Sterling Oaks Rehabilitation

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: The facility failed on 5.26.26 to seal and cover food stored in refrigerator and out in open area of kitchen. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one of six residents (Resident # 51) reviewed for accommodation of needs. Resident #51's call light was not left within his reach or within sight. This failure could place residents at risk of not having their needs met and a decline in their quality of care and life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident #22) reviewed for privacy, in that: The facility failed to ensure opened mail of Resident #22's was not out in a common area for anyone to see. This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 2 (Resident #98 and Resident #128) of 12 residents observed for oxygen management and CPAP use. The facility failed on 05/26/2026 to post oxygen in use signs outside Resident #98's and Resident #128's rooms. The facility failed 0n 05/26/2026 to properly store Resident #98's CPAP machine in a bag when it was not in use. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support, decline in health, at risk for cross contamination, spread of infection, and at risk of fire hazards by not posting oxygen signs outside the residents' rooms. Addendum to; Observation and interview on 05/26/2026 at 9:01 a.m. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure that drugs and biologicals used in the facility were properly stored and or disposed of according to professional standards in 2 of 2 (Medication Room Hall 300/400) reviewed for medication storage. The facility failed to dispose of expired IV mixed solution medications. The facility failed to properly store 1 glass bottle medication in the refrigerator which led to the breaking of the bottle. This failure caused the medication to be spilled inside of the plastic zip bag and caused breakdown of the box the mediation was stored in resulting in the medication being unsafe to administer. This failure could place residents receiving medication that is expired at risk of not receiving the intended therapeutic benefit of their medication, or other adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #113) of 3 residents reviewed for infection control. CNA A failed to change her gloves after they became contaminated while assisting Resident #113 with incontinent care. CNA A also used the same wipe to wipe the resident's peri-area several times with the same side of the wipe. (Peri-care is the hygienic cleaning and maintenance of the genital and anal areas to prevent infection, skin breakdown, and odor, especially for individuals who need assistance). These failures could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure the residents' right to secure and confidential personal and medical records for 6 (unknown resident) residents. The facility failed to ensure the privacy of the unknown residents by locking the laptop screen, so the residents' information could not be seen by someone walking by. This failure put residents at risk for confidential health information exposure, psychosocial harm, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 5 Residents (Resident #1 and Resident #2) reviewed for medical records accuracy, in that: Resident #1's September 2025 MARs did not reflect documentation that heart rate and blood pressure was done. Resident #2's September 2025 nurse's notes did not document reasons why blood pressure medication was given when it was supposed to be held. This deficient practice could affect residents whose records were maintained by the facility, by placing them at risk for errors in care, and treatment. Record review of Resident #1's admission face sheet dated 09/26/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that residents were provided pharmaceutical services to meet the needs of each resident for 1 of 5 residents reviewed for pharmaceutical services (Resident #2). The facility failed to ensure that Resident #2's, medication Metoprolol for high blood pressure was held as ordered by the physician when it was 118/62 and 110/64. This failure placed all residents who received medications at risk of not getting their medications as ordered, which could result in residents not receiving the therapeutic benefits of the medication including decreased in blood pressure and decreased quality of life. Record review of Resident #2's admission face sheet dated 9/29/2025 revealed Resident # 2 was a [AGE] year-old female who was admitted on [DATE]. Resident #2's diagnoses included hypertension (high blood pressure). [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 5 Residents (Resident #1 and Resident #2) reviewed for medical records accuracy, in that: Resident #1's September 2025 MARs did not reflect documentation that heart rate and blood pressure was done. Resident #2's September 2025 nurse's notes did not document reasons why blood pressure medication was given when it was supposed to be held. This deficient practice could affect residents whose records were maintained by the facility, by placing them at risk for errors in care, and treatment. Record review of Resident #1's admission face sheet dated 09/26/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that residents are free of medications errors for 1 of (Resident #2) 5 residents reviewed for medications errors. The facility failed to ensure that Resident #2's, medication Metoprolol for high blood pressure was held as ordered by the physician when it was 118/62 and 110/64. This failure placed all residents who received medications at risk of not getting their medications as ordered, which could result in residents not receiving the therapeutic benefits of the medication including decreased in blood pressure and decreased quality of life. Record review of Resident #2's admission face sheet dated 9/29/2025 revealed Resident # 2 was a [AGE] year-old female who was admitted on [DATE]. Resident #2's diagnoses included hypertension (high blood pressure). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for and 2 of 5 medication carts (medication cart Hall 100 and 200) reviewed for medication storage. - The facility failed to ensure the back of 100 and 200 hall medication carts did not contain eyedrops, ointment, cream and nasal spray that were opened and not labeled with the resident's name and date. This failure could place residents at risk of adverse medication reactions and infections. Findings Include: Observation on [DATE] at 2:11 PM revealed the medication cart for 100 hall with MA A. The 100 hall medication cart had the following medications with no open date documented: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet a resident mental, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Resident #6 and #30) reviewed for care plans. 1. The facility failed to ensure Resident #6's diagnoses were addressed in her comprehensive care plan. 2. The facility failed to ensure Resident #30's diagnoses and medications were addressed in her comprehensive care plan. This failure could place residents at risk of not receiving appropriate care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 8 residents (Resident #14) reviewed for respiratory care. The facility failed to change Resident #14's oxygen tubing and humidifier bottle every 7 days. This failure could place residents at risk for respiratory infections, unwanted hospitalization and decrease in quality of life.

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 4 halls reviewed for infection control. 1. The facility failed to dispose soiled linen inside of a waste barrel in the soiled utility room on Hall 200. 2. The facility failed to place a trash bag in the trash barrel instead of on the floor in the utility room on Hall 300. These failures could place residents at risk for cross contamination, infections, and a decrease in quality of life.

Inspectors wroteBased on interviews 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 3 of 5 Residents (Resident #1, #2, #3). The facility failed to administer Resident #1's medication according to her physician order at the prescribed time. The facility failed to administer Resident #2's medication according to her physician order at the prescribed time. The facility failed to administer Resident #3's medication according to her physician order at the prescribed time. The facility failed to administer Resident #3's medication because they did not have the correct dosage. These failures could affect all residents and place them at risk of injury, pain, decline in health, or diminished quality of life. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a safe, functional, sanitary, comfortable, and homelike environment for five of five residents (five residents interviewed during a confidential group interview) who utilized laundry services at the facility. -The facility failed to ensure residents who utilized laundry services clothing was returned to them in a timely manner. These failures could place the residents at risk of decreased quality of like due to the lack clothing.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 1 of 5 Residents (Resident #38) and 1 of 8 medication carts (100 Hall Medication Aide Cart) reviewed for medication storage. The facility failed to ensure LVN B secured insulin from Resident #38's bedside when left unattended. The facility failed to ensure MA A locked 100 Hall Medication Cart before leaving it unattended. These failures could place residents at risk for possible drug diversions or accidental ingestion.