Pennsylvania Department of Health
STERLING HEALTH CARE AND REHAB CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

STERLING HEALTH CARE AND REHAB CENTER
Inspection Results For:

There are 154 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


STERLING HEALTH CARE AND REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Findings of an Abbreviated Complaint Survey completed on April 27 2026, Sterling Health Care and Rehab Center identified deficient practice, related to the reported complaint allegations, under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Findings include:

Review of facility policy "Wandering and Elopements" dated November 2025, stated "Missing Resident- Process: ... if a resident is missing, initiate the elopement/missing resident emergency procedure; determine if the resident is out on an authorized leave or pass; if the resident was not authorized to leave, initiate a search of the building(s) and premises; and if the resident is not located, notify the Nursing Home Administrator and the Director of Nursing Services, the resident's legal representative, the attending physician, and law enforcement officials and( as necessary) volunteer agencies."

Review of Resident 1's clinical record revealed Resident 1 was admitted to the facility on November 19, 2025.

Review of Resident 1's clinical record revealed diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance,(general loss of cognitive abilities, including memory without specific behavioral symptoms )psychotic disturbance(disruption in a person's thoughts and perceptions) mood disturbance(involves prolonged emotions that can be either excessively sad or excessively happy, and anxiety(persistent and excessive worry).

Review of facility investigation documentation revealed that on April 14, 2026, Resident 1 closely followed the housekeeper through the double doors on the ground floor into the back hallway and out the side door. The housekeeper was unaware the resident came through the door.

Review of information submitted by the facility to Department of Health, dated April 14, 2026, revealed that "On 4/14/2026, An elopement alarm was activated after the resident was not accounted for on the secured unit. The facilities established protocols were immediately initiated, including notification of local law enforcement. The resident was located a short time later and safely returned to the facility without injuries."

Review of facility investigation documentation revealed a written statement dated April 14, 2026, from Director of Nursing that stated "A call was received from local police regarding an individual found matching the description of resident (Resident 1). The Corporate Nurse, Business Office Director and I responded to the provided location. Upon arrival Resident 1 was observed sitting in a relaxed manner conversing appropriately with officers and holding a beverage (coke). He presented with no visible injuries and denied any pain or discomfort ...When asked about his whereabouts, he stated he was attempting to get to 69th street and reported that a woman had approached him to ask if he needed assistance or if he was lost. He also mentioned intending to take a train but acknowledged he had gone in the wrong direction ..."

Review of facility documentation provided by facility of receipt from McDonald's dated April 14, 2026, at 1:53pm revealed evidence of a purchase Resident 1 had made of a filet o-fish sandwich and a small coke.

Review of Resident 1 clinical record revealed progress note dated April 14, 2026, at 17:01 a health status note stated "Resident noted not on unit and a immediate search was conducted with administration/staff notified. Proper authorities notified and family notified by administration of event. Resident returned safely after aggressive search completed. Skin check completed by 3-11 charge nurse. Message left with answering service of Team Health for CRNP on call@ 4:35 pm. Resident currently in his room eating dinner."

Observations made on the ground floor on April 27, 2026, 2026, at 11:10am revealed that a code is required to be entered to exit the unit and the floor. Observations made on the ground unit confirmed that the unit is a locked unit.

Observed Resident 1 on April 27, 2026, at 11:20 am sitting at table writing in notepad. Resident 1 was wearing a shirt and jacket with dress pants, and wander guard was on left wrist.

Interview with Resident 1 on April 27, 2026, at 11:21am, on the April 14, 2026, incident, Resident 1 stated "It was taking too long to get out the building, and so I waited for the opportunity and took it" Resident 1 stated "They brought me here and wouldn't let me leave. I wanted to go back to my place."

Interview with the Nursing Home Administrator on April 27, 2026, at 1:45pm confirmed that the staff failed to ensure Resident 1's safety by not checking for residents before and after exiting the unit.

The facility self-identified the deficient practice at the time of the incident, April 14, 2026. The facility implemented a corrective action of staff education and review of residents for elopement risk.

The facility's immediate action plan included the following:

QAPI (Quality Assurance Performance Improvement) conducted April 14, 2026.

Signs were placed on doors to check for residents before and after exiting doors.
Resident 1 was immediately placed on 1:1 supervision

Facility Maintenance Director changed the facility door codes.

Facility Maintenance Director checked facility door to ensure securement and function.

Nursing Home Administrator reviewed the elopement policy.

Education was completed for Employee 4 including a documented counselling warning on April 16, 2026.

Education was initiated for all facility staff on the policy of Elopement, which includes recognizing, preventing and responding to resident elopement to ensure resident safety. All staff completed training by April 19, 2026.

Residents were reviewed for elopement risk and to ensure interventions were in place. No other residents were identified as immediate risk.

Residents with code alert bracelets/ wander guards were checked for placement and functioning.

Facility Maintenance Director or designee will check exit doors daily for function and security. Maintenance immediately intervenes if a door is identified with any issues. Results of these checks are reviewed by the QAPI committee for further actions as needed.

Director of Nursing or designee will review newly completed elopement assessments daily for 5 days, weekly for 3 weeks, then monthly to ensure residents identified with risk have a plan in place. Results of these checks are reviewed by the QAPI committee for further recommendations as needed.

Nursing Home Administrator or designee will complete door audits daily for 5 days and weekly for 3 weeks and monthly for 3 months.

During an interview on April 14, 2026, at 11:35 a.m. LPN (Licensed Practical Nurse) Employee E5 verified receiving education on Elopement and was able to verbalize understanding.

During an interview on April 14, 2026, at 11:40 a.m. CNA (Certified Nurse Assistant) Employee 6 verified receiving education on Elopement and was able to verbalize understanding.

The facility has demonstrated compliance with the above since April 15, 2026.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(1)(e)(1) Management.

28 Pa. Code 211.10(d) Resident care policies.

28 Pa. Code 211.12(d)(5) Nursing services.

Plan of Correction - To be completed: 05/20/2026

Past noncompliance: no plan of correction required.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement