Sterling Village

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide care and services consistent with professional standards of practice for indwelling urinary catheters for three Residents (#15, #157 and #114), of six applicable residents, out of a total sample of 28 residents, increasing the Residents risk for indwelling urinary catheter complications. Specifically, the facility failed to:1. for Resident #15, replace the Resident's indwelling urinary catheter with the correct sized catheter as ordered by the Physician during the scheduled monthly catheter change, and secure the urinary drainage bag away from contaminated surfaces. 2. for Resident #157, maintain/secure the urinary drainage bag away from contaminated surfaces.3. [...]

Inspectors wroteBased on observations, and interviews, the facility failed to maintain a clean and homelike environment for two Residents (#10 and #59) out of a total sample of 27 residents, and on one unit (Aspen Unit) out of three units observed. Specifically, the facility staff failed to ensure:-for Resident #10, that the Resident's enteral tube feeding (nutritional supplement provided through a tube to the stomach) equipment was maintained in a clean and sanitary manner.-for Resident #59, that the Resident's enteral tube feeding equipment pump and pole, and the Resident's upper left side bed rail located next to the feeding equipment was maintained in a clean manner.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide Activity of Daily Living (ADL - basic care tasks that an individual requires on a day-to-day basis such as grooming, eating, bathing, and dressing) care to one Resident (#127), of three applicable residents, out a total sample of 27 residents. Specifically, for Resident #127, the facility failed to provide grooming services for facial hair removal when the Resident's preference was daily facial hair removal and he/she was dependent on staff for assistance, causing a decrease in the Resident's quality of life.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide three Residents (#113, #20, and #92), out of a total sample of 25 residents, with an environment as free of accidental hazards as possible. Specifically, the facility staff failed to: 1. provide adequate supervision and food of the required texture to ensure Resident #113's safety while eating when the Resident had a diagnosis of Oropharyngeal Phase Dysphagia (disorder or impairment in the ability to swallow), required his/her food to be pureed (soft, smooth foods that require no chewing), and required supervision and verbal cues while eating, increasing the Resident's risk for aspiration (inhaling food/drink into one's airways or lungs, and can result in Pneumonia). 2a. [...]

Inspectors wroteBased on record and policy review, and interview, the facility failed to ensure that one Resident (#52) out of a total sample of 25 residents was free from significant medications errors. Specifically, the facility staff failed to adhere to the Physician's orders to hold the dose of Losartan Potassium (a medication used to decrease blood pressure and decrease the incidence of Stroke in patients with Hypertension [HTN: high blood pressure. When the blood pressure measures consistently above 130/80 millimeters of mercury [mmHg]) for a Systolic Blood Pressure (SBP) of less that 110 mmHg.

Inspectors wroteBased on interview and policy review, the facility failed to develop an infection prevention and control policy and procedure (IPCP) in accordance with current accepted national standards and guidelines relative to controlling COVID-19 infection. Specifically, the facility failed to indicate what measures would be implemented to identify and control the spread of COVID-19 infection for residents and staff in the facility in the event of a COVID-19 outbreak.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the Minimum Data Set (MDS) Assessment was accurately coded to reflect the correct status for one Resident (#129) out of three applicable residents. Specifically, the facility staff failed to ensure that the MDS Assessment accurately reflected that Resident #129 was discharged home.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included the administration of a narcotic medication as needed for pain, the Facility failed to ensure they maintained a complete and accurate medical record when nursing failed to transcribe into the Controlled Substance Log (a book used by nursing to keep an accurate count of all narcotics and to record administration of narcotics), a change in the directions for the use of the narcotic, and failed to document the administration of the narcotic in his/her Medication Administration Record.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide peripherally inserted central catheter (PICC: flexible tube inserted through a vein in one's arm and passed through to the larger veins near the heart, used to deliver medications intravenously [IV]) care and services in accordance with professional standards of practice and plans of care for two Residents (#237 and #45), out of two residents receiving IV treatments via PICC, in a total sample of 26 residents. Specifically, facility staff failed to: 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to accurately execute Advance Directives (written documents that tells your health care providers who should speak for you and what medical decisions should be made if you become unable to speak for yourself) for one Resident (#21) out of a total sample of 26 residents. Specifically, the facility failed to ensure that the MOLST (Massachusetts Medical Order for Life-Sustaining Treatment) decisions were made by the designated and invoked (activated) Health Care Proxy (HCP- a legal document that allows you to appoint someone you trust to make medical decisions on your behalf if you are unable to do so) for Resident #21, when the Resident was deemed as lacking the capacity for informed decision making by the facility's Physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one Resident (#337), out of a total sample of 26 residents, received care of a colostomy (a surgical procedure that creates an opening [stoma] from the large intestine through the abdomen allowing for stool to pass from the intestine to outside the body) system consistent with professional standards. Specifically, the facility staff failed to provide care and maintenance of the adhesive barrier/wafer pouching system per facility policy.

Inspectors wroteBased on policy review, observation, record review and interview, the facility failed to ensure its staff maintained appropriate infection control measures related to the use of Personal Protective Equipment (PPE) for two Residents (#125 and #52) out of a total sample of 26 residents. Specifically, the facility failed to ensure staff wore gowns and gloves when providing care for Resident's #125 and Resident #52 who were both on Contact Precautions (intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct of indirect contact with the resident or the resident's environment).