Sterling Care Hillhaven

In the surveyor’s words

From the most serious findings on record at Sterling Care Hillhaven, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF730Jun 9, 2025

  Based on facility staff interviews and surveyor record review of employee personnel files, it was determined that the facility failed to conduct performance reviews of Geriatric Nursing Assistants (GNAs) at least once every 12 months. This finding was found to be evident for 5 (GNA #15, 16, 17, 18 and 19) of 5 GNAs randomly selected nursing staff personnel files reviewed for nurse aide performance review. The findings include: On 06/06/2025 at 12:35 PM a review of the randomly selected Geriatric Nursing Assistant (GNA) personnel files revealed that GNAs #15,16,17,18 and 19 did not have current annual performance reviews. Further review of the 5 GNA personnel files failed to produce a record of an annual performance evaluation for GNAs #16 and #17. […]

• No harm, potential for more than minimal, isolatedF578Jun 9, 2025

  Based on facility staff interview and surveyor record review it was determined that the facility failed to offer and provide a Resident and/or Resident Representative with educational information and forms on advance directives. This finding was found to be evident in 1(Resident #302) of 2 Residents reviewed for advance directives. The findings include: An advance directive is a legal document that specifies a person's wishes for end-of-life healthcare. It also specifies who should make healthcare decisions on your behalf if they were unable to do so themselves. On 06/04/2025 at 8:47 AM the surveyor conducted a review of Resident #302's medical record. The record review revealed that Resident #302 did not have an advance directive in the medical record. […]

• No harm, potential for more than minimal, isolatedF655Jun 9, 2025

  Based on record review and interview, it was determined that the facility failed to develop a baseline care plan within 48 hours of admission. This was found to be evident for 1 (Resident #26) of 1 resident reviewed for baseline care plans. The findings include: According to Centers for Medicare and Medicaid Services (CMS), long term care facilities must develop and implement a baseline care plan for each resident within 48 hours of admission. The guidelines state the 48-hour baseline care plan must include ' the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, ' including, but not limited to: initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and… […]

• No harm, potential for more than minimal, isolatedF685Jun 9, 2025

  Based on observations, interviews with the resident and facility staff, it was determined that the facility failed to provide treatment and services to maintain hearing function. This was evident for 1 (Resident #27) out of 1 resident reviewed for hearing-related treatment and devices during the recertification survey process. The findings include: Hearing aids are medical devices used to assist individuals with hearing loss by amplifying sound. They are typically prescribed and fitted by a licensed audiologist and customized to meet the user ' s specific hearing needs. Hearing aids improve the ability to hear speech, environmental sounds, and alarms, thereby enhancing safety, communication, and quality of life. […]

• No harm, potential for more than minimal, isolatedF686Jun 9, 2025

  Based on surveyor observation, facility staff interview and surveyor record review, it was determined that the facility staff failed to document the delivery of daily wound care for a Resident with a pressure ulcer. This finding was found to be evident in 1 (Resident #45) of 1 Resident reviewed for treatment and services of pressure ulcers. The findings include: During the initial tour of the facility on 06/03/2025 at 12:30 PM Resident #45 was lying in bed asleep with an air mattress pump on the footboard of the bed. The Medication and Treatment Administration Record (MAR/TAR) is a record used to keep track of every dose of medication or treatment that a Resident is administered. […]