Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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.
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 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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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.
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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 | — | 2 | 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.