Sterling Park Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF578Aug 1, 2025

  Based on interview and document review, the facility failed to follow process to ensure advanced directives were accurately documented and updated on the resident's electronic health record (EHR) banner, physician orders and Physician's Orders for Life Saving Treatment (POLST) which affected 2 of 16 residents (R35 and R19) reviewed for advance directives. These findings constituted an immediate jeopardy (IJ) situation for R35 and R19 who would not have received cardiopulmonary resuscitation measures (CPR) according to their wishes. The IJ began on [DATE], when R35's POLST, indicating R35's wishes for resuscitation was signed by the medical provider and it was not changed within the facility's EHR to reflect R35's wishes. […]

• No harm, potential for more than minimal, widespreadF727Aug 1, 2025

  Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) was on-site for at least 8 consecutive hours on a daily basis. Lack of consistent RN coverage may result in delayed assessment, clinical decision-making, or care interventions, potentially jeopardizing resident health and safety. This failure had the potential to negatively impact resident care and oversight.Findings include: Facility payroll based journal (PBJ) staffing data report for fiscal year 2025, quarter 2 (January 1- March 31) triggered excessively low weekend staffing. Facility assessment dated [DATE]- indicated facility need for 1 RN for 40 residents. Facility staffing schedules indicated RNs were scheduled for 12-hour shifts (6am-6:30pm, and 6pm-6:30am). […]

• No harm, potential for more than minimal, widespreadF812May 2, 2024

  Base on observation, interview, and document review, the facility failed to store and label food properly, dispose of undated and expired food items, to reduce the risk of food borne illness. This deficient practice had the potential to affect 34 residents who were provided meals from the kitchen. Findings include: During initial tour of kitchen on [DATE], at 11:33 a.m., with dietary manager (DM) the following was observed: - in the room with the serving window, on the back wall was a three door free standing cooler. Behind the first door was two plastic serving cups of jello uncovered/undated, three plastic serving cups of fruit cocktail uncovered/undated. Behind the third door a meal that had been saved had no label of when it was placed in the cooler. […]

• No harm, potential for more than minimal, isolatedF550Aug 6, 2026

  Based on observation, interview, and document review, the facility failed to ensure residents' grooming needs were met for 1 of 2 residents (R12) in the sample who were observed for the provision of activities of daily living cares. Findings include: R12's electronic health record (EHR) printed 8/6/26, indicated R5's diagnoses included; acute respiratory failure with hypoxia (the bodies tissues do not get enough oxygen to function), pleural effusion (an abnormal buildup of fluid between the tissues that line the lungs and the inside of the chest cavity), repeated falls, and wedge compression fractures of T11-T12 vertebra. […]

• No harm, potential for more than minimal, isolatedF582Aug 6, 2026

  Based on interview and document review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) (CMS-10055) to 1 of 3 residents (R49) reviewed for beneficiary notices.Findings include:R49's electronic health record (EHR) indicated Medicare Part A coverage for skilled nursing facility services ended on 2/2/26. Following the end of Medicare Part A coverage, R49 remained in the facility and transitioned to private-pay status.R49's EHR and beneficiary notice documentation lacked evidence that a completed SNFABN (CMS-10055), had been provided to R49 and/or R49's representative when Medicare Part A covered ended and R49 became financially responsible for continued services.During an interview on 8/4/26 at 11:32 a.m., the Assistant… […]