Sterling Park Health Care Center

Inspectors wroteBased on interview and document review, the facility failed to follow process to ensure advanced directives were accurately documented and updated on the resident's electronic health record (EHR) banner, physician orders and Physician's Orders for Life Saving Treatment (POLST) which affected 2 of 16 residents (R35 and R19) reviewed for advance directives. These findings constituted an immediate jeopardy (IJ) situation for R35 and R19 who would not have received cardiopulmonary resuscitation measures (CPR) according to their wishes. The IJ began on [DATE], when R35's POLST, indicating R35's wishes for resuscitation was signed by the medical provider and it was not changed within the facility's EHR to reflect R35's wishes. This error was not identified despite multiple opportunities; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a Registered Nurse (RN) was on-site for at least 8 consecutive hours on a daily basis. Lack of consistent RN coverage may result in delayed assessment, clinical decision-making, or care interventions, potentially jeopardizing resident health and safety. This failure had the potential to negatively impact resident care and oversight.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure parameter mattress (a type of mattress cover, or encasement designed to create a gentle barrier around the edge of the bed, preventing falls) was not used in a manner to restrain resident while in bed for 1 of 1 resident (R21) reviewed for restraints.

Inspectors wroteBased on interviews and document review, the facility failed to ensure that a safe and orderly discharge was arranged for 1 of 2 residents (R40) who was discharged against medical advice (AMA). The facility did not complete a comprehensive discharge plan, or adequate documentation of efforts to educate the resident about the risks of leaving AMA. Findings Include: R40's quarterly Minimum Data Set (MDS) dated [DATE], identified R40 had intact cognition and required minimal or limited assistance with activities of daily living (ADL)'s. R40's diagnoses included type II diabetes mellitus (DM) with other specified complication, major depressive disorder, hypertension, bilateral primary osteoarthritis of knee, postprocedural; hypothyroidism, and hyperlipidemia. [...]

Inspectors wroteBased on interview and record review the facility failed to develop a person-centered care plan for 1 of 2 residents (R25) reviewed for care planning.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and implement interventions to ensure proper wheelchair positioning and prevent potential complications for 1 of 1 resident (R21) reviewed for wheelchair usage. Further, the facility failed to ensure medications were administered per physician's order for 1 of 1 resident (R25) reviewed for assessment prior to medication administration.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess a resident for safe electric recliner usage for 1 of 1 resident (R21) reviewed for accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices during meal service for 3 of 3 dining observations. Specifically, staff failed to intervene when a resident (R25) was observed touching the tops of other residents' coffee cups during meal service, creating a risk for cross-contamination and transmission of communicable diseases.

Inspectors wroteBased on interview and document review, the facility failed to promptly notify a physician of a change in condition for 1 of 3 residents (R1) reviewed when a right lower leg abscess worsened and required hospitalization.

Inspectors wroteBased on interview and document review, the facility failed to implement treatment consistent to the resident's physician's orders and professional standards of practice, and revise interventions as appropriate for 1 of 3 residents (R1) when R1 was not sent sustenance with to his appointment.

Inspectors wroteBase on observation, interview, and document review, the facility failed to store and label food properly, dispose of undated and expired food items, to reduce the risk of food borne illness. This deficient practice had the potential to affect 34 residents who were provided meals from the kitchen.

Inspectors wroteBased on observation, interview and document review, the facility failed to assess residents for the ability to self-administer medications after staff set up, or obtain order for medication self-administration for 1 of 1 (R27) residents observed self-administering medication.

Inspectors wroteBased on interview and document review the facility failed to ensure adequate and required information was documented and communicated to a receiving healthcare facility to ensure continuity of care when transferred emergently to a hospital setting for 1 of 1 residents (R38) reviewed for hospitalizations.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 1 residents (R38), or legal representative had been informed of bed hold rights at the time of hospitalization.

Inspectors wroteBased on observation, interview, and documentation review the facility failed to ensure coordination of care and communication between the facility and the dialysis center for 1 of 1 resident (R27) receiving hemodialysis.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were available to be administered as prescribed by the physician, for 1 of 1 residents (R27) reviewed for medication.

Inspectors wroteBased on interview and document review, the facility failed to offer or provide the pneumococcal vaccine for 1 of 5 (R26) residents reviewed for immunizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices regarding disinfection of mechanical Hoyer lifts for 3 of 6 residents (R10, R12 and R22) who utilized a multiple-resident use lift. R10's quarterly Minimum Data Set (MDS) dated [DATE], identified that R10 was a total assist of two staff with transfers and required the use of a total body mechanical lift. R12's quarterly MDS dated [DATE], identified that R12 was an extensive assist of two staff with transfers and required the use of a total body mechanical lift. R22's quarterly MDS dated [DATE], identified that R22 was an extensive assist of two staff with transfers and required the use of a total body mechanical lift. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure 3 of 5 residents (R13, R24 and R31) were offered or received the pneumococcal vaccine (PCV20) in accordance with the Center for Disease Control (CDC) recommendations.