Sterling Hills Rehabilitation and Healthcare Cente

Inspectors wroteBased on interview and record review the facility failed to transmit completed discharge assessment that accurately reflected the residents' status for 1 of 23 sampled residents (Resident #83) whose records were reviewed, in that: Resident #83 discharge MDS was not transmitted within 14 days of the completed date. This failure could place residents at risk by not receiving the appropriate assessments. Based on interview and record review the facility failed to transmit completed discharge assessment that accurately reflected the residents' status for 1 of 23 sampled residents (Resident #83) whose records were reviewed, in that: Resident #83 discharge MDS was not transmitted within 14 days of the completed date. This failure could place residents at risk by not receiving the appropriate assessments.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 23 residents (Resident #43) reviewed for pain management. The facility failed to ensure Resident #43 had effective pain management by failing to have their PRN pain medication available. This failure could place residents at risk for increased pain and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 23 residents (Resident #43) reviewed for pharmacy services. The ADON failed to document pain medication given on 03/18/26 to Resident #43 on the residents' narcotics count sheet and the MAR. This failure could place residents at risk for medication error and drug diversion.

Inspectors wroteBased on interview and record review the facility failed to ensure in accordance with accepted professional standards and practices, medical records maintained on each resident were accurately documented for 1 of 23 residents (Resident #43) reviewed for accuracy of records. LVN E failed to document an incident when she could not get access to Resident #43's pain medication during the night shift on 03/23/2026 because she could not get ahold of the pharmacy provider in the electronic health record. These failures could affect residents whose records are maintained by the facility and could place the residents at risk for errors in care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Resident #8 and Resident #52) reviewed for incontinence care. CNA C failed to utilize hand hygiene between glove changes when performing indwelling Foley catheter (a flexible tube inserted into the bladder to drain urine) care for Resident #8. CNA D failed to utilize hand hygiene between glove changes when performing incontinence care for Resident #52. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to notify residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally or in writing; the right to file grievances anonymously; the contact information of the grievance office with whom a grievance can be filed, that is, his or her name business address and business phone number, a reasonable expected time frame for completing the review of the grievance, and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system for 20 of 20 confidential residents reviewed for grievances . [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in experimental research, and to formulate advance directives for 2 of 2 residents (Residents #4 and #63) reviewed for advanced directives. The facility failed to ensure Residents #4 and #63, who were listed as DNR had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that did not have required information on the OOH-DNR. This failure could place residents at risk for not having their end of life wishes honored and incomplete records.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 2 medication carts (Medication Cart 2 and Medication Cart 4) reviewed for medication storage . 1. The facility failed to keep Medication Cart 2 free of loose and unlabeled pills. 2. The facility failed to keep Medication Cart 4 free of loose and unlabeled pills. These failures could place residents at risk of harm or decline in health due to lack of medication labeling.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received and the facility provided food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 3 food forms (puree) at 2 of 4 meals (12/12/24 noon meal and 12/11/24 dinner meal) reviewed for palatability. The facility failed to provide food that was palatable for 1 of 3 food forms served (regular, mechanical soft and puree) at 2 of 4 meals observed (12/10/24 lunch and 12/11/24 dinner) . These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Residents #229) reviewed for infection control. CNA C and CNA D failed to utilized enhanced barrier precautions during foley care for Resident #229 on 12/11/2024. This failure could place residents at risk for infection and cross contamination.

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 in 1 of 1 kitchen reviewed for dietary services, in that: 1)The facility failed to ensure foods were processed and pureed under sanitary conditions. 2) The facility failed to ensure foods were stored in a manner to prevent contamination. 3) The facility failed to ensure foods were served at temperature above 135 degrees Fahrenheit. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interviews and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with an accurate PASRR Level I for 3 of 24 residents (Residents #8, #35, and #59) reviewed for PASRR screening, in that: Residents #8, #35, and #59 did not have an accurate PASRR Level 1 assessments when they had a diagnosis of mental illness. These failures could place residents with an inaccurate PASRR Level 1 Evaluation and no PASRR Level 2 Evaluation at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable and sanitary environment to help prevent the development and transmission of diseases for 4 of 4 (Residents #19, #26, #59, and #171) and 5 of 7 (LVN A, CNA A, CNA C, CNA E, and CNA F) staff reviewed for infection control. 1. LVN A failed to wear gloves while checking the blood sugar for Resident #26 or perform hand hygiene after the procedure. 2. CNA A failed to perform hand hygiene between glove changes when providing incontinent care for Resident #19. 3. CNA C failed to perform hand hygiene between glove changes when providing incontinent care for Resident #171. 4. CNA E and CNA F failed to perform hand hygiene between glove changes when providing incontinent care for Resident #59. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 1 of 26 (Resident #26) residents in that: LVN A failed to provide Resident #26 privacy during a blood sugar check. This could place residents at risk for diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 2 of 26 residents (Residents #18 and #39) reviewed for care plans as follows: 1. Resident #18 did not have a care plan for indwelling catheter. 2. Resident #39 did not have a care plan for activities of daily living/rehabilitation potential, urinary incontinence, nutritional status, pressure ulcer risk or pain. These failures could place residents at risk of not receiving the care required to meet their individualized needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature for 2 of 2 meal reviewed for palatability. 1) The facility failed to provide food that was palatable for 1 of 3 food forms served (Regular, Mechanical soft and pureed) at 2 of 2 meal observed (10/17/23 and 10/18/23 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.