Inspection Reports for
Sterling Place Healthcare &Amp; Rehabilitation Center
3888 NORTH BLVD, BATON ROUGE, LA, 70806
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Inspection Report — Jul 31, 2024
Complaint Investigation CMS
Date: Jul 31, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding verbal abuse by a staff member towards a resident and other related regulatory concerns.
Complaint Details
The complaint investigation was substantiated for verbal abuse by staff member S23LPN towards Resident #98. The facility failed to report the abuse allegation to the state survey agency within the required 2-hour timeframe.
Findings
The facility substantiated verbal abuse by a staff member towards Resident #98 and failed to timely report the abuse allegation to the state survey agency. Additionally, the facility had deficiencies in accurate resident assessments, failure to implement PASRR recommended services, inadequate ADL care including nail care, food storage and safety violations, environmental maintenance issues, and pest control problems.
Deficiencies (8)
F 0600: The facility failed to protect Resident #98 from verbal abuse by staff member S23LPN, who engaged in a loud, profane altercation with the resident.
F 0609: The facility failed to report an allegation of verbal abuse to the state survey agency within the required 2-hour timeframe after the incident involving Resident #98 and staff member S23LPN.
F 0641: The facility failed to ensure accurate MDS assessments reflecting residents' PASRR Level II status for 4 residents (#11, #68, #100, #119).
F 0644: The facility failed to incorporate PASRR Level II recommended services into care planning and failed to document refusals for 3 residents (#14, #100, #109).
F 0677: The facility failed to provide adequate nail care for Residents #40 and #119, resulting in long, dirty fingernails with black debris.
F 0812: The facility failed to store and label food properly, including expired milk and unlabeled opened food items in refrigerators and dry storage.
F 0921: The facility failed to maintain a safe, sanitary, and comfortable environment in multiple resident rooms and utility areas, including water damage, mold, missing ceiling tiles, damaged walls and floors, and unsanitary conditions in a cleaning station.
F 0925: The facility failed to maintain an effective pest control program, with observations of live and dead roaches, spiders, and flies in kitchen and storage areas.
Report Facts
Residents reviewed for abuse: 4
Residents affected by verbal abuse: 1
Date of verbal abuse incident: May 29, 2024
Date verbal abuse reported: May 29, 2024
Residents reviewed for PASRR accuracy: 8
Residents with inaccurate PASRR coding: 4
Residents reviewed for PASRR service coordination: 8
Residents with failed PASRR service coordination: 3
Residents reviewed for ADL nail care: 2
Residents affected by inadequate nail care: 2
Residents served meals from kitchen: 126
Rooms observed for environmental concerns: 5
Residents currently residing in facility: 128
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S23LPN | Licensed Practical Nurse | Named in verbal abuse incident with Resident #98 |
| S13ADON | Assistant Director of Nursing | Witness and intervener in verbal abuse incident |
| S19ADON | Assistant Director of Nursing | Witness and intervener in verbal abuse incident |
| S1ADM | Administrator | Responsible for incident reporting and interviewed about abuse and facility issues |
| S2AADM | Assistant Administrator | Interviewed about verbal abuse incident |
| S12DON | Director of Nursing | Interviewed about abuse incident and nail care deficiencies |
| S5MDS | MDS Coordinator | Interviewed about PASRR assessment inaccuracies and care planning |
| S16SSD | Social Services Director | Interviewed about PASRR service coordination and refusals |
| S10AM | Food Service Manager | Interviewed about food storage and pest control issues |
Inspection Report — Jun 11, 2024
Routine CMS
Date: Jun 11, 2024
Visit Reason
The inspection was conducted to assess the safety, sanitation, and comfort of the nursing home environment based on observations and interviews.
Findings
The facility failed to provide a safe, sanitary, and comfortable environment in 12 rooms observed, with issues including gaps around air conditioner units, damaged ceiling tiles, peeling paneling, missing face plates on wall sockets, and a bed headboard missing bolts.
Deficiencies (3)
F 0921: The nursing home area was unsafe and unsanitary with gaps around air conditioner units, peeling paneling, and holes in ceiling tiles in multiple rooms.
Damaged and missing components were observed including hanging wires, broken laminate coverings, stained and drooping ceiling tiles, and missing face plate covers on wall sockets.
A bed headboard was missing bolts and brackets, causing it to lean improperly, confirmed by facility administration.
Report Facts
Rooms with environmental concerns: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S2MAIN | Conducted environmental tour and confirmed findings | |
| S1ADM | Facility administrator who confirmed the findings and observations |
Inspection Report — Oct 18, 2023
Complaint Investigation CMS
Date: Oct 18, 2023
Visit Reason
The investigation was conducted due to a complaint alleging physical abuse of Resident #1 by a certified nursing assistant (S5CNA) on 10/18/2023.
Complaint Details
The complaint was substantiated. The investigation confirmed physical abuse of Resident #1 by S5CNA on 10/18/2023. The staff member was terminated and law enforcement notified.
Findings
The facility failed to protect Resident #1 from physical abuse by S5CNA, who shoved the resident causing a fall. The abuse was confirmed by video footage, staff interviews, and record reviews. Corrective actions including termination of the employee and staff training were implemented prior to the State Agency's investigation.
Deficiencies (1)
F 0600: The facility failed to protect residents from physical abuse by a staff member who shoved Resident #1 causing a fall. The incident was witnessed and confirmed by multiple staff and video evidence.
Report Facts
Residents affected: 3
Date of incident: Oct 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5 CNA | Certified Nursing Assistant | Named as the staff member who physically abused Resident #1. |
| S3 LPN | Licensed Practical Nurse | Witnessed the abuse incident and prepared the incident report. |
| S4 CNA | Certified Nursing Assistant | Witnessed the incident and provided a statement confirming abuse. |
| S2 DON | Director of Nursing | Received report of abuse and confirmed incident after video review. |
| S1 ADM | Administrator | Confirmed awareness of the incident and abuse by S5CNA. |
Inspection Report — Sep 6, 2023
Complaint Investigation CMS
Date: Sep 6, 2023
Visit Reason
The inspection was conducted following a complaint regarding failure to provide timely assistance to a resident needing help to use the bathroom, which resulted in a fall and injury.
Complaint Details
The investigation was complaint-driven based on Resident #1's fall after waiting over an hour for toileting assistance. The complaint was substantiated as staff failed to provide timely help despite multiple requests, leading to injury.
Findings
The facility failed to provide appropriate assistance to Resident #1, who required help to use the bathroom, resulting in a fall causing a hematoma and facial abrasion. Staff delays and failure to assist the resident promptly were confirmed through interviews and video review.
Deficiencies (1)
F 0690: The facility failed to provide appropriate care for residents who are continent or incontinent of bowel/bladder, resulting in actual harm to Resident #1 who fell while attempting to go to the restroom unassisted. Resident #1 sustained a right frontal scalp hematoma and facial abrasion due to delayed assistance.
Report Facts
Residents affected: 1
Date of fall: Aug 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S5CNA | Certified Nursing Assistant | Failed to assist Resident #1 to the bathroom leading to fall |
| S3LPN | Licensed Practical Nurse | Notified about Resident #1's need for assistance and fall |
| S6CNA | Certified Nursing Assistant | Was asked for assistance but was busy with other residents |
| S7UC | Unit Coordinator | Received 911 call and notified nursing staff |
| S2DON | Director of Nursing | Reviewed video footage and confirmed findings |
| S1AADM | Assistant Administrator | Reviewed video footage and confirmed findings |
Inspection Report — Aug 16, 2023
CMS
Date: Aug 16, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident environment safety, abuse prevention, and accuracy of resident assessments.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment due to damaged walls, missing ceiling tiles, and unsecured baseboards in resident rooms. Additionally, a physical abuse incident involving a staff member and a resident was substantiated, resulting in staff termination and corrective actions. The facility also failed to accurately code active diagnoses in resident assessments (MDS) for several residents.
Deficiencies (3)
F 0584: The facility failed to maintain walls free of holes, secure baseboards, keep sheetrock intact, and ensure ceiling tiles were undamaged and secured in multiple resident rooms.
F 0600: The facility failed to protect a resident from physical abuse by a staff member, resulting in a physical altercation and substantiated abuse.
F 0641: The facility failed to ensure resident assessments accurately reflected active diagnoses for 4 of 5 residents reviewed.
Report Facts
Residents reviewed: 5
Residents affected: 3
Residents affected: 1
Residents affected: 4
Compliance monitoring frequency: 2
Monitoring duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S6CNA | Staff member involved in physical abuse incident | |
| S4LPN | Nurse who witnessed and reported physical altercation | |
| S7CNA | Staff who witnessed and separated parties during physical altercation | |
| S2DON | Director of Nursing who initiated corrective actions and monitoring | |
| S1ADM | Administrator who reviewed incident and camera footage | |
| S3MDS | Staff responsible for resident MDS assessments |
Inspection Report — Jun 27, 2023
Annual Inspection CMS
Date: Jun 27, 2023
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with health and safety regulations at Sterling Place Healthcare & Rehabilitation Center.
Findings
The facility was found to have multiple deficiencies including environmental maintenance issues, expired enteral nutritional feedings, improper medication storage, and unsanitary food storage practices. These deficiencies posed potential risks to residents' safety and health.
Deficiencies (4)
F 0584: The facility failed to maintain a safe, functional, sanitary, and comfortable environment. Issues included holes in walls and doors, damaged ceiling tiles, unsecured baseboards, broken toilet paper holders, and malfunctioning privacy curtains affecting some residents.
F 0693: The facility failed to ensure expired enteral nutritional feedings were not available for resident use, potentially affecting one resident receiving Isosource 1.5 calorie feeding.
F 0761: The facility failed to ensure medications were properly stored in locked compartments. Expired FluAd vaccines were found in the medication refrigerator.
F 0812: The facility failed to store and prepare food under sanitary conditions. Observed issues included undated, unsealed packages of sliced ham stored improperly above other food items and an unlabeled pan of brown gravy.
Report Facts
Residents potentially affected: 125
Residents potentially affected: 1
Residents potentially affected: 122
Expiration date: 202210
Expiration date: May 31, 2023
Inspection Report — Jun 22, 2022
Routine CMS
Date: Jun 22, 2022
Visit Reason
Routine inspection to assess compliance with food safety, COVID-19 testing protocols, and pest control standards at Sterling Place Healthcare & Rehabilitation Center.
Findings
The facility failed to properly label and date food items in the kitchen, did not comply with COVID-19 testing frequency requirements for unvaccinated staff, and had an ineffective pest control program evidenced by multiple observations and resident reports of roaches and gnats throughout the facility.
Deficiencies (3)
F0812: The facility failed to label food in accordance with professional standards, with multiple opened and undated food packages found in storage areas.
F0886: The facility failed to ensure COVID-19 routine testing compliance for unvaccinated staff, testing them weekly instead of twice weekly as required by community transmission levels.
F0925: The facility failed to maintain an effective pest control program, with numerous observations and resident reports of roaches, gnats, and flies throughout the facility.
Report Facts
Residents affected: 113
Unvaccinated staff reviewed: 12
Unvaccinated staff tested weekly: 11
Food items improperly labeled: 7
Gnats observed: 15
Gnats observed: 6
Gnats observed: 4
Roaches observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| S8LPN | Unvaccinated staff member interviewed regarding COVID-19 testing frequency and exemption | |
| S7ADON | Administrator interviewed about COVID-19 testing compliance and community transmission levels | |
| S2LPN | Unvaccinated staff member interviewed regarding COVID-19 testing and pest observations | |
| S9UC | Unvaccinated staff member interviewed regarding COVID-19 testing | |
| S4MS | Unvaccinated staff member interviewed regarding COVID-19 testing and pest control logs | |
| S1ADM | Administrator interviewed about COVID-19 testing practices and pest control awareness | |
| S10CNA | Staff member interviewed about pest sightings | |
| S11CNA | Staff member interviewed about pest sightings | |
| S3LPN | Staff member interviewed about pest infestation severity |
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