Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sterling Rehabilitation And Nursing, Llc during CMS and state inspections, most recent first.
Failure to Prevent and Track Pressure Injuries: Two residents with pressure injuries did not receive consistent offloading, timely wound interventions, or accurate skin monitoring. One resident’s heel DTI progressed to a stage 3 wound while staff observed the foot resting on the wheelchair footrest or ground without pressure relief, and the care plan did not match the wound physician’s documented heel-protection measures. Another resident with a heel DTI and later a stage 3 coccyx ulcer had delayed orders, delayed air mattress use, no new care plan interventions, and inaccurate weekly skin checks.
Kitchen Food Storage, Labeling, Expiration, and Sanitation Deficiencies: Staff stored raw bacon with ready-to-eat foods in a walk-in refrigerator, left nutritional shakes past the thawed shelf life, and kept multiple food items unlabeled with no dates or contents identified. The dish room also had black and brown wall discoloration behind and above sinks, and sheet trays were leaning against the wall with water visible on one tray.
Missed showers and inadequate ADL assistance. Four residents with conditions including Parkinson's disease, dementia, schizophrenia, and spinal disorders did not receive bathing and grooming as scheduled. Records showed repeated missed showers, and interviews with residents, a representative, CNAs, and the DON confirmed residents often went without scheduled showers, with some appearing disheveled, unshaven, or having body odor and greasy hair.
Medication storage and labeling were not maintained consistently across multiple carts and a medication room. Surveyors found used insulin pens and inhalers without resident names and/or dates opened, along with expired insulin and naloxone still stored in medication areas. Staff acknowledged that the items should have been labeled or discarded, and a lorazepam container for a deceased resident remained in the refrigerator.
The facility failed to maintain an effective antibiotic stewardship process. The IP, DON, and RCR reported inconsistent use of the antibiotic surveillance log, and the logs reviewed were incomplete with missing infection details and documentation supporting antibiotic necessity. Two residents with significant medical histories received antibiotics for a wound infection and cholecystitis, but their antibiotic use was not identified on the tracking log, adverse reactions were not consistently monitored, and one resident had no antibiotic care plan documented.
Failure to timely report alleged resident-to-resident verbal abuse: A CNA reported that one resident yelled a threat at her roommate, and the nurse documented the incident in the chart. The facility could not show the allegation had been reported to the State Agency within the required timeframe. The NHA later stated he was still investigating the event and had not been able to substantiate or unsubstantiated the allegation.
Medication Given Without Physician Order: A resident with chronic migraines and anticoagulant use received Excedrin Migraine from an RN without a physician's order. The resident said the RN was the only nurse who gave her the medication and that it relieved her pain. Records showed the medication had been discontinued by the physician, other migraine and pain medications were ordered instead, and the RN did not document the dose in the EMR.
Failure to obtain new eyeglasses and arrange a cataract consult for a resident with impaired vision. The resident had chronic medical conditions including schizophrenia, emphysema, Parkinson’s disease, and cognitive impairment, and was documented as needing corrective lenses. Staff and the resident’s representative reported the glasses were very old and not being worn, while the record showed no evidence that the new prescription had been ordered or that an ophthalmology referral for cataract evaluation had been made.
A resident with OSA, respiratory failure with hypoxia, and asthma had a CPAP order with daily mask cleaning instructions, but the mask was repeatedly observed unwashed and stored improperly in the room. The resident said staff did not wash the mask, while the MAR/TAR still documented daily cleaning. Staff gave conflicting accounts about who was responsible for CPAP care, and the DON confirmed the cleaning and storage were not being followed as ordered.
A resident receiving hemodialysis had repeated abdominal cramping and several shortened dialysis treatments, but the facility did not consistently complete the dialysis communication forms or fully document pre- and post-dialysis assessments. The dialysis center documented a recommendation to stop milk of magnesia and obtain a GI consult, yet the facility record still showed milk of magnesia ordered and no documented follow-up on the GI referral recommendation.
Failure to complete annual CNA performance reviews and related in-service education. Record review showed that three CNAs did not have completed annual performance evaluations or an in-service education plan based on review outcomes. The DON stated the reviews should be done annually to identify retraining needs, while RCR #1 reported HR could not locate the evaluations.
Medication error rate exceeded 5 percent after surveyors found three errors in 26 opportunities. An RN failed to have a resident rinse his mouth after an inhaler dose as ordered, and another RN administered two insulin injections without priming the insulin pens first, despite manufacturer instructions and the DON’s confirmation that priming was required to ensure the correct dose.
Failure to Prime Insulin Pens Before Insulin Administration: An RN prepared and administered two insulin injections to a resident with diabetes and CKD without performing the required safety test/priming on either insulin pen. Manufacturer instructions for NovoLog and Lantus required priming before each injection to confirm proper dosing, and the DON stated the RN should have primed the pens to ensure the correct dose was delivered.
Failure to Provide Timely Dental Services: Two residents did not receive needed dental care. One resident had ill-fitting dentures for months and had not had a dental consult in over two years, despite staff and the resident’s representative reporting the problem. Another resident had broken and missing teeth, pain with chewing, and no documented dental referral or scheduled consult in the orders, even though the resident had asked staff and the NP for help and said the issue had gone unresolved.
A resident received a bed bath in a manner that did not follow the facility’s infection control and hygiene procedure. CNAs washed the feet and legs first, then the perineal area and chest without changing gloves, and one CNA later reached into the basin for another washcloth and brought it close to the resident’s face before stopping. The facility policy and the DON both stated the bath should be done head to toe, with the face first and the perineal area last, using clean washcloths and changing water between body parts.
Survey findings binder not available to residents. Cognitively intact residents said they did not know where to access the survey findings binder, and RN, IP, NHA, and the CNO were all unable to locate it at the nurses' station, front desk, or elsewhere in the facility. The NHA stated the facility was working on putting a binder together because none could be found.
A resident with multiple complex medical conditions reported shortness of breath to CNAs, who notified an LPN of the significant change in condition. The LPN failed to perform a full assessment, did not obtain a complete set of vital signs, and did not notify an RN or physician as required. The resident was later found unresponsive and deceased, with no evidence of appropriate intervention or escalation by nursing staff.
A resident admitted with five rings, including a wedding ring, signed an admissions agreement and inventory form that waived the facility's liability for lost or stolen personal property. Upon discharge, the rings were missing and the facility could not locate the discharge inventory form. The facility's policy required documentation of personal belongings, but the agreement and inventory form both included waivers of liability, resulting in a deficiency for not protecting the resident's right to reimbursement for lost property.
A verbal altercation occurred between two residents over a television channel, where one resident yelled obscenities at the other, causing emotional distress. Despite staff intervention, the aggressive resident repeatedly returned to the room to continue the altercation. Both residents were monitored closely following the incident.
A resident with a history of mental health issues expressed suicidal ideation, but the facility failed to provide timely behavioral health care. The resident was not sent to the ER until nearly 24 hours later, and there was inadequate documentation and communication among staff. The baseline care plan lacked specificity, and a comprehensive care plan was delayed.
A resident with multiple health issues, including diabetes and foot ulcers, did not receive proper wound care and documentation in a LTC facility. Hospital discharge instructions for non-weight bearing status and Prevalon boots were not recorded in the EMR or care plan. The resident missed several wound care physician visits, and the facility failed to document changes in the wound condition or notify the physician. Staff interviews revealed inconsistencies in care plan updates and communication lapses.
A resident at risk for pressure ulcers developed an unstageable pressure injury due to the facility's failure to notify the wound care team and obtain treatment orders. The resident's care plan was not updated, and timely wound care was not provided. Additionally, an unsuitable wheelchair cushion contributed to the condition. Despite a performance improvement plan, the facility did not follow procedures, leading to delayed reporting and treatment.
A resident was improperly restrained in a wheelchair using a Hoyer lift sling, with straps brought up between the legs and over the shoulders, hooked onto the wheelchair handles. The DON and an RN were present and involved in the incident, which was not documented in the resident's medical record. The resident, who was cognitively intact, had a history of sliding out of the wheelchair and was experiencing confusion. The facility failed to follow its policy on abuse and neglect.
The facility failed to maintain an effective infection prevention and control program during wound care, as observed in two residents. Staff did not use clean fields for supplies, failed to change gloves and perform hand hygiene, and did not follow Enhanced Barrier Precautions (EBP) by wearing gowns. Additionally, wounds were not treated separately, increasing the risk of cross-contamination.
The facility failed to ensure timely follow-up on an audiology referral for a resident with severe cognitive impairment and multiple diagnoses. The resident's physician ordered the consult due to dizziness and headaches, but the facility delayed arranging the appointment, resulting in a 51-day wait for the necessary services.
Failure to Prevent and Track Pressure Injuries
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new ulcers from developing for two residents with pressure injuries. Resident #4 was admitted and later readmitted with risk factors for pressure injury development, including dementia, impaired mobility, and dependence for transfers and repositioning. A right heel suspected deep tissue injury was first documented shortly after readmission, and the initial order was to float the heel with a pressure relief boot at all times. That order was later discontinued, and the record did not show why it was stopped or what other offloading measures were added. The wound later progressed from a DTI to a stage 3 pressure injury, and survey observations showed the resident was repeatedly sitting with the right foot resting directly on the wheelchair footrest or on the ground without any pressure-relieving device in place. For Resident #4, the record also showed inconsistent documentation of prevention measures. The wound care physician later documented heel protectors and wedges as preventative measures, but the care plan did not include heel protectors and wedges, and there were no physician orders for heel protector boots. Staff interviews showed the wound care physician expected heel protectors in the wheelchair and offloading in bed, while the DON stated staff relied on the care plan, TAR, and EMR communication board to know what interventions to use. The DON also stated there was no physician order and no care plan for heel protector boots, and staff therefore did not know what interventions to use to promote healing. The resident’s wound worsened over time, with later notes describing infection, foul odor, inflammation, and increased depth. Resident #52 also had pressure-related skin breakdown and did not receive timely or accurately documented interventions. He was cognitively intact but dependent on staff for most care and transfers, and his care plan identified risk for skin impairment with a left heel DTI already present. The record showed he developed a left heel DTI and later a stage 3 coccyx pressure ulcer, but no new interventions were added to the care plan after either wound developed. The facility did not implement an air mattress until 19 days after the left heel DTI was identified, and the physician’s order for coccyx wound treatment was not entered until 8 days after the coccyx wound was identified. Weekly skin checks were also inaccurate, because one assessment did not identify the coccyx wound even though it was later found by the wound care physician, and a later skin check still did not reflect the coccyx pressure ulcer that remained present during wound care observation.
Kitchen Food Storage, Labeling, Expiration, and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. During an initial walk-through of the walk-in refrigerator, a large metal basin on the second shelf contained ready-to-eat foods, including lettuce, yogurt, raspberries, and blueberries, along with an opened gallon-sized ziplock bag that appeared to contain raw bacon. Liquids were leaking from the bag onto the other food items in the basin. The dietary manager later observed the bag and stated the raw bacon should have been separated from the ready-to-eat foods. The nursing home administrator stated he was not aware raw bacon had been stored with ready-to-eat food and acknowledged raw animal food should not be stored in the same area with ready-to-eat food. The facility also failed to discard food after its expiration or use-by date. In the walk-in refrigerator, two large cardboard boxes of Vital Cuisine Mighty Shakes were observed, including chocolate flavor shakes with a pulled date of 8/1/25 written on the box. The manufacturer information cited in the report stated refrigerated and thawed shakes have a shelf life of 14 days. The dietary manager stated he did not know there were different shelf lives depending on storage conditions and acknowledged the chocolate Mighty Shakes should have been discarded because more than 14 days had passed since they were placed in the refrigerator and thawed. The nursing home administrator also stated the chocolate Mighty Shakes should have been discarded because it was beyond the 14-day thaw shelf life. The facility further failed to label food items appropriately. In the walk-in refrigerator, a container with a white thick substance that looked like frosting had no date or food name, four additional containers with items resembling tomato sauce, chicken vegetable noodle soup, gravy, and chicken noodle soup were also unlabeled, and an unopened gallon ziplock bag that appeared to contain raw bacon was not labeled with the contents, opening date, or discard date. The dietary manager stated food removed from original packaging should be labeled with the food name, opening date, and use-by date, and the nursing home administrator agreed that the containers and bag should have been labeled accordingly. The kitchen was also not maintained in a clean manner. In the dish room, the wall behind the dishwashing sink had multiple black discolorations, and the wall above the three-compartment sink had black and brown discolorations. Three large sheet trays were leaning against the wall on the right drainboard of the three-compartment sink, with water visible on the top tray. The dietary manager stated he had not noticed the discoloration and said the deep cleaning should have included the walls behind the sinks. The maintenance director and nursing home administrator stated they were not aware of the wall conditions during the interview.
Missed showers and inadequate ADL assistance
Penalty
Summary
The facility failed to provide assistance with activities of daily living, specifically bathing and showering, for four residents reviewed for ADLs. The deficiency was identified through observations, record review, and interviews, and involved residents who required varying levels of assistance with bathing, personal hygiene, dressing, and grooming. The facility policy stated that residents' abilities in ADLs should not deteriorate unless unavoidable and that residents unable to carry out ADLs should receive necessary services to maintain personal and oral hygiene. Resident #23, who had Parkinson's disease, diabetes, an intracranial injury, and malnutrition, was cognitively intact and required set-up assistance with eating and showering and substantial assistance with personal hygiene and dressing. She stated she had not received showers as scheduled for several weeks because the facility did not have enough staff to complete them. Her shower record showed 10 showers out of 24 scheduled opportunities over the review period. CNAs stated residents sometimes had to wait until the next day for showers because there was not enough time to complete them, and the DON acknowledged the resident should have received showers as scheduled but did not. Resident #65, who had dementia, COPD, anxiety, and kidney disease, was cognitively intact and required set-up assistance with eating and moderate assistance with showering, personal hygiene, and dressing. He reported it had been about a week since his last shower and that he had washed up at the sink because he had not received one as scheduled. His shower record showed 11 showers out of 24 scheduled opportunities, and staff observed greasy, dirty hair and stated he often appeared not to have received all of his showers. Resident #8, who had schizophrenia, severe obesity, emphysema, and Parkinson's disease, had moderate cognitive impairment and required supervision with eating and bathing and moderate assistance with personal hygiene and dressing. His representative reported he was not groomed, had long, disheveled, greasy hair, and body odor. His shower record showed 11 showers out of 16 scheduled opportunities, and staff stated he often appeared to have greasy, dirty hair and had missed showers. Resident #43, who had spondylosis with radiculopathy, muscle wasting, and bipolar disorder, was cognitively intact and required moderate assistance with showering, personal hygiene, and dressing. He was observed to be unshaven and stated he was not getting all of his showers, that Friday showers were often delayed until Saturday, and that Monday showers were sometimes missed entirely. He also said it had been several weeks since his facial hair was shaved. His shower record showed 7 showers out of 10 scheduled opportunities since admission. Staff said he typically did not refuse showers and that some showers were likely missed. The DON stated the resident should have received showers as scheduled but had missed showers since admission.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in one medication storage room and three medication carts. During observations, surveyors found multiple insulin pens and inhalers that were not labeled with the resident’s name and/or the date they were opened. These included used HumaLog, Lantus Solostar, NovoLog, and insulin glargine pens stored with residents’ glucometers in medication cart storage bags, as well as used Symbicort, Trelegy Ellipta, and fluticasone propionate/salmeterol inhalers that were not dated when opened. Staff members told surveyors that the insulin pens and inhalers should have been labeled with the resident’s name and the date opened, and one RN stated she did not know how long an inhaler could be used once opened. Surveyors also found expired or discontinued medications that remained in storage. In the East overflow medication storage room, a lorazepam container labeled for a resident who had died on 6/19/25 was still in the medication refrigerator. In the medication carts, a Lantus insulin vial dated opened 5/27/25 was identified as expired, and an unopened naloxone package with a July 2025 expiration date was still present after the expiration date had passed. Another Lantus insulin vial dated opened 7/1/25 was also identified as expired. RN staff acknowledged that these medications should have been discarded. The DON and regional clinical resource stated that insulin pens and inhalers should be labeled with the resident’s name and date opened, that medications should be discarded when residents are discharged, and that all medications should be discarded upon expiration. The observations showed that these practices were not consistently followed across the East cart, the named medication cart, the Central cart, and the overflow medication storage room.
Failed Antibiotic Stewardship and Monitoring
Penalty
Summary
The facility failed to establish an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. The infection surveillance policy stated that nurses were to report residents started on antibiotics and that the facility would collect data to identify infections, including the infection site, pathogen, signs and symptoms, and resident location. However, the infection surveillance binder for June, July, and August 2025 showed inconsistent and incomplete antibiotic surveillance logs, with missing entries for ordering practitioner, documentation supporting necessity, site of infection, pathogen, and community or health care-associated status. The infection preventionist said she had not used the antibiotic surveillance log since starting at the facility, and the DON and regional clinical resource said the logs were not being used correctly to track infections and antibiotic use. Resident #3 had multiple chronic conditions including chronic kidney disease with heart failure, chronic respiratory failure, type 2 diabetes mellitus, systemic lupus erythematosus, depression, anxiety, and dependence on renal dialysis. The resident was cognitively intact and used a wheelchair. Although the resident’s assessment did not indicate antibiotic use, the EMR showed amoxicillin-potassium clavulanate was ordered for a right-hand wound infection for five days. The facility did not identify the right-hand wound infection on the infection tracking log, and the EMR showed the resident was not consistently monitored for adverse reactions related to the antibiotic. The resident also had a skin integrity care plan related to altered skin integrity and a left middle finger skin issue, with interventions to notify the physician if the condition did not respond to treatment or if an adverse reaction occurred. Resident #7 had type 2 diabetes mellitus, chronic kidney disease, acquired absence of the right leg below the knee, benign prostatic hyperplasia with lower urinary tract symptoms, chronic gastritis and melena, and a suprapubic catheter. The resident was cognitively intact and used a wheelchair. The EMR showed vancomycin hydrochloride was ordered for cholecystitis for 21 days, but the facility did not identify the antibiotic use on the infection tracking log. The EMR also showed the resident was not consistently monitored for adverse reactions related to the antibiotic, and there was no care plan for the resident’s antibiotic use during the period reviewed. Staff interviews confirmed that the facility was not consistent in monitoring adverse reactions and that the antibiotic use and infection type were not documented in the care plan.
Failure to Timely Report Alleged Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to timely report an allegation of resident-to-resident verbal abuse to the State Agency. The facility policy stated that alleged violations of abuse must be reported to the administrator, State Agency, adult protective services, and other required agencies within the specified timeframes, including within 24 hours when the event did not involve abuse or serious bodily injury. The report identified one allegation involving Resident #5 and Resident #32. Resident #5 was an older adult with diagnoses including dementia, COPD, and CKD. Her 7/2/25 MDS showed severe cognitive impairment with a BIMS score of 4 out of 15, wheelchair use, and need for assistance with eating, toileting, personal hygiene, and showering. Resident #32 was an adult under age 65 with diagnoses including dementia, spondylosis, depression, OCD, and anxiety disorder. Her 8/11/25 MDS showed cognitive impairment with a BIMS score of 11 out of 15, walker use, and assistance needs for oral and personal hygiene and showering. A 7/27/25 nurse progress note documented that a CNA reported Resident #32 was verbally aggressive toward her roommate, Resident #5, and yelled, "Well, my husband is going to come in here and kill you." The note stated Resident #32 was educated on being polite and that threats could not be made, and she was later in the dining room drinking coffee. On 8/19/25, the facility could not provide documentation that the alleged verbal abuse had been reported to the State Agency. During interviews, the NHA stated he was not familiar with the note at first, later said he reported the alleged event during the survey, and stated the nurse who wrote the note was not working and he was trying to gather more information. He also stated the investigation was ongoing as of 8/20/25 and he had not been able to substantiate or unsubstantiated the allegation.
Medication Given Without Physician Order
Penalty
Summary
The facility failed to ensure Resident #39 did not receive Excedrin Migraine without a physician's order. Resident #39 was cognitively intact, had diagnoses including insufficient sleep syndrome, heart failure, and major depressive disorder, and had a documented history of chronic headaches and migraines. Her care plan addressed acute and chronic pain, and her physician had previously discontinued Excedrin Migraine on 3/31/25 because she also took anticoagulants; the physician instead ordered acetaminophen, Topamax, and later sumatriptan for headache management. Record review and resident interview showed that Resident #39 continued to seek Excedrin Migraine for migraine relief. Nursing documentation showed prior PRN administration of Excedrin Migraine earlier in the year, but the physician progress note documented that the medication was discontinued because of anticoagulant use and that other pain and migraine treatments were ordered. The resident reported that RN #4 was the only nurse who gave her Excedrin Migraine and said the nurse administered two tablets on the night before the survey interview, which relieved her pain. RN #4 confirmed she gave the resident two tablets of Excedrin Migraine and said she thought there was a physician's order for it. She also said she did not document the administration in the electronic medical record and instead wrote it on paper and later shredded it. Other staff stated they did not administer Excedrin because there was no physician's order, and the PCP and DON stated medications should not be given without an order. The record also showed the resident had brought Excedrin Migraine into the facility in July, and staff removed and secured it after being informed she could not bring medications into the facility.
Failure to Obtain Eyeglasses and Cataract Referral
Penalty
Summary
The facility failed to ensure proper treatment and services to maintain vision abilities for Resident #8, who had diagnoses including schizophrenia, severe obesity, emphysema, and Parkinson's disease, and whose MDS assessment documented impaired vision requiring corrective lenses. The resident’s last eye exam note, dated 8/20/24, stated that his glasses improved his vision somewhat, a new prescription would be provided, and a cataract surgery consultation with an ophthalmologist was needed for best visual outcome. However, review of the medical record on 8/20/25 did not show that the new eyeglasses had been ordered or received, and there was no documentation that a referral had been made for the cataract exam. During observations, the resident was not wearing glasses, and his representative reported that his eyeglasses were very old and needed replacement. Staff interviews confirmed that the resident had been using the same glasses for several years and had not been seen wearing them in a while. The SSD stated she did not know whether the resident needed a cataract consult or new eyeglasses because she had not seen the eye exam note, and the DON stated that when a vision provider order included follow-up, the scheduler should arrange the appointment the next day and that eyeglasses should be ordered within a few days after a prescription was obtained.
CPAP Mask Not Cleaned or Stored per Order
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident who used a CPAP machine for obstructive sleep apnea and respiratory failure with hypoxia. The resident was cognitively intact, required assistance with several activities of daily living, and had physician orders for CPAP use at bedtime with 2 liters of oxygen and for CPAP mask cleaning in warm, soapy water with rinsing and air drying between uses every day shift. The resident stated she had not seen staff wash her CPAP mask and said the mask was usually kept in her nightstand drawer, while two other CPAP masks were observed in the bathroom sink area and the resident’s mask was repeatedly seen on the nightstand attached to the machine. The manufacturer’s instructions for the CPAP machine required daily cleaning of the mask, humidifier tub, and other components, with specific directions for washing, rinsing, and air drying, and the instructions also stated not to use harsh cleaners or place parts in a dishwasher or washing machine. The resident’s care plan addressed respiratory monitoring but did not include cleaning frequency or instructions for the CPAP machine and its parts. Although the June through August MAR/TAR documented daily CPAP mask cleaning as completed, the resident’s observations and interview indicated the mask had not been washed as ordered. Staff interviews showed inconsistent understanding of responsibility for CPAP care. A CNA said she only put the mask on and took it off and did not clean it, while another CNA said she was not familiar with CPAPs and did not know who cleaned the masks. An RN said she checked whether the mask was clean and would wipe it if she saw residue, but she did not know how often the mask should be cleaned and was not aware of the two masks in the bathroom sink. The DON stated staff should have followed the physician’s order for daily cleaning and observed that the storage of the masks in the room was not acceptable.
Incomplete dialysis communication and failure to follow dialysis recommendations
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care for a resident who required hemodialysis. The resident was cognitively intact, had chronic kidney disease with heart failure, chronic respiratory failure, type 2 diabetes, systemic lupus erythematosus, depression, anxiety, and dependence on renal dialysis. She also had a central venous catheter in the right chest and was scheduled for dialysis three times weekly. Her dialysis care plan addressed dialysis attendance, access-site infection monitoring, and comfort measures, but it did not include monitoring vital signs and weights before and after dialysis. The dialysis communication forms between the facility and the dialysis center were not consistently or thoroughly completed. On multiple dates, the pre-dialysis section was left blank for the access-site assessment and nurse signature, and the post-dialysis section was left blank in its entirety on several occasions. The forms also documented repeated abdominal pain and cramping during dialysis, with several treatments ending early because of cramping. One form documented that the resident’s milk of magnesia should be discontinued because it was contraindicated in hemodialysis patients and that Miralax or lactulose should be used instead, but the resident continued to have an active milk of magnesia order in the facility record. The facility also did not collaborate with the dialysis center regarding recommendations documented on the communication forms. The dialysis center noted the need for a gastroenterology consultation because of the resident’s persistent abdominal cramping, but the facility record did not show follow-up on that recommendation. Staff interviews confirmed that nurses were responsible for reviewing the dialysis communication forms, entering new orders or recommendations into the resident’s record, and ensuring appointments were scheduled, but the DON was not aware of the gastroenterology recommendation, the medication change recommendation, or that some of the dialysis communication forms were incomplete.
Failure to Complete Annual CNA Performance Reviews and Related In-Service Education
Penalty
Summary
The facility failed to complete annual performance reviews for three certified nurse aides and did not provide regular in-service education based on the outcome of those reviews. Record review showed that annual performance evaluations were requested for CNA #1, CNA #2, and CNA #3, but the facility was unable to provide completed reviews for CNA #1, who was hired 10/25/16, CNA #2, who was hired 4/8/22, and CNA #3, who was hired 6/26/23. The record also showed that none of the three CNAs had an annual performance review completed or an in-service education plan based on the review outcome. During interviews, the DON stated that annual performance evaluations should be completed annually and that they were important for identifying when retraining or skill refreshers were needed. RCR #1 stated that human resources was looking for the reviews because they were not kept in her office, and later reported that human resources could not find the annual performance evaluations for the three CNAs.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5 percent; surveyors identified a rate of 11.53 percent, based on three errors out of 26 opportunities for error. One error involved a resident who was ordered fluticasone propionate/salmeterol inhaler 250 mcg/50 mcg, one puff twice daily with instructions to rinse the mouth with water after use. RN #1 observed the resident take one puff from the inhaler and then walked away without having the resident rinse his mouth afterward. A second error involved a resident ordered NovoLog insulin aspart 24 units subcutaneously with meals and insulin glargine 47 units subcutaneously twice daily. RN #3 prepared both insulin pens, cleaned the pen tips, applied new needles, dialed the ordered doses, and administered the injections consecutively, but did not perform a safety test or prime the insulin pens before administration. RN #3 stated she thought she had primed the pens before attaching the needles, and the DON stated the pens should have been primed to ensure no air was in the pens and to ensure the correct dose was administered.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The facility failed to ensure that one resident with diabetes and chronic kidney disease was free from significant medication errors during insulin administration. The resident was cognitively intact, required only limited assistance with activities of daily living, and had physician orders for NovoLog 24 units subcutaneously with meals and insulin glargine 47 units subcutaneously twice daily. During observation, an RN prepared both insulin pens, cleaned the pen tips, attached new needles, and dialed the ordered doses, then entered the resident’s room and administered the two insulin injections consecutively. The RN did not perform the required safety test or prime either insulin pen before administering the medications. The manufacturer instructions for both NovoLog and Lantus required a priming or safety test before each injection to ensure proper dosing and confirm the pen and needle were working correctly. During interview, the RN said she thought she had primed the pens before attaching the needle tip but could not verbalize the importance of priming. The DON stated the RN should have primed the insulin pens to ensure no air was in the pens and that the correct dose would be administered.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide dental services for two residents reviewed for ancillary services. One resident had dentures that were reported by staff and the resident’s representative to have been ill fitting for several months, yet the resident had not received a dental consultation for more than two years. The facility policy stated that residents with lost or damaged dentures were to be referred for dental services within three days, but the resident’s record did not show that the denture fit problem had been identified in the care plan or that a timely dental referral had been completed. The resident’s representative said the dentures had not fit correctly for a long time and the resident had not been able to wear them. A CNA said the resident had not worn the dentures in months because they did not fit correctly and that nurses and the scheduler were aware, but the appointment had not been scheduled. The DON also said she had not seen the resident wear the dentures for several months and confirmed that staff were expected to notify nursing leadership so an appointment could be made. The SSD stated that if a resident had denture problems, a referral would be expected within a few days and consultation within one month. A second resident had missing and broken teeth and reported difficulty chewing and pain when eating, but the record did not show a specific dental referral, consult, or scheduled appointment in the physician orders. The resident stated she had not been able to see a dentist since admission and had told nursing staff and the NP months earlier that she wanted to see the dentist, but no follow-up occurred. During interview, the resident had broken and missing teeth and reported that her gums swelled and hurt when she ate. The SSD said she could not find documentation that the resident had been offered dental services since admission and noted that the resident’s dental appointment had been canceled and later rescheduled.
Infection Control Failure During Bed Bath
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection for one of three units. The deficiency involved a bed bath provided to Resident #55 in a manner that was not sanitary and did not follow the facility’s bed bath policy and procedure dated 4/11/25. During observation on 8/19/25 at approximately 2:00 p.m., CNA #1 and CNA #4 were seen providing a bed bath to Resident #55. The CNAs gathered supplies and spoke with the resident before beginning the bath. They turned the resident side to side to remove bedding and placed a bath blanket under him. They told the resident they were going to work from the bottom up, then washed his feet first and then his legs. CNA #4 washed his perineal area, including genitals, and then washed his chest without changing gloves. CNA #1 washed the resident’s back and buttocks, removed a small dressing from the sacral area, and then reached into the water basin to obtain another washcloth. She wrung out the washcloth and moved it to within a few inches of the resident’s face before stopping when prompted. CNA #1 then walked away from the bedside, removed her gloves, wet a towel in the bathroom sink, and washed the resident’s face and hair. The facility policy stated that bed baths should be performed top to bottom, with the face first and the perineal area last, using clean washcloths and changing bath water between body parts. In interview, CNA #5 said bed baths should start at the head and work to the toes, with the private areas done last. The DON stated the bath should begin at the face and proceed head to toe, using different washcloths and changing water between body parts, and said the CNAs who started at the feet and worked to the face were not correct and not hygienic. After the bath, the resident stated that his skin and body were very sensitive to touch and turning.
Survey Findings Binder Not Available to Residents
Penalty
Summary
The facility failed to ensure residents and their representatives had access to the most recent survey findings, including survey results, certifications, complaint investigations, and plans of correction. During a resident council group interview, cognitively intact residents stated they did not know where to access the survey findings binder. On observation, RN #1 attempted to locate the binder at the nurses' station and front desk but could not find it. The infection preventionist and the nursing home administrator also tried to locate the binder and were unable to find it. In staff interviews, RN #1, the infection preventionist, the nursing home administrator, and the chief nursing officer each stated they could not locate the survey findings binder, and the nursing home administrator said the facility was working on putting one together because he had not been able to find one in the facility.
Failure to Respond to Resident's Change in Condition Resulting in Serious Harm
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The resident, who had a history of right leg above the knee amputation, left arm paralysis following stroke, peripheral vascular disease, dysphagia, respiratory failure, and diabetes, reported shortness of breath to certified nurse aides (CNAs) in the early morning. The CNAs observed the resident's symptoms and promptly informed an LPN of the significant change in condition. Despite being notified multiple times by the CNAs about the resident's shortness of breath and complaints of not feeling well, the LPN failed to collect comprehensive information regarding the resident's condition. The LPN did not perform a full assessment, did not obtain a complete set of vital signs, and did not notify a registered nurse (RN) or the physician about the resident's significant change in condition. The LPN only measured the resident's oxygen saturation, which was 92%, and did not further investigate or escalate the situation as required by facility policy and professional standards. As a result of these inactions, the resident was later found unresponsive and not breathing, and was pronounced deceased. Documentation and interviews confirmed that no RN assessment or complete evaluation was conducted after the resident began experiencing a change in condition. The CNAs continued to report the resident's symptoms to the LPN, but did not escalate the concern to another nurse or the DON at the time. The failure to promptly identify and appropriately intervene when the resident experienced a significant change in condition resulted in a situation of serious harm.
Failure to Protect Resident Rights Regarding Personal Property Loss
Penalty
Summary
The facility failed to update its admissions agreement to ensure that residents did not waive their rights for reimbursement in the event of loss of personal property. Specifically, the admissions agreement signed by a resident included language stating that the facility was not responsible for theft, misplacement, loss, or damage to the resident's personal property and would not be responsible for repayment or replacement. The personal belongings inventory form, also signed at admission, reiterated that all items retained in the resident's possession were the responsibility of the resident and that the facility assumed no responsibility for lost or damaged items. A resident, who was cognitively intact and required varying levels of staff assistance for activities of daily living, was admitted with five rings, as documented on the personal belongings inventory form. Upon discharge, the resident reported that the five rings, including a wedding ring, were missing. The facility's records confirmed the rings were present at admission, but the discharge personal belongings inventory form could not be located by the facility. Staff interviews confirmed that the rings were not present at discharge and that the resident had been encouraged to use a lockbox for valuables, which she declined. The facility's policy supported residents' rights to possess personal belongings and required inventory documentation at admission and discharge. However, the admissions agreement and inventory form both included waivers of facility liability for lost or stolen property, contrary to regulatory requirements. The facility did not ensure that the resident retained her right to reimbursement for lost personal property, resulting in a deficiency related to the protection of resident property rights.
Verbal Abuse Incident Between Residents Over Television Dispute
Penalty
Summary
The facility failed to prevent verbal abuse between two residents, resulting in a deficiency. Resident #5 was subjected to verbal abuse by Resident #6, who yelled obscenities over a disagreement about the television channel in their shared room. Despite the intervention of the floor nurse, Resident #6 repeatedly returned to the room to continue the verbal altercation, causing Resident #5 to become very upset and emotional. Resident #5, who has a history of schizoaffective disorder, depression, and anxiety, was admitted to the facility with intact cognitive ability. During the incident, Resident #5 was watching a television show when Resident #6 demanded to change the channel. The situation escalated when Resident #6 used profanities and pointed a finger at Resident #5, leading to Resident #5 crying and expressing a desire to go to her grave. Despite the emotional distress, Resident #5 denied being fearful of Resident #6. Resident #6, who has diagnoses of depression and anxiety, was also cognitively intact. The resident became upset over the television channel and engaged in verbal aggression towards Resident #5. The facility's staff, including RN #1, intervened by asking Resident #6 to leave the room and later offering a room change, which Resident #6 accepted. The incident was reported to the nursing home administrator and director of nursing, and both residents were monitored closely following the altercation.
Failure to Provide Timely Behavioral Health Care for Suicidal Resident
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident who expressed suicidal ideation. The resident, who had a history of alcohol abuse, dementia, and other mental health issues, expressed a desire to harm herself on January 1st. Despite this, there was no immediate action taken to increase monitoring or notify key personnel such as the resident's physician, the nursing home administrator, or the director of nursing. The resident was not sent to the emergency room for evaluation until nearly 24 hours after the initial expression of suicidal thoughts. The facility's baseline care plan for the resident was inadequate, as it did not specify the resident's mental health diagnoses or the medications required for treatment. Additionally, there was a lack of documentation regarding the implementation of 15-minute checks, which were supposed to be conducted after the resident expressed suicidal ideation. The facility also failed to initiate a comprehensive care plan focus for suicidal ideations until five days after the resident expressed wanting to kill herself. Interviews with staff revealed communication breakdowns and a lack of immediate response to the resident's suicidal ideations. The DON was not made aware of the situation until the following day, and there was no documentation of the 15-minute checks that were reportedly conducted. The facility also failed to refer the resident for behavioral health services in a timely manner, with a psychological assessment not conducted until eight days after the resident expressed suicidal ideation.
Deficiency in Wound Care and Documentation
Penalty
Summary
The facility failed to ensure that Resident #4 received treatment and care in accordance with professional standards of practice. Resident #4, who had multiple diagnoses including type 2 diabetes mellitus with chronic kidney disease, foot ulcers, heart failure, and osteomyelitis, was admitted with surgical wounds to both heels and a wound vacuum on the left heel. The hospital discharge instructions specified that the resident was to be non-weight bearing and wear Prevalon boots on both feet. However, these instructions were not entered into the resident's electronic medical record (EMR) or included in the skin and pressure ulcer care plan upon admission. The facility also failed to ensure consistent wound care and physician oversight. Resident #4 was scheduled for weekly visits by the wound care physician, but documentation revealed missed visits on several occasions, including 10/1/24, 10/23/24, 11/6/24, and 11/26/24. Additionally, there were lapses in changing the wound vacuum as ordered, and the facility did not document notifying the physician of these lapses or the resident's refusal to have the wound vacuum changed. The resident's left heel wound worsened over time, with increased size and the presence of eschar and odor, yet there was no documentation of physician notification regarding these changes. Interviews with facility staff revealed further deficiencies in communication and documentation. The regional director of quality and compliance (RDQC) and the director of nursing (DON) acknowledged inconsistencies in the medical record and the failure to update care plans to reflect the resident's non-weight bearing status and the use of Prevalon boots. The DON admitted that the wound care physician was not always available, and nurses were expected to conduct wound rounds in his absence. Despite a performance improvement plan initiated in October 2024, the facility did not update Resident #4's care plan or complete weekly skin assessments as required.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident who was at risk for pressure ulcers and had a history of such conditions. Upon readmission to the facility, the resident had a scabbed area on the coccyx, which was not properly documented or communicated to the wound care nurse or physician. This lack of notification and absence of a treatment order led to the worsening of the skin condition, which eventually developed into an unstageable pressure injury. The resident's care plan was not updated to reflect the current pressure injury, and there was a failure to perform timely wound care. The resident did not have a protective dressing applied after a shower, leaving the wound uncovered for nearly six hours. Additionally, the resident was provided with a new wheelchair cushion that was unsuitable, contributing to the development of the pressure ulcer. Despite the initiation of a performance improvement plan aimed at addressing pressure ulcers, the facility did not adhere to its procedures. The resident's skin issue was not reported in a timely manner, and treatment orders were delayed. The facility's inaction and lack of communication among staff members contributed to the deterioration of the resident's skin condition.
Improper Use of Hoyer Lift Sling as Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by the use of a Hoyer lift sling to restrain a resident in a wheelchair. The incident involved a resident who was observed sitting in a wheelchair with the Hoyer lift sling straps brought up between his legs, over his shoulders, and hooked onto the wheelchair handles. This positioning was done by the Director of Nursing (DON) and observed by Registered Nurse (RN) #3, who were both present at the nurses' station with the resident. The resident, who was cognitively intact with a BIMS score of 15 out of 15, had a history of sliding out of his wheelchair and was experiencing increased confusion and hallucinations. The resident's care plan did not indicate the need for a Hoyer lift for transfers, and there was no documentation in the electronic medical record regarding the incident. The resident was admitted with diagnoses including prostate cancer, bladder cancer, and congestive heart failure, and required assistance with mobility and transfers. Multiple staff members, including CNAs and RNs, observed the resident in the restrained position but did not intervene or report the situation immediately. The DON admitted to the police that she placed the sling in such a position, and RN #3 confirmed witnessing the action. The facility's policy on abuse and neglect was not followed, as the incident was not documented in the resident's medical record, and the use of the sling as a restraint was not justified or documented as a medical necessity.
Infection Control Deficiencies in Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during wound care procedures. Specifically, the facility did not ensure that wound care supplies were placed on a clean field, nor did they ensure that a clean barrier was placed under the wound. Additionally, staff failed to change gloves and perform hand hygiene during wound care, and did not treat each wound separately. Enhanced Barrier Precautions (EBP) were also not followed, as staff did not don gowns during wound care. During an observation, a registered nurse (RN) was seen providing wound care to a resident with a pressure ulcer on the coccyx. The RN placed wound care supplies directly on the resident's bed sheet, did not wear a gown, and failed to place a clean barrier under the wound. The RN also did not change gloves after cleansing the wound and before applying medication, and did not perform hand hygiene after removing soiled gloves. Another observation involved the infection preventionist (IP) providing wound care to a resident with a pressure ulcer on the heel and an open wound on the toe. The IP did not wear a gown, failed to change gloves between treating different wounds, and did not treat each wound separately. Interviews with staff revealed a lack of adherence to infection control protocols. The RN admitted to not performing hand hygiene between glove changes and not using a clean field for wound care supplies unless performing a sterile dressing change. The IP acknowledged the need to change gloves between treating different wounds and to treat each wound separately. The Director of Nursing (DON) confirmed that EBP should be followed, including the use of gowns and gloves, setting up a clean field, and treating each wound separately to prevent cross-contamination.
Failure to Ensure Timely Audiology Referral
Penalty
Summary
The facility failed to ensure proper treatment and services to maintain hearing for an 83-year-old resident with severe cognitive impairment and multiple diagnoses, including falls, dementia with mild agitation, and anxiety disorder. The resident's physician ordered an audiology consult on 4/9/24 due to complaints of dizziness and headaches, but the facility did not arrange the consult in a timely manner. The resident's representative expressed concerns about the delay, and the record review revealed that the initial recommendation for an ENT referral was made on 3/6/24 after the resident returned from the emergency room. However, the facility did not follow up on this recommendation promptly, resulting in a significant delay in the resident receiving the necessary audiology services. Interviews with the nursing home administrator and the director of nursing (DON) confirmed that the former DON did not follow up on the emergency department's recommendation timely. The current DON acknowledged that she did not send the referral information to the audiologist until 4/23/24, and the appointment was not confirmed until 4/22/24, 45 days after the initial recommendation. The resident did not see the audiologist until 51 days after the initial recommendation, highlighting a failure in the facility's process to ensure timely follow-up on physician-ordered referrals.
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Illustrative
What surveyors actually found near you
We read the 23 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sterling
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Devonshire Care Center | 2.1 mi | ★★★★★ | 23 | 0 |
| Eben Ezer Lutheran Care Center | 33.5 mi | ★★★★★ | 1 | 0 |
| South Platte Rehabilitation And Nursing Llc | 33.8 mi | ★★★★★ | 3 | 1 |
| Srmc Long Term Care, Llc Dba Pole Creek Estates | 38.7 mi | ★★★★★ | 0 | 0 |
| Valley View Villa | 39 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.