A list of the most recent deficiencies for Sterling Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2024-01-25 | 2024-02-27 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-01-25 | 2024-02-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-25 | 2024-02-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-25 | 2024-02-27 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-01-25 | 2024-02-27 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2024-01-25 | 2024-02-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-25 | 2024-02-27 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-01-25 | 2024-02-27 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-09-28 | 2023-11-15 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-09-28 | 2023-11-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-14 | 2023-08-24 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2023-04-25 | 2023-06-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-25 | 2023-06-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-25 | 2023-06-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-25 | 2023-06-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-25 | 2023-06-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-25 | 2023-06-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-25 | 2023-06-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-04-25 | 2023-06-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-25 | 2023-06-16 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-04-25 | 2023-06-09 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-04-25 | 2023-06-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-25 | 2023-06-09 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-04-25 | 2023-06-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-25 | 2023-06-09 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-04-25 | 2023-05-31 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-04-25 | 2023-05-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-25 | 2023-05-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-25 | 2023-05-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-25 | 2023-05-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-25 | 2023-05-31 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-04-25 | 2023-05-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-25 | 2023-05-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-25 | 2023-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-25 | 2023-05-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-25 | 2023-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-23 | 2022-06-23 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-06-06 | 2022-06-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-06 | 2022-06-08 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-02-23 | 2022-04-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-23 | 2022-04-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-23 | 2022-04-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-23 | 2022-04-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-23 | 2022-04-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-02-23 | 2022-03-11 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-02-23 | 2022-03-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-23 | 2022-03-11 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-02-23 | 2022-03-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-23 | 2022-03-11 | N |
| Dispose of garbage and refuse properly. | Health | 2022-02-23 | 2022-03-11 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-23 | 2022-03-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-23 | 2022-03-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-02-23 | 2022-03-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-23 | 2022-03-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-23 | 2022-03-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-23 | 2022-03-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-02-23 | 2022-03-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-02-23 | 2022-03-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-02-23 | 2022-03-09 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-02-23 | 2022-03-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-23 | 2022-03-08 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-02-23 | 2022-03-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-23 | 2022-03-07 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-12-29 | 2022-01-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-24 | 2021-09-28 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-11-02 | 2021-04-04 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-11-02 | 2020-11-24 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2020-11-02 | 2020-11-23 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-11-02 | 2020-11-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-11-02 | 2020-11-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-11-02 | 2020-11-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-11-02 | 2020-11-19 | N |
