Inspection Reports for Sterling Care Forest Hill
109 Forest Valley Dr, Forest Hill, MD 21050, United States, MD, 21050
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% better than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 7
Date: Aug 7, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, care, environment, staffing, food safety, and facility maintenance.
Findings
The facility was found deficient in multiple areas including restricting resident movement by locking Unit 300, failure to follow up on ophthalmologist recommendations, poor maintenance of resident rooms and equipment, inadequate supervision leading to resident elopement, incomplete nurse staffing records, improper food storage, and failure to maintain a safe and comfortable environment.
Deficiencies (7)
Facility failed to allow residents on Unit 300 to move freely as the unit was locked and required a code to enter and exit.
Facility failed to address and follow up on an ophthalmologist's recommendation for Resident #31.
Facility failed to maintain equipment in good repair and provide a clean homelike environment in residents' rooms.
Facility failed to provide supervision to a cognitively impaired resident with elopement risk, resulting in an Immediate Jeopardy event.
Facility staff failed to ensure nurse assignment sheets were completed daily and retained for the required period.
Facility failed to store food in accordance with professional standards, including undated and expired items.
Facility failed to ensure repairs were made in a resident's room, including separated baseboards and bathroom sink needing caulking.
Report Facts
Residents reviewed for vision: 5
Residents reviewed for elopement: 12
Length of baseboard separation: 25
Date of survey completion: Aug 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) Unit Manager #35 | Interviewed regarding locked Unit 300 and nurse assignment sheets. | |
| Geriatric Nursing Assistant (GNA) #34 | Provided codes to residents and family for Unit 300 access. | |
| Staff #24 (Unit Manager for Unit 1) | Interviewed about scheduling specialty appointments and ophthalmologist consult for Resident #31. | |
| Staff #16 (Business Manager) | Interviewed about insurance issues related to Resident #31's ophthalmologist appointment. | |
| Geriatric Nursing Assistant (GNA) #27 | Interviewed regarding supervision of Resident #82 prior to elopement. | |
| Registered Nurse (RN) #28 (11 PM-7 AM nursing supervisor) | Returned Resident #82 after elopement and conducted assessment. | |
| Licensed Practical Nurse (LPN) #29 (11 PM-7 AM shift) | Assisted with assessment of Resident #82 after elopement. | |
| Assistant Director of Nursing (ADON) | Provided information on elopement incident, root cause analysis, and corrective actions. | |
| Administrator | Discussed post-elopement interventions and facility corrective actions. | |
| Dietary Aide Staff #13 | Observed and removed improperly stored food items. | |
| Maintenance Technician Staff #4 | Confirmed observations of equipment disrepair and maintenance needs. | |
| Unit Manager Staff #35 | Confirmed ongoing maintenance issues during follow-up observation. | |
| Assistant Director of Nursing #5 | Interviewed about nurse assignment sheet completion and retention. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 24, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding a failure to timely report an allegation of abuse involving Resident #1 at Sterling Care Forest Hill.
Complaint Details
The complaint investigation found that the facility did not report the abuse allegation within the required 2-hour timeframe to OHCQ. The allegation involved Resident #1 and a Geriatric Nursing Assistant. Law enforcement was notified on 9/28/2023, but OHCQ notification was delayed until 3:27 PM the same day. The facility leadership acknowledged errors in reporting dates and documentation.
Findings
The facility staff failed to report an allegation of abuse within the required 2-hour window to the Office of Health Care Quality (OHCQ). Resident #1 alleged inappropriate conduct by a Geriatric Nursing Assistant during care on 9/27/2023, but the report was not submitted to OHCQ until 9/28/2023 at 3:27 PM, more than 24 hours later. Law enforcement was notified on 9/28/2023 at 12:30 PM. The facility leadership could not validate timely reporting of the allegation.
Deficiencies (1)
Failure to timely report suspected abuse to the regulatory agency within 2 hours of the allegation.
Report Facts
Date of incident: Sep 27, 2023
Date report submitted to OHCQ: Sep 28, 2023
Law enforcement notification time: 1230
Law enforcement response time: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GNA #5 | Geriatric Nursing Assistant | Named in abuse allegation involving Resident #1 |
| Director of Nursing | Director of Nursing (DON) | Involved in reporting and investigation of abuse allegation |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Involved in reporting and investigation of abuse allegation |
| Staff #6 | Social Work Director | Provided emotional support and submitted report after Resident #1 recounted incident |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 18
Date: Sep 27, 2019
Visit Reason
Annual recertification survey of Sterling Care Forest Hill nursing home to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to ensure call bells were within reach, inconsistent advance directive documentation, unsafe and unclean environment, failure to report theft allegations, failure to notify responsible parties of hospital transfers, improper pain medication administration, inadequate assistance with meals, failure to revise care plans for weight loss, failure to administer medications as ordered, failure to provide adequate nurse aide training, failure to secure medications, failure to obtain ordered lab tests, failure to arrange dental care, failure to maintain food safety and sanitation, and failure to maintain accurate medical records.
Deficiencies (18)
Facility staff failed to treat residents in a dignified manner.
Facility staff failed to ensure call bells were within reach for Resident #94.
Facility staff failed to ensure residents were competent for health care decision making prior to signing medical forms.
Facility failed to provide a safe, clean, comfortable and homelike environment.
Facility staff failed to notify the state agency upon accusation of theft of resident property.
Facility failed to notify responsible party and/or resident in writing of hospital transfers.
Facility staff failed to administer pain medication in accordance with standard nursing practice.
Facility staff failed to aid Resident #55 with meals by not cutting meat.
Facility staff failed to revise resident's plan of care related to significant weight loss and skin tear prevention.
Facility staff failed to ensure medication was given as ordered for Resident #120.
Facility failed to provide at least 12 hours of nursing aides' in-services within a year for one staff member.
Facility staff failed to ensure medications were secured in a locked environment.
Facility staff failed to obtain laboratory blood specimens as ordered for Resident #94.
Facility staff failed to arrange dental consult to repair or replace broken dentures.
Facility failed to provide food at a safe and appetizing temperature.
Food service employees failed to ensure sanitary practices and equipment maintenance to reduce risk of foodborne illness.
Facility staff failed to maintain medical records in a complete and accurate form, including failure to document medication administration and blood sugar results.
Facility failed to maintain an effective pest control program as evidenced by presence of flies in the main kitchen.
Report Facts
Residents in survey sample: 56
Residents affected by dignity deficiency: 5
Residents affected by call bell deficiency: 1
Residents affected by advance directive deficiency: 2
Residents affected by environment deficiency: 2
Residents affected by theft reporting deficiency: 1
Residents affected by hospital transfer notification deficiency: 3
Residents affected by pain medication deficiency: 1
Residents affected by meal assistance deficiency: 1
Residents affected by care plan revision deficiency: 1
Residents affected by medication administration deficiency: 1
Staff affected by in-service training deficiency: 1
Medication administrations observed unlocked: 1
Residents affected by lab test deficiency: 1
Residents affected by dental care deficiency: 1
Food temperature measured: 96
Food temperature measured: 109.7
Food temperature measured: 102
Food temperature measured: 116
Medication doses administered too close: 6
Medication doses missed documentation: 3
Blood sugar results not documented: 5
House flies observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Geriatric Nursing Assistant | Observed walking out while resident was talking |
| Employee #14 | Certified Medication Aide | Observed administering medication with unlocked cart |
| Employee #21 | Nursing Aide | Received only 1 hour of in-service training in past year |
| Employee #23 | Observed pulling Resident #54 backwards out of dining room | |
| Director of Nursing | Director of Nursing | Interviewed multiple times confirming deficiencies and investigations |
| Nurse #1 | Nurse | Interviewed regarding medication administration timing for Resident #120 |
| Staff #11 | Food Service Manager | Observed food temperature and kitchen conditions |
| Staff #12 | Assistant Food Service Manager | Observed and corrected wet stacked pans in kitchen |
| Unit Manager | Second-floor Unit Manager | Interviewed regarding Resident #19 Geri sleeve order and documentation |
Inspection Report
Annual Inspection
Deficiencies: 19
Date: Jun 5, 2018
Visit Reason
The inspection was conducted as part of the annual survey process to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found to have multiple deficiencies including failure to promote resident dignity, failure to ensure access to clean bathroom facilities, failure to provide ordered showers, failure to honor end-of-life wishes, inadequate housekeeping and maintenance, failure to timely report abuse allegations, inaccurate resident assessments, incomplete care plans, transcription errors in physician orders, failure to follow physician orders, inadequate mobility assistance, unsafe resident environment, failure to document supplement intake, failure to obtain weights as ordered, failure to maintain accurate medical records, and failure to follow infection control protocols.
Deficiencies (19)
Failure to promote and enhance resident dignity during showers and meal service.
Failure to ensure access to clean bathroom facilities for a resident with physical disability.
Failure to provide showers as ordered for a resident for four months.
Failure to honor end-of-life wishes by obtaining weights contrary to orders.
Failure to maintain a clean, comfortable, and homelike environment including discolored ceiling tiles, dirty urinals, torn chairs, peeling wallpaper, and non-working clock.
Failure to timely report allegations of abuse to the Office of Health Care Quality.
Failure to document accurate assessments on the Minimum Data Set (MDS) including nutritional status.
Failure to develop and implement a complete care plan addressing severe pain and opioid use.
Failure to review and revise care plan to reflect accurate assessments and interventions.
Failure to accurately transcribe physician orders into electronic medical records and identify transcription errors.
Failure to follow physician order for no straws for a resident with dysphagia.
Failure to follow physician orders for opioid medication administration according to pain level.
Failure to provide appropriate care to maintain or improve range of motion and mobility as ordered.
Failure to maintain a resident's environment free from accident hazards including unsecured medication bottles.
Failure to provide dietary interventions as ordered, document supplement intake, obtain weights as ordered, and assess/intervene for weight changes.
Failure to provide safe and appropriate respiratory care including maintenance of oxygen humidifiers.
Failure to dispose of expired medical supplies in medication room.
Failure to maintain complete and accurate medical records including documentation of blood pressure readings and dialysis communication records.
Failure to follow contact isolation precautions for a resident with Vancomycin-resistant Enterococcus (VRE).
Report Facts
Residents reviewed: 38
Residents affected: 2
Weight loss percentage: 8.04
Weight measurements: 12
Medication administrations: 19
Medication administrations: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Don | Director of Nursing | Named in multiple findings including failure to promote dignity, failure to report abuse, and transcription errors |
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