Citadel of Sterling,The

In the surveyor’s words

From the most serious findings on record at Citadel of Sterling,The, in the surveyor’s own words.

• Actual harm, isolatedF744May 22, 2025

  Based on observation, interview, and record review the facility failed to ensure consistent dementia care was provided for 1 of 1 resident (R41) reviewed for dementia care in the sample of 23. This failure resulted in R41 exhibiting repetitive, uncontrolled combative behaviors, medication not being provided as ordered and a femur fracture. The findings include: R41's face sheet showed she was admitted to the facility 7/7/20 with diagnoses to include dementia without behavioral disturbance, Type 2 Diabetes, diverticulosis of intestine, dysphagia, major depressive disorder, seizures, and age-related osteoporosis. R41's facility assessment dated [DATE] showed she has severe cognitive impairment and is dependent on staff for all cares. […]

• Actual harm, isolatedF692Jun 12, 2024

  Based on observation, interview, and record review the facility failed to ensure there was no delay in notifying a dietitian of severe weight loss in residents and failed to ensure there was no delay in implementing the dietitian's recommendations for residents with severe weight loss. This failure resulted in the delayed treatment and monitoring of residents with severe weight loss. This applies to 3 of 3 residents (R27, R339, R61) reviewed for severe weight loss in the sample of 18. The findings include: 1. R27's Weights and Vitals Summary report showed on 9/5/23 R27 weighed 127.5 pounds and on 10/4/23 weighed 112.4 pounds. A severe weight loss of 13.4% in one month. R27's Progress Note dated 10/12/23 showed the dietitian recommended R27 to receive a dietary supplement twice a day. […]

• Actual harm, isolatedF686Jan 25, 2024

  Based on observation, interview and record review the failed to prevent a resident from developing pressure injuries and failed to identify pressure injuries prior to becoming stage 3, and unstageable for 1 of 3 residents (R1) reviewed for pressure injuries in the sample of 3. The findings include: R1's census report shows she was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses include obesity, hemiplegia and hemiparesis following a cerebral infarction affecting left non dominant side. The facility assessment of 11/30/23 documents R1 is a moderate risk for developing pressure sores due to being chairfast and very limited mobility. […]

• No harm, potential for more than minimal, widespreadF812Apr 30, 2026

  Based on observation, interview, record review the facility failed to ensure the 3-compartment sink was at the correct sanitization level, failed to serve cold food below 41 degrees Fahrenheit and failed to wash hands and change gloves after touching contaminated surfaces for all 87 residents reviewed for dietary services residing in the facility.The findings include: The CMS Form 671 dated 4/28/26 shows a resident census of 87.On 4/28/26 at 9:46 AM, V5 [NAME] tested the 3-compartment sink which had dishes in every compartment. V5 dipped the test strip into the disinfectant compartment, and the strip showed orange in color indicating 100 PPM. V5 said the strip should be green, closer to 200 PPM. […]

• No harm, potential for more than minimal, widespreadF804May 22, 2025

  Based on observation, interview and record review the facility failed to provide proper fitting plate lids to keep foods hot during transport and failed to ensure palatable food temperatures. These failures have the potential to affect all 96 residents who receive meals in the facility. Findings include: Facility Room Roster (provided on 5/20/25) indicates 96 residents/occupied beds. On 5/20/25 at 9:50 AM, R17 stated she always eats in her room and often her food is cold when they deliver her tray. V27, Family stated R17's food often is cold and does not like to eat it that way. […]