Sterling Place Healthcare & Rehabilitation Center

Inspectors wroteBased on interviews and record reviews, the facility failed to report a serious bodily injury of unknown origin ,resulting in a fracture, to the State Survey Agency within the required 2 hour timeframe for 1 (#64) of 2 residents reviewed for accidents.

Inspectors wroteBased on observation, interviews, and policy review, the facility failed to store food in accordance with professional standards for food service safety by failing to document temperatures on temperature logs. This had the potential to affect the 121 residents who were served by the kitchen.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to affect 127 residents who were served from the kitchen.

Inspectors wroteBased on record review and interviews the facility failed to implement a comprehensive person-centered care plan which met the needs of 2 (#9 and #124) of 2 (#9 and #124) residents reviewed for weight loss. The facility failed to ensure weekly weights were completed as ordered.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain acceptable parameters of nutritional status by failing to monitor, modify, and implement interventions after weight loss for 1 (#124) of 3 (#12, #98, and #124) residents reviewed for nutrition. The facility failed to ensure 1. Resident #124 was assessed for food preferences; and 2. Resident #124 was weighed weekly, treating providers were notified of weight loss, and new interventions were implemented.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure 2 (#44 and #56) of 5 (#42, #44, #56, #332, # and #381) resident's records had documentation indicating the resident either received or did not receive a pneumococcal immunization due to medical contraindication or refusal.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident's call light was within reach for 1 (#9) of 2 (#9 and #61) residents reviewed for call lights.

Inspectors wroteBased on observations and interviews, the facility failed to ensure resident's room were clean and maintained in a sanitary manner for 1 (#117) of 3 (#20, #95, and #117) sampled residents investigated for environment. The facility failed to ensure Resident #117's room were properly cleaned and free of urine odor. The deficient practice had potential to affect all incontinent Residents in facility.

Inspectors wroteBased on record reviews and interviews, the facility failed to coordinate assessments with the resident's Pre-admission Screening and Resident Review (PASRR) Level II by failing to incorporate a PASRR Level II determination and recommendations into a resident's MDS (Minimum Data Set ) for 1 (#42) of 2 (#42 and #99) residents reviewed for PASRR. Review of Resident #42's Clinical Record revealed an admission date of 06/20/2023 and diagnoses, which included Schizoaffective Disorder - Bipolar Type, Psychotic Disorder with Hallucinations, and Unspecified Psychosis. Review of Resident #42's BHSF Form 142 revealed she was approved for admission by Level II PASRR effective 11/20/2024. Review of Resident #42's Significant Change MDS with an ARD (Assessment Reference Date) of 01/08/2025 revealed question A1500, Resident evaluated for PASRR, was answered as no. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene by failing to ensure each resident received scheduled baths for 1 (#73) of 2 (#9 and #73) residents reviewed for ADLs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities based on the comprehensive assessment for 1 (#12) of 2 (#12 and #41) residents reviewed for activities. This had the potential to affect any of the 125 residents' residing in the facility.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This had the potential to affect 126 residents who were served meals from the kitchen.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure resident MDS assessments accurately reflected the resident's status for 4 (#11, #68, #100, and #119) of 8 (#10, #11, #23, #68, #100, #109, and #119) residents reviewed for PASRR by failing to correctly code the residents PASRR evaluations.

Inspectors wroteBased on interview and record review, the facility failed to incorporate the recommendations from Preadmission Screening and Resident Review (PASRR) Level II Determinations and PASRR Evaluation Reports into resident's assessment, care planning, and transitions of care for 3 (#14, #100, and #109) of 8 (#10, #11, #14, #23, #68, #100, #109, and #119) residents reviewed for PASRR.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out ADLs received the necessary services to maintain good grooming and personal hygiene for 2 (#40 and #119) of 2 (#40 and #119) residents reviewed for ADL's. The facility failed to clean and trim fingernails for Residents #40 and #119.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a safe, functional, sanitary and comfortable environment for 5 of 5 (a, b, c, d, e) rooms observed for environmental concerns. The facility failed to ensure maintenance of: 1. The walls, door frame and facing, and ceiling tiles in Room a; 2. Water entering the interior of Room a; 3. Water entering from windows and from ceiling above electrical outlet in Room b; 4. Ceiling tiles and prevention of sagging, black discolorations for Room c; 5. The walls and flooring of Room d; 6. Sanitary conditions for cleaning station, eye wash station, and ceiling tiles of Room e

Inspectors wroteBased on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free of pests and insects. This deficient practice had the potential to affect 128 residents who currently reside in the facility.

Inspectors wroteBased on record reviews and interviews, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for 1 (#98) of 4 (#68, #72, #98, and #99) residents reviewed for abuse.

Inspectors wroteBased on record review and interviews, the facility failed to ensure an allegation of abuse was reported immediately, but no later than 2 hours, after the allegation was made to the state survey agency for 1 (#98) of 4 (#68, #72, #98, and #99) residents reviewed for abuse.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, sanitary, and comfortable environment in 12 of 12 (a, b, c, d, e, f, g, h, i, j, k, and l) rooms observed for environmental concerns.

Inspectors wroteBased on observations of video footage, interviews, and record reviews, the facility failed to protect the residents' right to be free from physical abuse by S5CNA for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance Citation.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide services and assistance to maintain bladder continence for 1 (#1) of 2 (#1 and #5) continent residents reviewed. This deficient practice resulted in an actual harm for Resident #1, a continent resident, on 08/19/2023 at 5:53 a.m. when she attempted to go to the restroom and fell in her room. Resident #1 was admitted to the facility on [DATE] after a left knee replacement surgery which required one person assist with utilization of a walker for mobility. On 08/19/2023 at 4:27 a.m., Resident #1 began asking S5CNA for assistance to the restroom. S5CNA failed to assist Resident #1 to the restroom. On 08/19/2023 at 5:53 a.m., Resident #1 fell on the floor hitting her face after attempting to go to the restroom to prevent urination on herself. [...]