Medilodge of Gtc

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive pain assessments were completed prior to the administration of opioid medications for three of three residents (Residents #1, #2, and #3) reviewed for unnecessary medications resulting in Resident #1 experiencing an opioid overdose requiring hospitalization and the use of intravenous (IV) drip administration of opioid reversal medications medications. without appropriate evaluation of pain characteristics, severity, or need placing residents at risk for adverse effects including oversedation, respiratory depression and ineffective pain management.

Inspectors wroteBased on interview and record review the facility failed to ensure timely assessment and intervention for a significant change in condition (hypotension) for one Resident (#1) of three residents reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary treatment and services to prevent the development and promote the healing of pressure injuries for two Residents (#9 & #1) of three residents reviewed for wounds. This deficient practice resulted in the development of an unstageable pressure ulcer on the right foot of Resident (#9) and the deterioration of a left gluteus pressure injury from a stage three to an unstageable wound for Resident (#1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 3/2/2026 at 11:20 AM, the floor, sewage drain lines and floor drain under the three-compartment sink were observed soiled with dirt and food debris. On 3/2/2026 at 11:22 AM the drain line coming from the 2-compartment vegetable wash sink was observed soiled. On 3/2/2026 at 12:04 PM The floor under the hand sink was observed soiled. On 3/2/2026 at 12:05 PM, when asked who was responsible for cleaning of floors and equipment in the kitchen Dietary Director (DD) confirmed, that the dietary staff are responsible for these tasks, not the maintenance staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications securely and discard expired medications in two of two medications rooms and two of three medication carts reviewed for medication storage.

Inspectors wroteThis citation pertains to intake #2732400Based on observation, interview, and record review, the facility failed to:Provide Resident #49 (R49) sanitary catheter care,Provide a sanitary barrier and administration for medication,Implement and utilize enhanced barrier precautions (EBP) while performing Resident #12 (R12) high contact care administering medication via feeding tube,Maintain facility equipment in a sanitary manner, and;Ensure personal protective equipment (PPE) was stored in a sanitary manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate consents for restraints were in place for two Residents (#54 & #107) of three residents reviewed for restraints.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Long-Term Care Ombudsman was notified of a resident's discharge from the facility for two Residents (#7 & #12) of two residents reviewed for discharge practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor for acute illness and provide timely physician notification of change in condition for two Residents (#68 & #78) of five residents reviewed for hospitalization. This deficient practice resulted in delay of treatment and the potential for worsening of condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure smoking paraphernalia was stored in a secure location for one Resident (#52) of two residents reviewed for smoking.

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately assess and implement timely interventions for weight loss for one Resident (R54) of three reviewed for weight loss.

Inspectors wroteBased on interview and record review, the facility failed to complete, readily act upon, and implement monthly pharmacy recommendations for two Residents (#2 e) of five residents reviewed for medication review.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately dispense insulin to one Resident (Resident #28) of one resident reviewed for insulin administration resulting in a significant medication error.

Inspectors wroteThis deficient practice pertains to Intakes 2704447 and 2691458. Based on interview and record review, the facility failed to perform timely emergency medical care and Cardiopulmonary Resuscitation (CPR) for one Resident (#1) of five residents reviewed for quality of care, resulting in the death of Resident #1.

Inspectors wroteThis deficient practice pertains to Intakes 2704447 and 2691458. Based on interview and record review, the facility failed to obtain informed consent prior to changing a code status for one Resident (#1) of five residents reviewed for resident rights.

Inspectors wroteThis deficient practice pertains to Intakes 2704447 and 2691458. Based on interview and record review, the facility failed to ensure medical records were accurately documented in accordance with professional standards and practices for one Resident (#1) of five residents reviewed for accurate medical records.

Inspectors wroteThis deficient practice pertains to Intake 2647525. Based on interview and record review, the facility failed to implement infection control measures and ensure comprehensive infection surveillance to prevent the transmission of scabies (a highly contagious skin condition caused by parasitic itch mites that burrow into the skin). This deficient practice resulted in transmission of scabies with associated physical discomfort for six Residents (#2, #3, #4, #5, #6, #7) of twenty residents reviewed for infection control.

Inspectors wroteThis deficient practice pertains to Intake 2646261. Based on interview and record review, the facility failed to ensure a safe community discharge for one Resident (#1) of three residents reviewed for transfer and/or discharge. This deficient practice resulted in the need for repeated emergency room visits for Resident #1 due to the inability to care for a colostomy (a surgical procedure that creates an opening in the abdominal wall to divert fecal matter from the colon to the outside of the body) and infection of the colostomy site.

Inspectors wroteThis deficient practice pertains to Intakes 2646261 and 2647525. Based on interview and record review, the facility failed to coordinate post-surgical care and follow established bowel protocol for two Residents (#1 and #2) of three residents review for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and determine if self-administration of medications was clinically appropriate for two Residents (#18 and #49) of two residents reviewed for self-administration of medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate assessments and timely notification of a change in condition were completed per professional standards for one Resident (#10) of two resident's reviewed for respiratory infection, resulting in R10 being transferred to the emergency department with the potential for complications/worsening of influenza, including pneumonia and sepsis, as a result of delay in treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Accurately document a wound, 2. Determine wound etiology, 3. Ensure physician assessment and documentation of a wound, 4. Implement Enhanced Barrier Precautions (EBP), and 5. Complete wound treatments as ordered for one Resident (#32) of two residents reviewed for pressure injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper infection control measures pertaining to indwelling catheters (a tube inserted into the bladder to accommodate emptying of the bladder) for one Resident (#44) of four residents reviewed for indwelling catheters. This deficient practice resulted in the potential for infections and illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure completion of respiratory assessments for one Resident (R10) receiving supplemental oxygen and to ensure supplemental oxygen was administered per physician order for one Resident (R32) of two residents reviewed for oxygen administration, resulting in the potential for unidentified worsening of condition and administration of unwarranted respiratory treatments. Based on observation, interview and record review, the facility failed to: 1. Ensure completion of respiratory assessments for residents receiving supplemental oxygen, and 2. Ensure oxygen was administered per physician orders, for two Residents (#10 ) of two residents reviewed for respiratory care and services, resulting in the potential for unidentified worsening of condition and administration of unwarranted respiratory treatments.

Inspectors wroteThis deficiency pertains to Facility Reported Incident (FRI) #MI00144562. Based on observation, interview, and record review, the facility failed to provide adequate supervision per the plan of care for three residents (Residents #508, #509, and #510) during mealtimes. This deficient practice resulted in two choking/aspiration events for Resident #509 which resulted in hospitalization and subsequent death. Findings Include: The Immediate Jeopardy began on 5/5/24 at 2:40 PM when the facility failed to provide supervision during a mealtime for a resident (Resident #508) with a known history of choking/aspiration. This resulted in R508 experiencing a choking event in his room. R508 experienced a subsequent choking event on 5/7/24 at 6:24 PM when R508 was left unsupervised on two different occasions in the dining room during a dinner time meal and was found unresponsive. [...]

Inspectors wroteThis deficiency pertains to Intake #MI00144052 and Facility Reported Incident (FRI) #MI00144263. Based on interview and record review, the facility failed to provide pharmaceuticals for one resident (Resident #502) of three residents reviewed for pharmacy services. This deficient practice resulted in Resident #502 going without administration of a prescribed medication for an extended period of time resulting in increased likelihood of exacerbation of symptoms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain interventions to prevent the development and progression of a pressure ulcer for one Resident (#46) of three residents reviewed for pressure injuries. This deficient practice resulted in the development of a stage four pressure ulcer (a wound affecting skin, fat, and muscle tissue) for a high-risk resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety potentially resulting in a food borne illness among any or all 84 residents.

Inspectors wroteBased on observation and interview the facility failed to ensure the resident environment was maintained in clean, comfortable and homelike conditions by allowing noxious odors to permeate resident rooms and corridors and failed to maintain functioning exhaust ventilation units in resident bathrooms. This deficient practice has the potential to result in depression, isolation and feelings of an undignified existence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a secured/locked medication cart, expired biologicals were removed from an active medication cart and maintain clean and sanitary medication cart for three of five medication carts reviewed for medication storage. This deficient practice had the potential for medications to be misappropriated, medication loss, and contamination.

Inspectors wroteBased on observation and interview, the facility failed to deliver food which was palatable and appetizing to 10 (#'s: R25, R29, R35, R44, R46, R58, R71, R76, R85, R392) of 18 sampled residents, and a contingent of confidential residents. This deficient practice has the potential to result in weight loss, and feelings of depression, disillusionment and being powerless in determing their daily routines and desires.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure follow-up for the highest practicable mental and psychosocial well-being for one Resident (#72) of one resident reviewed for mood and behavior. This deficient practice has the potential for psychosocial adjustment difficulty and the possibility for an atypical response in mental health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication administration error rate of less than 5% based on three medication errors of 25 medication administration opportunities. This deficient practice resulted in a medication administration error rate of 12% and the potential for inaccurate dosage of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure droplet transmission-based precautions for four rooms, (38, 39, 42, 43) of six rooms reviewed were correctly posted and followed to prevent the spread of contagious organisms. This deficient practice placed other residents, staff, and visitors at risk for transmission of infectious organisms and illness throughout the facility.