Medilodge of Sterling

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the safety of 1 resident (Resident #46) during 3 transfer's using a mechanical lift (wrong sling size used, it was too large) for 1 of 1 resident reviewed for mechanical (Hoyer) lift, resulting in the residents lower back and bottom hanging out of the large opening on the backside of the sling, verbalizing of discomfort and fear while being transferred. Findings Included:Resident #46:Review of the Face Sheet, Material Data Set/MDS dated 9/25, care plans dated 9/1/25, and admission nursing assessment dated [DATE], revealed Resident #46 was [AGE] years old, alert, admitted to the facility on [DATE], incontinent of bowel and bladder with a Foley urinary catheter in place, totally dependent on staff for his Activities of Daily Living/ADL's, and was mechanical lift for all transfers. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident dignity by 1) not ensuring a dignity bag was covering 1 resident's (Resident #46) urinary catheter bag, and 2) acknowledge 1 resident (Resident #19) when yelling for help for 2 of 13 residents reviewed for dignity. Findings Include: Resident #46: Review of the Face Sheet, Material Data Set/MDS dated 9/25, care plans dated 9/1/25, and admission nursing assessment dated [DATE], revealed Resident #46 was [AGE] years old, alert, admitted to the facility on [DATE], incontinent of bowel and bladder with a urinary catheter (Foley) in place, totally dependent on staff for Activities of Daily Living/ADL's, and required a mechanical lift for all transfers. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate use and administration of insulin with an insulin pen per manufacturer recommendations and professional standards of practice for one (#35) of two residents reviewed for insulin administration.

Inspectors wroteBased on interview and record review, the facility failed to implement and operationalize procedures to ensure follow-up assessment and monitoring of abnormal laboratory testing results of medications with for one (#19) of five residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Enhanced Barrier Precautions/EBP were used, and handwashing was done after glove removal for 1 resident (Resident #46) of 13 resident's reviewed for handwashing and proper personal protective equipment usage, resulting in the protentional for cross contamination, resident and staff illness and increased antibiotic use. Findings Include: Resident #46:Review of the Face Sheet, Material Data Set/MDS dated 9/25, care plans dated 9/1/25, and admission nursing assessment dated [DATE], revealed Resident #46 was [AGE] years old, alert, admitted to the facility on [DATE], incontinent of bowel and bladder with a Foley urinary catheter in place, totally dependent on staff for his Activities of Daily Living/ADL's, and was mechanical lift for all transfers. [...]

Inspectors wroteBased on observation, interview and record review, 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Properly label and date food and food products, 2. Dispose of expired food and food products, 3. Thoroughly dry dishes prior to stacking, and 4. Ensure air gap for ice machine drainage pipe, resulting in the potential for cross-contamination and foodborne illness. These deficient practices have the potential to affect 37 residents who receive food from the kitchen. Findings Include: During a tour of the facility kitchen on 8/19/24, beginning at 9:04 AM, the following items were noted: - Kitchen Aid stand mixer was uncovered and not in use. When the mixer was tilted back, chunks of dried food substances were observed. - The floor appeared dirty with a build up of unknown substances and dirt behind the tables, oven, and near the walls. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize a comprehensive infection control program encompassing outcome and process surveillance, resulting in a lack of accurate and comprehensive infection control tracking including potential infections, surveillance and data monitoring/analysis, appropriate Personal Protective Equipment (PPE) use, lack of implementation of water management sample recommendations, contamination of linens, and the likelihood for spread of microorganisms and illness to all 37 facility residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide palatable and appealing food per preference for one resident (Resident # 35) of two residents reviewed and seven of seven confidential group Residents resulting in feelings of frustration and verbalization of discontentment.

Inspectors wroteBased on interview and record review, the facility failed to accurately record and obtain code status (level of medical interventions that an individual wishes to have enacted in a medical emergency situation) documentation for two residents ( Resident #29 and Resident #35) of three residents reviewed for Advance Directives (legal documentation enabling an individual to specify end-of-life care decisions), resulting in lack of accurate assessment and documentation of code status and the potential for a Resident to receive life sustaining medical treatment against their wishes.

Inspectors wroteBased on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure prompt attending physician's review of pharmacy recommendations and documentation of rationale for lack of action related to pharmacy medication irregularity recommendation reports for one resident (Resident #11) of five residents reviewed for unnecessary medications, resulting in Resident #11 receiving double the recommended medication dosage, the potential for Adverse Drug Reactions (ADR), and additional medication errors despite pharmacy oversight.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate medication administration and storage of insulin for one resident (Resident #139) and two inhalers for one resident (Resident #23), resulting in the likelihood of decreased medication efficacy and side effects such as mouth discomfort and/or mouth infection.

Inspectors wroteThis Citation Pertains to Intake Numbers MI00141220 and MI00141312. Based on interview and record review, the facility failed to honor a resident's right to return to the facility following the hospitalization of one resident (Resident #702) of three residents reviewed for transfer and discharge, resulting in Resident #702 being transferred to the hospital for evaluation and treatment related to mental health, and not being allowed to return to the facility without an alternative placement arrangement, necessitating them to stay in the Emergency Department for six days.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a clean ice machine, a proper functioning dish machine, a clean process for clean drying dish racks and a clean fan in the main kitchen, resulting in cross contamination of clean dishes and dish racks, a leaking dish machine with the likelihood of dirty dust particles likely to contaminate clean dishes on the dying rack and the likelihood of cross contamination for all residents using dishes in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, monitor and follow up on Pacemaker checks and a Pacemaker machine for one resident (Resident #3), resulting in no follow up for 17 months, no documented assessment of Pacemaker function, no Pacemaker machine found with the likelihood of Pacemaker complications going unnoticed.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure ongoing assessment, accurate documentation, and care coordination of pressure ulcer (wounds caused by pressure) wound care for one resident (Resident #2) of one resident reviewed resulting in inaccurate documentation, insufficient facility knowledge of pressure ulcer status, lack of wound status and assessment documentation from external wound care provider and the potential for inappropriate and/or delayed care/treatment, wound progression, and decline in overall health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to institute and operationalize policies and procedures to ensure comprehensive Range of Motion (ROM) monitoring, documentation, and implementation of a restorative nursing program for one resident (Resident # 1) of two residents,, resulting in a lack of restorative nursing services to maintain and/or prevent further decline in ROM, lack of quantitative assessment and documentation of ROM limitation, and the likelihood for increased ROM limitations, pain, and decline in independence and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a gait belt and walker during a toilet transfer for one resident (Resident #3), resulting in the care plan not being followed and an unsafe transfer.