Sterling Care Bel Air

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide necessary respiratory care services. This was evident for 5 (Residents #102, #33, #22, #8 and #136) of 6 residents reviewed for respiratory care during the recertification survey.

Inspectors wroteBased on a review of employee files and interviews with facility staff, it was determined that the facility failed to ensure that Geriatric Nursing Assistants (GNAs) demonstrated competency in essential skills and techniques prior to providing resident care. This deficiency was identified in 4 out of 4 of the newly hired GNA employee charts (Staff #23, #24, #25, and #26) reviewed during the recertification/complaint survey.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility staff failed to ensure residents were properly evaluated for decision-making capacity, specifically failing to document the rationale for incapacity, and failed to ensure a resident either had an Advance Directive or was offered the forms to create one. This was evident for 4(#4, #147, #30, and #157) residents out of the 7 reviewed for Advance Directives during the recertification/complaint survey.

Inspectors wroteBased on observation, record reviews, and interviews, it was determined that the facility failed to provide adequate privacy to the resident by exposing their body parts. This was evident for 1 (Resident #136) of 1 resident sampled for privacy during the recertification survey.

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to develop and implement comprehensive care plans for oxygen therapy. This was evident for 3 (Residents #22, #8 and #136) of 31 residents reviewed for care planning during the recertification survey.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide necessary personal hygiene to dependent resident. This was evident for 1 (Resident #136) of 1 resident reviewed for Activities of Daily Living (ADLs) during the recertification survey.

Inspectors wroteBased on observation, clinical record review, resident interview, and staff interview it was determined that the facility failed to 1) follow a physician's order to turn and position a dependent resident and 2) failed to administer medications on time. This was evident for 1 (Resident #102) out of 1 resident reviewed for turning and positioning and for 1 (Resident #2) out of 2 residents reviewed for pain medication during the recertification/complaint survey.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to consistently monitor and document the temperatures of its medication refrigerators. This deficiency was identified in two medication refrigerators of two temperature logs reviewed during the recertification/complaint survey.

Inspectors wroteBased on resident interview, staff interview, and clinical record review, it was determined that the facility staff failed to 1) ensure that residents' names were accurately displayed at their room entrances, 2) failed to perform an accurate oral assessment, and 3) failed to ensure a resident's clinical records were in their most accurate form and free of another resident's information. This was evident for 2 residents (#39 and #57) out of a sample of 141 residents reviewed for room identification, and 2 (#64 and #157) residents out of 43 residents reviewed as part of the survey sample.

Inspectors wroteBased on observations, clinical record review, and staff interview, it was determined that the facility failed to use appropriate infection control practices for 1) the use and care of oxygen administration equipment and 2) urinary catheter maintenance and 3) failed to ensure that resident food stored in the nourishment room was properly dated to minimize the potential spread of infection. This was evident for 3 (Residents #33, #8, #133) of 31 residents reviewed for infection control practices during the recertification/complaint survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to update a resident's discharge plan to reflect the information received from home health services referral. This was evident for a discharged resident (Resident #3) during a complaint survey.

Inspectors wroteBased on medical record review, review of facility documentation and interview, it was determined the facility staff failed to prevent abuse of a resident resulting in psychosocial harm to the resident (Resident #5). This was evident for 1 of 3 residents reviewed for abuse during a complaint survey.

Inspectors wroteBased on medical record review, review of facility documentation and interview it was determined the facility failed to ensure a criminal background check was completed on an agency GNA (geriatric nursing assistant) which allowed a GNA (Staff #11) with a criminal background of assault and sexual assault to care for vulnerable residents. This was evident for 1 of 4 agency GNAs reviewed for criminal background checks during a complaint survey. Resident #5 alleged Staff #11 sexually abused him/her on 1/25/25. This resulted in psychosocial harm to Resident #5.

Inspectors wroteBased on review of complaint 302936, observation, interviews, review of resident council meeting minutes, attendance at the food committee meeting, and observations of the kitchen, it was determined that the facility failed to serve food that was attractive, palatable, matched what was on the tray ticket, timely, and at the proper temperature. This was evident for 19 (#34, #25, #18, #17, #19, #12, #13, #15, #16, #23, #10, #11, #35, #21, #31, #30, #32, #36, #5) of 19 residents interviewed or observed with the deficient practice having the potential to affect all residents.

Inspectors wroteBased on observation and interviews, it was determined the facility staff failed to provide maintenance services necessary to maintain resident wheelchairs. This was evident for 15 (#25, #26, #27, #14, #12, #28, #29, #30, #19, #20, #13, #16, #33, #34, #8) of 37 residents reviewed during a complaint survey.

Inspectors wroteBased on review of complaint, medical record review, and staff interview, it was determined the facility failed to provide care to meet the needs of a resident's physical, mental, and psychosocial health (Resident #7, #8, #4, #6). This was evident for 4 of 9 complaint residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #4, #7 and #9). This was evident for 3 of 9 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on review of complaint, medical record review, and interview, it was determined the facility violated the rights of a resident's representative (RP) by failing to follow the RP's wishes in where to send their loved one following their death in the facility. This was evident for 1 (#2) of 3 residents reviewed for death during a complaint survey.

Inspectors wroteBased on complaint, medical record review, and staff interview, it was determined the facility staff failed to timely notify a resident's physician/nurse practitioner of a change in condition. This was evident for 1 (#6) of 9 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to meet professional standards of practice as evidenced by licensed nursing staff documenting assessments, administration of medications, and treatments were completed when the resident was not in the facility (Resident #7 and #9). This was evident for 2 of 9 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by administering a medication not ordered by the physician (Resident #5). This was evident for 1 of 9 residents reviewed for complaints during a complaint survey.

Inspectors wroteBased on observation, staff interview, and documentation review, it was determined that facility staff failed to keep treatment and medication carts locked when unattended, failed to date medications when opened, discard medications/biologicals when expired, and refrigerate medication that required refrigeration. This was evident on 1 of 2 nursing units observed during random observations made during a complaint survey.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure that the garbage dumpster area was maintained in a sanitary manner to prevent the harborage of pests and rodents having the potential to affect all residents. There was garbage strewn around the dumpster on three days of the survey.

Inspectors wroteBased on observation of resident rooms and equipment and staff interview, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment. This was evident on 2 of 3 nursing units observed during a recertification/complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to assess and evaluate the nutrition needs of residents in a timely manner. (Resident #901, #902, #904, #906, #911, #910). This was evident for 6 of 33 complaint residents reviewed during a recertification/complaint survey.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure snacks were available to eight out of 33 sampled residents (Residents (R) 12, R112, R79, R106, R115, R87, R48, and R32) who desired snacks. The facility did not provide snacks to residents during the day and the evening/hours of sleep (HS) snack was not available to all residents who desired snacks.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure that the kitchen was maintained in a sanitary manner to prevent the potential spread of foodborne illness to all residents. Specifically, there were accumulated food and beverage spills, crumbs, and residue on kitchen surfaces such as on carts, shelving, tables, and the inside of the microwave; there was a black/grey substance on the wall above the dishwasher; there were unlabeled food items; and unclean cups and bowls stored as clean for one of one kitchen. This created the potential for the spread of foodborne illness for 105 out of 117 residents consuming food in the kitchen.

Inspectors wroteBased on observation, interviews, record review, review of the facility policy, the facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) for two of twelve residents (Resident (R) 13 and R51) reviewed for enhanced barrier precautions (EBP) when providing care, and staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease on 2 of 3 nursing units. These failures could promote the spread of multi-drug-resistant organisms (MDROs) throughout the facility.

Inspectors wroteBased on review of complaint, medical records, and interview, it was determined that the facility failed to review the admission agreement, which includes a notice of the resident's rights, with a resident and/or the Resident's responsible party at the time of admission and failed to ensure the admission agreement was signed and documented (Resident #906). This was evident for 1 of 33 complaint residents reviewed during a recertification/complaint survey.

Inspectors wroteBased on review of a closed medical record and staff interview, it was determined that the facility staff failed to complete a resident's discharge summary (Resident #913). This was evident for 1 of 33 complaint residents reviewed during the recertification/complaint survey.

Inspectors wroteBased on complaint, medical record review, and interview with facility staff, it was determined that the facility failed to provide needed showers for residents' dependent on assistance with care. This was evident for 2 (#907, #912) of 33 residents reviewed for complaints during a recertification/complaint survey.

Inspectors wroteBased on review of complaint, medical record review, and staff interview, it was determined the facility failed to provide care to meet the needs of a resident's physical, mental, and psychosocial health (Resident #904, #914, #918). This was evident for 3 of 33 complaint residents reviewed during a recertification/complaint survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to monitor the blood pressure and heart rate prior to administering a blood pressure medication per physician's orders. This was evident for 1 (#901) of 33 residents reviewed for complaints during the recertification/complaint survey.

Inspectors wroteBased on staff interview and medical record review it was determined the facility failed to ensure that a resident's laboratory tests were completed in a timely manner (Resident #40). This was evident for 1 of 33 complaint residents reviewed during a recertification/complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (#51, #901) of 33 residents reviewed for complaints during a recertification/complaint survey.

Inspectors wroteBased on record review and staff interview it was determined the facility failed to have a process in place to ensure nursing staff were receiving competency evaluations. This was evident for 8 of 10 employee records reviewed during the survey.

Inspectors wroteBased on record review and staff interview it was determined the facility failed to ensure nurses' aides received education that corresponded with annual performance evaluations. This was evident for 3 of 3 employee records reviewed.

Inspectors wroteBased on observation it is determined the facility staff failed to provide Resident # 115 with the means to communicate to nursing when the Resident is in the room. This was evident for 1 out of 43 Resident investigated during the survey process. The Finding Include: The Resident is a quadriplegic due to multiple sclerosis. On 6/27/19 around 10:00 AM, while interviewing the resident during the first part of the survey, it was noted that the Resident uses a touch pad call bell in the room that enables clients with limited movement to summon help easily. Due to Resident #115's lack of mobility, the Resident uses the chin to touch the pad and summon nursing when needed. The call bell must be placed under the Resident's chin in order for the Resident to use it. The call bell was observed with the cord of the pad clipped to the Resident's left sleeve. [...]

Inspectors wroteBased on observation, medical record review and staff interview it was determined the facility failed to ensure the medication error rate was less than 5%. Two administration errors were noted for Resident #102. This was evident for 1 of 4 residents observed while receiving medications.

Inspectors wroteBased on Resident complaint and observation it was determined that the facility staff failed to maintain adequate lighting for Resident #33. This is evident during the interview/observation part of the survey. The Findings Include: On 07/01/19 around 01:35 PM while interviewing Resident #33, the Resident complained that the cord to the over bed light fixture was too short, therefore the light could not be used. Further review of the Resident's room revealed the Resident's bed to be in its highest position (resident's preference) and the pull to the fixture still could not be accessed. The maintenance manager was notified It is the facility's responsibility to ensure that Residents have access to lighting and provides Resident control.

Inspectors wroteBased on review of resident medical records and interview with facility staff, it was determined that the facility failed to develop comprehensive pain care plans that included non-pharmacologic interventions for residents. This was evident for 1 (Resident #76) of 2 residents reviewed for pain.

Inspectors wroteBased on observation, medical record review and staff interview it was determined the facility failed to ensure dependent Resident #96 received personal care in a timely manner. This was evident for 1 of 43 residents investigated during the survey.

Inspectors wroteBased on medical records and staff interview, it was determined that the facility staff failed to respond to a consultant's response from a medical appointment for Resident #115. This was evident for 1 out of 2 residents investigated for a catheter during the survey process. The Findings Include: Resident #115 is a quadriplegic from multiple sclerosis and has a supra public catheter (tube that drains urine from your bladder), because of a neurogenic bladder (urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem). The Resident has been hospitalized multiple times from urinary tract infections and sepsis (a potentially life-threatening condition caused by the body's response to an infection). The Resident saw a urologist on 5/14/19 who recommended the catheter be changed every 2-3 weeks in an attempt to cut down on the number of infections. [...]

Inspectors wroteBased on review of resident medical records and interview with residents and facility staff, it was determined that the facility failed to ensure that residents with as-needed pain medication regimens received pain medication according to physician prescribed parameters. This was evident for 1 (Resident #76) of 2 residents reviewed for Pain Management.

Inspectors wroteBased on observation, medical record review and staff interview it was determined the facility failed to ensure the medication error rate was less than 5%. Two administration errors were noted for Resident #102. This was evident for 1 of 4 residents observed while receiving medications.