at the front entrance and stated that was where the daily staffing was kept. The Administrator also said they were unaware the information had to be in a clearly visible area.
The facility was found to have several deficiencies in food storage and kitchen sanitation, including undated and expired food items, improper dish drying practices, and issues with the drainage system lacking an air gap. These deficiencies were observed during a kitchen tour, highlighting a failure to adhere to safe food handling practices and proper maintenance.
The facility failed to implement a comprehensive infection control program, leading to deficiencies in hand hygiene audits, linen handling, and PPE use. Discrepancies in tracking resident infections and a lack of involvement in the water management plan were noted. Observations revealed staff not adhering to infection prevention protocols, such as carrying clean linens uncovered and assisting a resident with a urinary catheter without PPE.
A facility failed to provide palatable and appealing food, leading to dissatisfaction among residents. A resident with multiple health issues reported the food as cold and unappetizing, while a resident council highlighted issues like lack of food choices, small portions, and repetitive menus. Observations confirmed unappealing food items and strict meal request cut-off times, contributing to widespread resident dissatisfaction.
The facility failed to accurately document code status for two residents, leading to potential discrepancies in their medical treatment preferences. One resident's DNR consent was signed despite a prior determination of incapacity, and another resident had conflicting code status documentation. The errors were acknowledged by staff but not resolved.
A resident with cognitive impairment and multiple diagnoses received double the recommended dosage of Detrol LA due to the facility's failure to ensure timely review and action on pharmacy recommendations. Despite pharmacy oversight, the attending physician continued the excessive dosage without providing a rationale, contrary to facility policy.
A facility failed to properly administer and store medications for two residents, leading to potential decreased efficacy and side effects. A nurse did not wait the required time between administering two inhalers and failed to offer mouth rinsing. Another nurse did not perform a safety test before administering insulin, contrary to guidelines.
A resident with a history of mental health issues was transferred to the hospital for evaluation due to aggressive behavior but was not allowed to return to the facility after being cleared for discharge. The facility cited safety concerns and completed an involuntary discharge without providing the resident an opportunity to appeal, resulting in the resident staying in the emergency department for six days. The facility's actions and lack of proper documentation led to a deficiency.
Improper Sling Size Used During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure the safety of Resident #46 during three transfers using a mechanical lift by using a sling that was too large for the resident. Resident #46 was [AGE] years old, alert, incontinent of bowel and bladder, had a Foley catheter, was totally dependent for ADLs, and required a mechanical lift for all transfers. His diagnoses included chronic kidney disease, chronic systolic and diastolic heart failure, anemia, dysphagia, aphasia, BPH, depression, and anxiety. The care plan specified transfers with 2-person assist and use of a full mechanical lift with a green sling, which was identified as the proper size for the resident's height and weight. During observation, Nursing Assistants used a large blue Hoyer sling instead of the green sling that was present in the room. While the resident was lifted from his wheelchair to bed for peri care, his lower back and bottom hung out of the backside opening of the sling. The same large blue sling was then used again to transfer him back to his wheelchair for a shower, and he was observed falling out of the backside opening a second time. A third observation showed the resident being lifted from his wheelchair back to bed with the same large blue sling, again with his bottom hanging through the large open area. The resident later stated that he felt like he was going to fall during the transfers and that it hurt his lower back area.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure resident dignity for a resident with a Foley catheter by not keeping the catheter drainage bag covered with a privacy bag. Resident #46 was alert, incontinent of bowel and bladder, totally dependent for ADLs, and required a mechanical lift for transfers. The resident had diagnoses including chronic kidney disease, chronic systolic and diastolic heart failure, anemia, dysphagia, aphasia, BPH, depression, and anxiety. During observation, the resident’s Foley catheter bag was seen without a privacy bag while the resident was being transferred from wheelchair to bed, and the privacy bag was not placed on the catheter bag when the resident was returned to the wheelchair. On a later observation, the resident was in bed with the catheter bag still not in a privacy bag, the privacy bag hanging on the opposite side of the bed, and a strong urine odor was noted in the room. The facility also failed to acknowledge a resident calling for help after a bowel movement. Resident #19, who had Alzheimer’s disease, intellectual disabilities, bipolar disorder, seizures, and cerebral palsy, was severely cognitively impaired and required substantial to maximal assistance with toileting hygiene. The resident stated they needed help because they had a bowel movement and had been told to wait in their room. The resident was then heard yelling, "I need changed," from the hallway while multiple CNAs and a nurse walked past the room without stopping to acknowledge the resident. The resident self-propelled to the doorway and then down the hallway while continuing to call for assistance, and a strong bowel movement odor remained present.
Insulin Pen Not Held for Manufacturer-Recommended Time
Penalty
Summary
Ensure services provided by the nursing facility met professional standards of quality was not maintained when an LPN administered Lantus SoloStar insulin to Resident #35 without holding the insulin pen in place for the full manufacturer-recommended time. During a medication pass observation, the LPN prepared the resident’s medications, entered the room, administered oral medications, and then gave the insulin in the resident’s right upper abdomen. The LPN held the SoloStar pen in place for five seconds, including the time the injection button was depressed, before removing it from the resident’s abdomen. After the observation, the LPN stated that the pen should be held in place for five seconds and explained that it had to be held so the medication would be absorbed. When asked whether the time the injection button was held down counted toward that time, the LPN did not respond. The Administrator was informed of the concern that the pen was not held in place for 10 seconds and the potential for the resident not to receive the entire dose. The manufacturer’s instructions for Lantus SoloStar stated to slowly count to 10 before removing the pen to ensure the full insulin dose is received.
Failure to Follow Up on Abnormal Antiseizure Lab Results
Penalty
Summary
The facility failed to implement and operationalize procedures to ensure follow-up assessment and monitoring of abnormal laboratory testing results for a resident with epilepsy, Alzheimer’s disease, intellectual disabilities, bipolar disorder, and cerebral palsy. The resident was severely cognitively impaired, required substantial to maximal assistance with ADLs, and had a history of falls, including falls related to seizure activity. The resident was receiving Keppra 1000 mg every 8 hours and Depakote 500 mg three times daily, with orders for Keppra level, valproic acid level, hepatic function, and CBC monitoring at baseline and every 6 months. The record showed multiple seizure-related events and falls. After a seizure and fall from a wheelchair in the activity room, the resident was assessed, returned to the room, and given rectal Diazepam. The documented intervention after that event included asking nursing staff to be alerted when seizure activity was noted and placing a neuro monitoring order. Another seizure and fall occurred later when the resident was found on the floor in the room; the resident was again assessed, assisted into bed, and given rectal Diazepam. The immediate intervention documented after that event was to draw a Keppra level at the next lab draw. Laboratory review showed a Keppra level of 55.2 ug/mL in February and an elevated Keppra level of 89.9 ug/mL in March. The elevated result was scanned into the EMR, but there was no redraw and no dose adjustment documented. Nursing staff did not identify any notes showing that the HCP was contacted about the elevated level or that a repeat lab was advocated for. A later lab entry in July showed valproic acid at 69 ug/mL and Keppra listed as pending, but the facility did not have the Keppra result available at the time of review. During interview, the Administrator and DON acknowledged the concern and stated there was no explanation for why the abnormal Keppra result was not followed up and why the later Keppra result had not been obtained.
Failure to Use EBP and Perform Hand Hygiene After Glove Removal
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were used and failed to ensure handwashing was performed after glove removal for one resident. Resident #46 was alert, admitted to the facility, incontinent of bowel and bladder, had a Foley urinary catheter, was totally dependent on staff for ADLs, and required a mechanical lift for all transfers. His diagnoses included chronic kidney disease, chronic systolic and diastolic heart failure, anemia, dysphagia, aphasia, BPH, depression, and anxiety. His EBP care plan stated that EBP were to be used during high-contact resident care activities, including transferring, personal hygiene, changing linens, and urinary catheter care. During observation, CNA P and CNA N transferred the resident from a wheelchair to bed and provided peri care. The resident had signage on the room door indicating EBP was to be used for all care because he had a urinary catheter, and the EBP supplies were in a plastic bin just inside the room by the door. Neither CNA P nor CNA N put on a gown. CNA N performed care, then removed soiled gloves in the bathroom and put on another pair without washing hands. CNA P assisted with bed making while still wearing soiled gloves. CNA O entered the room, did not gown up, assisted with transfer, removed soiled gloves, discarded them, opened the door by touching the doorknob, and left the room without washing hands after glove removal.
Nurse Staffing Information Not Posted in a Visible Area
Penalty
Summary
The facility failed to ensure nurse staffing information was posted in a clear and prominent place readily accessible to residents and visitors for all 39 facility residents. Surveyors attempted to locate the nurse staffing information in the facility on 9/2/25, 9/3/25, and 9/4/25 without success. During an interview on 9/4/25 at 1:09 PM, the Administrator was asked where the facility nurse staffing data was posted and went to the front entrance, where a clipboard was removed from a bin on the wall. When asked if that was where the daily staffing was always kept, the Administrator said it was. When asked about the information not being in a clear and prominent area for residents and visitors to view, the Administrator stated they were unaware the staffing information had to be in a clearly visible area.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to properly manage food storage and sanitation in the kitchen, leading to several deficiencies. During a tour of the kitchen, it was observed that a Kitchen Aid stand mixer was uncovered and had chunks of dried food substances on it. The floor was dirty with a buildup of unknown substances and dirt, and there was a palpable film of grease on the stove/oven hood. Cobwebs and dust were also visible in various areas of the oven/stove hood. Additionally, several food items, including apple cider vinegar, thickened lemon water, apple butter, and milk, were found to be either undated or expired, indicating a lack of proper labeling and disposal practices. In the dry storage area, an open container of mustard and vanilla were found with past use-by dates, and a box of bananas had a black substance with one banana's peel split open. These findings suggest that the facility did not adhere to safe food handling practices, as outlined in their policy. Furthermore, in the dishwashing and drying area, cups with visible water and moisture were stacked on top of each other, which is not acceptable for clean dishes. This indicates a failure to thoroughly dry dishes before stacking, increasing the risk of contamination. The facility also had issues with the drainage system in the kitchen. Under the three-compartment sink, the drain cover was pushed to the side, and a PVC pipe was positioned directly in the drain hole without an air gap, which is necessary to prevent cross-contamination. The drainage pipe was identified as being from the ice machine, and it was noted that the pipe was sagging and had been improperly secured. Maintenance staff were unable to provide a clear explanation for these issues, indicating a lack of oversight and maintenance in the kitchen area.
Inadequate Infection Control Practices
Penalty
Summary
The facility failed to implement a comprehensive infection control program, which resulted in several deficiencies. During an interview and record review with the Infection Control (IC) Registered Nurse (RN) and the Director of Nursing (DON), it was revealed that the facility did not conduct regular hand hygiene audits across all shifts, particularly the midnight shift. Additionally, there were no official audits for the laundry facilities to ensure linens were processed, stored, and handled properly to prevent contamination. The IC RN admitted that staff had not consistently used Personal Protective Equipment (PPE) when required, such as when providing care to residents with enhanced barrier precautions. The facility's outcome surveillance data for January 2024 showed discrepancies in tracking resident infections. The number of infections on the line listing did not match the mapping tool, and carry-over infections from December 2023 were not included. The IC RN acknowledged that they were not tracking signs and symptoms of potential infections for residents not receiving treatment, which could lead to the spread of infections. Furthermore, the IC RN and DON were unaware of positive Legionella water testing results, and no follow-up actions were taken to address the issue, indicating a lack of involvement in the water management plan. Observations of staff practices further highlighted deficiencies in infection control. A Certified Nursing Assistant (CNA) was seen carrying clean linens uncovered, allowing them to touch their uniform, which could lead to contamination. In another instance, two CNAs assisted a resident with a urinary catheter without wearing the appropriate PPE, despite the resident being in an enhanced barrier room. These actions demonstrate a failure to adhere to infection prevention protocols, increasing the risk of spreading infections among residents.
Deficiency in Food Service and Resident Satisfaction
Penalty
Summary
The facility failed to provide palatable and appealing food that met the preferences of its residents, as evidenced by complaints from Resident #35 and a group of residents during a resident council meeting. Resident #35, who has a history of cerebral infarction with left-sided paralysis, epilepsy, depression, anxiety, and dysphagia, expressed dissatisfaction with the food, describing it as cold and unappetizing. The resident council echoed these sentiments, citing issues such as lack of food choices, small portion sizes, repetitive menus, and dissatisfaction with specific food items like confetti eggs. Additionally, residents reported not receiving menus in their rooms and having to adhere to strict time limits for selecting alternative meal options. Observations and interviews revealed further deficiencies in the facility's food service. A breakfast tray observation showed unappealing food items, including overly moist eggs and lukewarm coffee, with no salt or pepper provided. The Registered Dietician was unaware of the process for ordering from the alternative menu and acknowledged the residents' complaints about the taste and appearance of certain food items. A review of facility documents confirmed the existence of strict cut-off times for meal requests, with limited alternatives available if requests were made after these times. These findings indicate a failure to meet the nutritional and personal preferences of the residents, leading to widespread dissatisfaction.
Inaccurate Code Status Documentation for Residents
Penalty
Summary
The facility failed to accurately record and obtain code status documentation for two residents, leading to potential discrepancies in their medical treatment preferences. Resident #29, who was admitted with diagnoses including heart failure and dementia, was documented as Do Not Resuscitate (DNR) in the Electronic Medical Record (EMR). However, the resident's DNR consent form was signed by the resident in 2023, despite a prior determination in 2021 that the resident was incapable of making medical decisions. This inconsistency was not addressed by the facility, as they accepted documentation from another facility without verifying its accuracy. Resident #35, admitted with conditions such as cerebral infarction and epilepsy, had conflicting documentation regarding their code status. The EMR indicated a full resuscitate status, while an advance directive form signed by the resident's Durable Power of Attorney (DPOA) and a registered nurse indicated both DNR and full code statuses. This discrepancy was acknowledged by the Social Services Designee, who recognized the error but did not provide a resolution. The Director of Nursing confirmed the concerns regarding the advance directive documentation and code status for both residents.
Failure to Address Pharmacy Recommendations for Medication Dosage
Penalty
Summary
The facility failed to implement and operationalize its policies and procedures to ensure the prompt review of pharmacy recommendations by the attending physician and documentation of rationale for lack of action. This deficiency was identified in the case of a resident who was receiving double the recommended dosage of Detrol LA, a medication used to treat overactive bladder. Despite pharmacy oversight, the resident continued to receive an excessive dosage, which increased the risk of adverse drug reactions and medication errors. The resident, who was moderately cognitively impaired and had diagnoses including congestive heart failure and anxiety, was receiving Detrol LA at a dosage exceeding the FDA-approved maximum. The pharmacy had recommended a dosage reduction on two occasions, but the attending physician initially chose to continue the same dosage without providing a rationale. The facility's policy required timely action on pharmacy reports, but the Director of Nursing was unable to explain the delay in addressing the pharmacy's recommendations, indicating a lack of adherence to the facility's procedures.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration and storage for two residents, leading to potential decreased medication efficacy and side effects. During a medication administration task, a nurse administered Breo Ellipta and Spiriva inhalers to a resident without waiting the required one minute between puffs and did not offer the resident a chance to rinse their mouth afterward. This oversight was contrary to the facility's guidelines and pharmacy instructions, which specify a waiting time between inhalers and rinsing the mouth after using steroid inhalers. Additionally, another nurse did not perform the required safety test before administering Lantus insulin to a different resident. The nurse failed to prime the insulin pen by dialing it to 2 units before administering the full dose, as instructed by the Lantus pen guidelines. This resident had a medical history of diabetes, morbid obesity, and muscle weakness, and required assistance with activities of daily living. These deficiencies were identified through observation, interviews, and record reviews, highlighting lapses in following proper medication administration protocols.
Failure to Honor Resident's Right to Return After Hospitalization
Penalty
Summary
The facility failed to honor a resident's right to return following hospitalization, resulting in a deficiency. A resident was transferred to the hospital for a mental health evaluation due to aggressive behaviors but was not allowed to return to the facility after being cleared for discharge. The facility did not provide the resident with an opportunity to appeal the involuntary discharge, leading to the resident remaining in the emergency department for six days. The resident, who had a history of schizoaffective disorder, bipolar disorder, and other mental health conditions, was involved in an altercation with the former administrator, which led to their transfer to the emergency department. Despite being medically cleared and not requiring inpatient mental health treatment, the facility refused to readmit the resident, citing safety concerns due to previous altercations. The facility's corporate lawyers were involved, and an involuntary discharge was completed, but the discharge documentation was not properly served to the resident. Interviews with facility staff and community mental health representatives revealed that the facility had been working with the resident to find alternative placement but had not secured one at the time of the incident. The facility's actions, including the delivery of the discharge notice to the hospital and the lack of proper documentation, contributed to the deficiency. The facility's policy on transfers and discharges was not followed, as the resident was not provided with a bed hold notice or an opportunity to appeal the discharge.
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What surveyors actually found near you
We read the 57 citations issued within 25 miles in the last 12 months — 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.
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Nursing homes near Sterling
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mymichigan Skilled Nursing Facility | 8.5 mi | ★★★★★ | 9 | 0 |
| The Villa At West Branch | 15.6 mi | ★★★★★ | 1 | 0 |
| The Villa At Rose City | 22.8 mi | ★★★★★ | 17 | 0 |
| Gladwin Nursing And Rehabilitation Community | 24.1 mi | ★★★★★ | 14 | 0 |
| Gladwin Pines Nursing And Rehabilitation Center | 24.7 mi | ★★★★★ | 16 | 0 |
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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.