Sterling Rehabilitation and Nursing, LLC

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries from occurring or worsening for two (#4 and #52) of five residents reviewed for pressure injuries out of 45 sample residents. Resident #4, who was at risk for developing pressure ulcers, was admitted on [DATE] and readmitted on [DATE] after a five-day hospital stay. The 4/2/25 wound weekly observation assessment revealed the resident acquired a right heel suspected deep tissue injury (DTI) on 3/21/25, three days after she was readmitted to the facility. The right heel wound measured 3.5 centimeters (cm) in length, 3.5 cm in width and 0.0 cm in depth. The assessment revealed it was the first observation of the wound. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to:-Ensure uncooked meat was separated from ready-to-eat food; -Ensure food was discarded after the date of expiration; -Ensure food was labeled and dated appropriately; and, -Ensure the kitchen was maintained in a clean manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) to ensure the highest practicable quality of life and care for four (#23, #65, #8 and #43) out of eight residents reviewed for ADLs out of 45 sample residents. Specifically, the facility failed to provide bathing for Resident #23, Resident #65, Resident #8, and Resident #43 to maintain the residents' personal hygiene.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper storage of medications for one of three medication storage rooms and three of three medication storage carts. Specifically, the facility failed to:-Date residents' insulin pens with the date it was opened;-Label residents' insulin pens with the resident's name; -Discard medication that had expired; and,-Discard open medications from a medication refrigerator for a resident who had been discharged several months earlier.

Inspectors wroteBased on record review and interviews, the facility failed to establish an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for two (#3 and #7) of five residents reviewed for antibiotic use out of 45 sample residents. Specifically, the facility failed to: -Develop and implement an effective facility-wide system to monitor the use of antibiotics; and, -Effectively track and monitor the use of antibiotics for Resident #3 and Resident #7.

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of potential abuse to the state oversight agency in accordance with state laws for one of three allegations. Specifically, the facility failed to timely report an allegation of resident-to-resident verbal abuse of Resident #5 by Resident #32 to the State Agency.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#39) of three residents received care and services according to acceptable standards of clinical practice out of 45 sample residents. Specifically, the facility failed to ensure Resident #39 did not receive Excedrin (migraine relief medication) without a physician's order.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper treatment and services to maintain vision abilities for one (#8) of three residents reviewed for vision services out of 45 sample residents. Specifically, the facility failed to ensure Resident #8's new eyeglasses were obtained in a timely manner and the resident was scheduled for a cataract surgery consultation.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#66) of three residents reviewed for respiratory care out of 45 sample residents were provided respiratory care consistent with professional standards of practice. Specifically, the facility failed to ensure cleaning and proper care of Resident #66's CPAP (continuous positive airway pressure) machine according to manufacturer's instructions and per physician's orders.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards for one (#3) of two residents reviewed for dialysis out of 45 sample residents. Specifically, for Resident #3, the facility failed to: -Consistently and thoroughly complete the dialysis communication forms between the facility and the dialysis center; and, -Collaborate with the dialysis facility regarding dialysis care and services, specifically acknowledging a recommendation for a gastroenterology referral and medication changes made on the dialysis communication forms.

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for three of three certified nurse aides (CNA). Specifically, the facility failed to complete annual performance reviews and/or provide regular in-service education based on the outcome of the reviews for CNA #1, CNA #2 and CNA #3.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure the medication error rate was less than five percent (%). Specifically, the facility had a medication error rate of 11.53 percent, which was three errors out of 26 opportunities for error.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#20) of two residents reviewed for insulin administration out of 45 sample residents was kept free from significant medication errors. Specifically the facility failed to ensure insulin pens were primed prior to two insulin medication administrations for Resident #20.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#8 and #39) of two residents reviewed for ancillary services out of 45 sample residents received routine dental care and 24-hour emergency dental care. Specifically, the facility failed to:-Ensure Resident #8 was provided timely dental services to repair his of dentures; and, and-Ensure Resident #39 was provided a routine dental appointment.

Inspectors wroteBased on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for one out of three units at the facility. Specifically, the facility failed to provide a bed bath for Resident #55 in a sanitary manner.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents and their representatives had access to the most recent survey findings including survey results, certifications, complaint investigations and plans of correction. Specifically, the facility failed to ensure the survey findings binder was available, ensure staff members were aware of where the binder was located and ensure the binder was accessible for review.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (#6) of five residents out of nine sample residents. Resident #6 was admitted to the facility on [DATE] with diagnoses of right leg above the knee amputation, left arm paralysis following stroke, peripheral vascular disease (reduced blood flow to limbs), dysphagia (difficulty swallowing), respiratory failure and diabetes. On [DATE] at 6:20 a.m. Resident #6 told the certified nurse aides (CNA) he was experiencing shortness of breath. The CNAs observed the resident was experiencing shortness of breath and informed licensed practical nurse (LPN) #1 of the resident's significant change in condition. [...]

Inspectors wroteBased on record review and interviews, the facility failed to update the admissions agreement so it did not waive the facilities liability for loss of resident's personal property for one (#3) of two residents out of nine sample residents. Specifically, the facility failed to ensure Resident #3 did not waive her rights for reimbursement for the loss of personal property (five rings) during her stay in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to prevent verbal abuse for one (#5) of seven residents reviewed for abuse out of 14 sample residents. Specifically, the facility failed to ensure Resident #5 was free from verbal abuse from Resident #6.

Inspectors wroteBased on record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for one (#4) of seven residents reviewed for behavioral and emotional status out of 14 sample residents. Specifically, the facility failed to coordinate timely necessary behavioral, mental and emotional health care and services for Resident #4 after the resident expressed suicidal ideation.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (#4) of four residents out of 15 sample residents. Resident #4, who had diagnoses of type 2 diabetes mellitus with chronic kidney disease and foot ulcers, heart failure and osteomyelitis (infection of the bone) of the left ankle and foot, was admitted from the hospital on 9/16/24 with surgical wounds to both heels following surgical debridement (removal of dead tissue) of his diabetic wounds and placement of a wound vacuum (negative pressure wound therapy) on the left heel. Hospital discharge instructions included the resident was to be non-weight bearing to bilateral lower extremities and Prevalon boots (soft heel protection boots) were to be worn on both feet. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries from occurring or worsening for one (#8) of four residents reviewed out of 15 sample residents. Resident #8, who was at risk for developing pressure ulcers and had a history of pressure ulcers, was admitted on [DATE] and readmitted to the facility on [DATE] after a three-day hospital stay. The readmission skin assessment, dated 11/6/24, documented the resident had a 1.0 centimeter (cm) by 1.0 cm scabbed area on his coccyx which the nurse covered with a foam dressing. However, there was no documentation that a treatment order was requested or that the facility's wound nurse or the wound care physician were notified of the skin concern. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were free from physical restraints for one (#3) of one resident out of 15 sample residents. Specifically, the facility failed to ensure Resident #3 was not restrained in his wheelchair using a Hoyer lift (mechanical lift) sling.

Inspectors wroteBased on observations and interviews, the facility failed to 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 infection. Specifically, the facility failed to: -Ensure wound care supplies were placed on a clean field; -Ensure a clean barrier was placed under the wound; -Ensure gloves were changed and hand hygiene performed during wound care; -Ensure each wound was cleaned and treated separately; and, -Ensure enhanced barrier precautions (EBP) were used during wound care.

Inspectors wroteBased on interviews and record review, the facility failed to ensure proper treatment and services to maintain hearing for one (#3) of three residents reviewed for hearing problems out of eight sample residents. Specifically, the facility failed to ensure an audiology referral for Resident #3 was followed up on timely when recommended and ordered by the physician.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in three of 15 rooms. Specifically, the facility failed to: -Ensure resident rooms were cleaned in a sanitary manner; and, -Ensure manufacturer recommended surface contact times were followed for effective disinfection.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#14) of five residents reviewed out of 21 sample residents had the right to be informed of, and participate in, his or her treatment including the right to be informed, in advance, of the care to be furnished. Specifically, the facility failed to ensure informed consent to review the risks associated for clonazepam (a benzodiazepine) was obtained prior to administration for Resident #14.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure the medication error rate was not greater than five percent. Specifically, the facility's medication error rate was 8% with two errors out of 25 opportunities.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#57) of 10 residents reviewed for medication errors out of 21 sample residents. Specifically, the facility failed to ensure that Resident #57 was administered the correct doses of insulin by properly priming the insulin pens before insulin administration.

Inspectors wroteBased on record review and interviews, the facility failed to ensure all residents were free from abuse, neglect, and exploitation, for one (#101) of two out of 29 sample residents. Specifically, the facility failed to ensure Resident #101 was not neglected by staff from 8/24/21 to 8/30/21 by providing the care and services the resident required to maintain the highest practicable well-being. The facility failed to implement timely treatment for Resident #101 who had a history of osteomyelitis (bone infection) to her right tibia/fibula (lower leg bone). Resident #101 readmitted to the facility following a below the knee amputation (BKA) to her right lower extremity (RLE) on 8/24/21. The facility failed to implement treatment to the surgical wound upon admission. The facility failed to notify the physician and obtain physician orders for treatment for six days. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to: -Ensure glucose monitor was disinfected after use; -Ensure proper hand hygiene before and after glove use and administration of medications; and, -Ensure residents were offered hand hygiene prior to eating ready to eat foods.

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to ensure two (#31 and #18) of two residents, received medication management treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 29 sample residents. Specifically, the facility failed to ensure Resident #31 and Resident #18, who were taking anticoagulant medications, were: -Consistently monitored for signs and symptoms of bleeding; and, -A care plan developed while taking an anticoagulant medication.

Inspectors wroteIV. Resident #16 A. Resident status Resident #16, under [AGE] years old, was admitted initially on 10/16/19 and readmitted on [DATE]. According to the June 2022 computerized physician orders (CPO), diagnoses included cerebral palsy (motor disability from childhood causing stiff muscles, uncontrolled movements, poor balance and coordination), peripheral neuropathy (weakness, numbness, and pain from nerve damage), and protein-calorie malnutrition (combination of poor nutrient absorption and illness that causes increased nutrient requirements). The 4/8/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required extensive assistance with two persons physical assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and total dependence for bathing. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the residents environment remained as free of accident hazards are possible, and the resident received adequate supervision and assistive devices to prevent accidents for one (#27) of two out of 29 sample residents. Specifically, the facility failed to conduct an assessment for Resident #27, who was at risk for bleeding due to taking an anticoagulant, to ensure she was capable of shaving her own facial hair with a hand held razor blade, and updating the care plan to include these interventions.