Sterling Health Care and Rehab Center

Inspectors wroteBased on review of facility policy, clinical record review, facility documents, and staff interviews it was determined the facility failed to ensure that the residents' environment remained free of accident hazards for one of four residents (Resident 1) identified as an elopement risk. This was identified as a past non-compliance for Resident R1.

Inspectors wroteBased on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to timely notify the physician of the significant change in weight for one of two residents reviewed (Resident CL1).

Inspectors wroteBased on review of facility policy, clinical records, hospital records, facility investigative documentation, and staff interviews, it was determined the facility failed to provide an environment free from physical abuse and timely abuse reporting for one of 28 residents reviewed (Resident 78). The facility's failure to protect Resident 78 resulted in Resident 78 being sent to the hospital for facial bruising and a hematoma (collection of blood that pools outside of a blood vessel in an organ, tissue, or body space) to the forehead. The facility's failure to timely report the witnessed abuse continued to put Resident 78 and residents from two of four units at risk for further abuse when Employees E3 and E4 continued to provide care. [...]

Inspectors wroteBased on review of facility policy, clinical record, facility investigation documentation, and staff interviews, it was determined the facility failed to ensure that residents received adequate supervision and assistance to prevent accidents, which resulted in a laceration to the forehead requiring 10 staples to close, for one of seven residents reviewed (Resident 97). Findings Include: Review of Resident 97's clinical record revealed diagnoses including but not limited to; Unspecified Dementia (neurodegenerative disease effecting memory, thinking, and social abilities), lack of coordination, Abnormal posture, muscle weakness, Anxiety disorder, and Intervertebral Disc Degeneration lumbar region (cartilage between the vertebrae begins to deteriorate). [...]

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to maintain safe and sanitary conditions in the kitchen area.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to maintain a safe and sanitary environment on the patio and loading dock area.

Inspectors wroteBased on a review of the facility's policy, clinical records, and staff interview, it was determined the facility failed to thoroughly investigate missing personal property for one of the 36 residents reviewed (Resident 136).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined the facility failed to ensure that physician's orders for wound treatments were followed for one of seven resident reviewed (Resident 9).

Inspectors wroteBased on review of facility policy, clinical record, and staff interview, it was determined the facility failed to adequately monitor significant weight changes for two of four residents reviewed for nutrition (Residents 94 and 116).

Inspectors wroteBased on job description reviews, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility by ensuring resident were provided an environment free from abuse or potential of abuse and staff report abuse situations timely.

Inspectors wroteBased on observations and staff interview, it was determined the facility failed to ensure Enhanced Barrier Precautions (infection control prevention designed to reduce transmission of multidrug-resistant organisms in nursing homes) were in place for residents requiring enhanced barrier precautions for one of two residents reviewed (Resident 95).

Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interviews it was determined that the facility failed to ensure a resident was free from physical restraint (Resident R1).

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility failed to ensure that the pharmacy provided medications timely for two of three residents reviewed (Resident R1 and R2).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment, and maintain resident care equipment, on three of four units of the facility.

Inspectors wroteBased upon review of staffing records and performance reviews it was determined the facility failed to ensure performance reviews were completed for five of five staffing records reviewed.

Inspectors wroteBased on observation and interviews with staff it was determined that the facility failed to ensure infection control and prevention was implemented during medication administration for three of the three residents observed (Residents 44, 61, and Resident 7)

Inspectors wroteBased upon review of staffing records and inservice documentation, it was determined the facility failed to ensure nurse aides received required 12 hour annual re-training for five of five records reviewed. Findings Include: Review of five staffing records and inservice documentation revealed one nurse aide received the required 12 hour annual retraining. Further review of the staffing records and inservice documentation revealed four of the five records reviewed failed to reveal evidence of retraining. Interview with the Nursing Home Administrator on October 27, 2023 at 1:00 p.m. confirmed that the nurse aides did not received the required in-service retraining. 28 Pa.

Inspectors wroteBased upon clinical record review, it was determined the facility failed to provide an opportunity to formulate an advance directive for one of 32 residents reviewed (Resident 131).

Inspectors wroteBased on observation, a review of clinical records and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 28 residents reviewed (Resident 23).

Inspectors wroteBased on clinical records review and staff interviews, it was determined that the facility failed to follow a recommendation from a consulting psychiatry provider for a resident exhibiting a behavioral symptom for one of 28 residents reviewed (Resident 65).

Inspectors wroteBased upon clinical record review, it was determined that the facility failed to ensure that medication irregularities were acted upon by a physician for one of three residents reviewed (Resident 58).

Inspectors wroteBased on facility policy, clinical record review, and staff interviews, it was determined the facility failed to monitor the skin of residents at risk for skin impairment causing actual harm by discovering a pressure ulcer at an advanced stage for one of eight residents reviewed (Resident 81).

Inspectors wroteBased on resident interviews, observation, and staff interview, it was determined that the facility failed to provide foods that were served at the proper temperature to ensure resident satisfaction on one of four units (1st floor).

Inspectors wroteBased on policy and clinical record review and interview, it was determined that the facility failed to provide evidence that education was provided to residents on the risks and benefits of the COVID-19 vaccine for five of five residents reviewed that refused the COVID-19 vaccine (Residents 23, 92, 112, 127, and 147).

Inspectors wroteBased on resident and staff interviews, it was determined that the facility failed to consistently afford residents the ability to readily withdraw funds from the resident petty cash fund.

Inspectors wroteBased on a review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to thoroughly investigate a bruise of unknown origin for one of the 28 residents reviewed (Resident 91).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for one of 32 residents reviewed (Resident 8).

Inspectors wroteBased on a review of the clinical record and interview with resident and staff, it was determined that the facility failed to develop a plan of care with interventions to meet the resident needs identified in the comprehensive assessment for two of 28 residents reviewed (Residents 49 and 58).

Inspectors wroteBased on clinical record review, interviews with the staff it was determined that the facility failed to assess a resident after a change in condition in a timely manner for one out of 32 residents (Resident 85) reviewed causing pain during a delay of service.

Inspectors wroteBased on policy, interview, observation, and clinical record review, it was determined that the facility failed to assess a resident for safety during smoking for one of one residents reviewed (Resident 23).

Inspectors wroteBased on policy, interview, observation, and clinical record review, it was determined that the facility failed to obtain a physician's order for oxygen therapy for one of one resident reviews (Resident 58).

Inspectors wroteBased upon clinical record review and staff interview, it was determined that the facility failed to ensure that any irregularities were acted upon by a physician for one of five residents reviewed (Resident 49).

Inspectors wroteBased on review of facility policy and clinical records, it was determined that the facility failed to ensure that the appropriate timeframe, justification, and non-pharmalogical interventions were in place for as needed (PRN) psychotropic medications for two of 28 residents reviewed (Residents 58 and 107).

Inspectors wroteBased on observation, review of the medication manufacturer's guidelines, and staff interview, it was determined that the facility failed to ensure medications were properly labeled and stored for one of three medication carts observed (Chateau Medication Cart two).