Sterling Place Healthcare & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Sterling Place Healthcare & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Feb 5, 2021

  Based on interviews and record review, the facility failed to ensure weekly skin/body audits, consistent with professional standards of practice, were conducted in order to prevent the development of avoidable pressure ulcers for 1 (#1) of 3 (#1, #3, R1) sampled residents reviewed for pressure ulcers. An Immediate Jeopardy situation occurred for Resident #1 on [DATE] at 10:00 a.m. when S5CNAS identified pressure ulcers to Resident #1's sacral area, left great toe and right foot. Prior to the discovery of these pressure ulcers, Resident #1 had no [DIAGNOSES REDACTED]. S4WCN discovered a fourth new pressure ulcer to Resident #1's right hip on [DATE] at 3:23 p.m. Resident #1 was transferred to a local hospital on [DATE] and diagnosed with [REDACTED]. […]

• Actual harm, isolatedF690Sep 6, 2023

  Based on interviews and record reviews, the facility failed to provide services and assistance to maintain bladder continence for 1 (#1) of 2 (#1 and #5) continent residents reviewed. This deficient practice resulted in an actual harm for Resident #1, a continent resident, on 08/19/2023 at 5:53 a.m. when she attempted to go to the restroom and fell in her room. Resident #1 was admitted to the facility on [DATE] after a left knee replacement surgery which required one person assist with utilization of a walker for mobility. On 08/19/2023 at 4:27 a.m., Resident #1 began asking S5CNA for assistance to the restroom. S5CNA failed to assist Resident #1 to the restroom. […]

• No harm, potential for more than minimal, widespreadF812Jun 23, 2025

  Based on observations, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to affect 127 residents who were served from the kitchen. Findings: Review of the facility's policy titled, Food Storage Labeling, with a revision date of 10/2018, revealed, in part: The facility will store and label all foods to ensure safety and quality. 7. Food is stored in containers that are sealable, leak proof, durable, and undamaged. Review of the facility's policy titled, Food Service Operation Standards for Purchasing, Cooking and Storage, with a revision date of 10/2018, revealed, in part: 5. Thawing a. The preferred method is to thaw under refrigeration at a temperature of 40 degrees F or below. i. […]

• No harm, potential for more than minimal, widespreadF812Jul 31, 2024

  Based on observations, interviews, and policy review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety. This had the potential to affect 126 residents who were served meals from the kitchen. Findings: Review of the facility's policy titled Storage Of Refrigerated Food revealed the following: Policy: The facility will ensure the quality and safety of refrigerated food through acceptable storage practices. Procedure: 4. All non-hazardous, opened foods are labeled with name of food and date stored 5. Foods are labeled with date to be discarded or the date stored. An observation was made on [DATE] at 8:45 a.m. of the facility's walk-in refrigerator with S10AM. […]

• No harm, potential for more than minimal, patternF656Jun 23, 2025

  Based on record review and interviews the facility failed to implement a comprehensive person-centered care plan which met the needs of 2 (#9 and #124) of 2 (#9 and #124) residents reviewed for weight loss. The facility failed to ensure weekly weights were completed as ordered. Findings: Resident #9 A review of Resident #9's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, and Cognitive Communication Deficit. Review of Resident #9's most recent Care Plan revealed Resident #9 was at risk for weight loss with an intervention of weighing resident as appropriate implemented on 10/20/2024. […]