Sterling Village

Inspectors wroteThe facility had a census of 26 residents. The sample included 12 residents, with seven reviewed for falls. Based on observation, record review, and interview, the facility failed to follow two residents' care plans: Resident (R) 128, who sustained a tibia (bone of the lower leg) fracture (break) during ambulation, and R4, who slid off the bed while on a bed pan. This placed the residents at risk for further falls and avoidable injury.

Inspectors wroteThe facility had a census of 26 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 26 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 26 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in the facility kitchen. This placed the residents who received their meals from the facility's kitchens at risk for foodborne illness.

Inspectors wroteThe facility had a census of 26 residents. The sample included 12 residents. Based on record review and interview, the facility failed to implement a water management program for waterborne pathogens including Legionella disease (Legionella is a bacterium that can cause pneumonia in vulnerable populations). This placed the residents in the facility at risk for infectious disease.

Inspectors wroteThe facility had a census of 26 residents. The sample included 12 residents with five reviewed for unnecessary medications. The facility failed to ensure the Consultant Pharmacist (CP) reviewed each resident's drug regimen monthly and reported irregularities to the attending physician, the facility medical director, and the director of nursing monthly for Residents' (R) 4, R8, R9, R11, and R22.

Inspectors wroteThe facility had a census of 26 residents. The sample included 12 residents, with one reviewed for hydration. Based on observation, record review, and interview, the facility failed to monitor Resident (R) 4's physician-ordered fluid restriction. This placed the resident at risk of complications related to fluid overload.

Inspectors wroteThe facility had a census of 26 residents. Based on record review and interview, the facility failed to ensure three of five Certified Nurse Aides (CNA) completed their required 12-hour annual in-service. This placed the residents at risk for receiving unskilled care.

Inspectors wroteThe facility had a census of 36 residents. The sample included 12 residents, with four reviewed for accidents/falls. Based on observation, interview, and record review the facility failed to use an appropriate lift sling during a mechanical lift transfer, which resulted in Resident (R) 6 falling out of a lift sling resulting in a head laceration, hematoma (collection of blood under the skin from an injury), and pain. The facility further failed to implement new interventions to prevent further falls for R14, who had multiple falls. This placed the residents at risk for further falls and fall-related injury.

Inspectors wroteThe facility had a census of 36 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food in a sanitary condition for 36 residents who resided in the facility and received meals from the facility kitchen, placing them at risk for food borne illness.

Inspectors wroteThe facility had a census of 36 residents. The sample included 12 residents with two reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide bed hold notices for two sampled Residents (R) 1 and R30, or their representatives when the resident was sent to the hospital. This deficient practice placed R1 and R30 at risk to not be allowed to return to his/her former room at the facility.

Inspectors wroteThe facility had a census of 36 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to review and revise the care plan for Resident (R) 9 after falls and development of a pressure ulcer and R14 after falls. This placed the residents at risk for uncommunicated care needs.

Inspectors wroteThe facility had a census of 36 residents. The sample included 12 residents, with two reviewed for pressure ulcers (PU -injury to skin and underlying tissue resulting from prolonged pressure on the skin). Based on observation, interview, and record review the facility failed to provide care and services in a timely manner after the development of a pressure ulcer for one of two sampled Residents (R) 9. This placed the resident at risk for delayed healing and further pressure injury.

Inspectors wroteThe facility had a census of 36 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to store oxygen cannulas (a lightweight tube with two prongs which are placed in the nostrils from which a mixture of air and oxygen flows) and tubing in sanitary condition for Resident (R) 13 and R11, and [NAME] dto ensure R11 received the correct oxygen flow setting. This placed the residents at risk for respiratory infection and insufficient oxygen level.

Inspectors wroteThe facility had a census of 36 residents. The sample included 12 residents, of which five were reviewed for unnecessary medication. Based on observations, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of a stop date for the use of an as needed antianxiety (class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication and documentation of targeted behaviors for the use of antianxiety and antipsychotic (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing)) and other mental emotional conditions) medications for Resident (R) 16, and lack of behavior monitoring and weekly vital signs for R10. [...]

Inspectors wroteThe facility had a census of 36 residents. The sample included 12 residents, with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to obtain weekly vital signs as ordered by the physician to monitor the efficacy of Resident (R) 10's blood pressure medication. This deficient practice placed R10 at risk for adverse effects of his medication.

Inspectors wroteThe facility had a census of 36 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R)16's as needed antianxiety (class of medications that calm and relax people with excessive nervousness, or tension) medication had a stop date as required and further failed to ensure targeted behavior monitoring for the use of antianxiety and antipsychotic (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions)) medication use. [...]

Inspectors wroteThe facility census totaled 35 residents with 12 included in the sample. Based on observation and interview the facility failed to remove two vials of Tubersol (Tuberculin purified Protein) one with an expiration date of 02/21/21 and one vial with no open date noted in one of two medications rooms reviewed for outdated medications. Interview with Administrative Nurse A on 06/08/21 at 1:02 PM revealed they expected the nursing staff to place an open date upon the vial (tubersol) and remove medications when expired. The facility policy Storage of Medications revised date April 2007 revealed Medication requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or secured location. Medications must be stored separately from food and must be labeled accordingly. [...]

Inspectors wroteThe facility census totaled 35 residents with five residents reviewed for unnecessary medications. Based on interview and record review the facility failed to ensure two of five resident (R)15 had labs drawn to monitor the Vitamin B-12 level requested per the pharmacy recommendation. R(24) the facility failed to follow the pharmacist recommendation.