Deficiencies (last 4 years)
Deficiencies (over 4 years)
13.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% worse than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 17, 2025
Visit Reason
The inspection was conducted as a complaint survey based on complaint #2602798 alleging that Resident #3 was discharged home without home health wound care services arranged.
Complaint Details
Complaint #2602798 alleged that Resident #3 was discharged home on 7/22/25 without home health wound care services arranged and had no wound care services as of 8/28/25. The complaint was substantiated by record reviews and interviews.
Findings
The facility failed to update a resident's discharge plan to reflect that home health services were declined prior to discharge. Resident #3 was discharged with wound care needs but without confirmed home health services, despite documentation indicating otherwise.
Deficiencies (1)
Failure to update a resident's discharge plan to reflect the lack of home health wound care services after the home health agency declined to provide services.
Report Facts
Dates related to discharge and services: Jul 22, 2025
Dates related to discharge and services: Aug 1, 2025
Dates related to discharge and services: Aug 4, 2025
Dates related to discharge and services: Oct 16, 2025
Dates related to discharge and services: Oct 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #5 | Confirmed discharging Resident #3 and documentation of discharge time | |
| Social Services Director | Interviewed regarding awareness of home health services being declined prior to discharge | |
| Director of Nursing | DON | Provided documentation of medical director consultation with Resident #3 prior to discharge |
| Medical Director | Consulted with Resident #3 about risks of discharge without home health services and stated discharge instructions should have been revised | |
| Administrator | Notified regarding concerns with discharge planning |
Inspection Report
Complaint Investigation
Deficiencies: 13
Date: Aug 21, 2025
Visit Reason
The inspection was conducted based on multiple complaints alleging issues including failure to follow a resident's representative's wishes regarding body donation, failure to notify physician of change in condition, inadequate maintenance of wheelchairs, abuse allegations, inaccurate documentation, medication errors, food service complaints, and other quality of care concerns.
Complaint Details
The complaint investigation included allegations of failure to follow resident representative's wishes for body donation, unacceptable and negligent care related to failure to notify physician of low blood pressure, failure to maintain wheelchairs, sexual abuse by staff, failure to conduct criminal background checks, inaccurate documentation of care and medication administration, failure to perform neuro checks after falls, failure to provide care meeting residents' needs, medication errors, unsecured medication carts, poor food service, and incomplete medical records.
Findings
The facility was found deficient in multiple areas including failure to follow resident representative's wishes for body donation, failure to notify nurse practitioner of low blood pressure and medication hold, inadequate wheelchair maintenance, failure to prevent abuse and failure to conduct proper background checks, inaccurate documentation of medication administration and assessments, failure to perform neuro checks after falls, failure to provide care according to physician orders, medication errors including administration of wrong drug, failure to secure medication carts and properly store medications, poor food service quality and timeliness, and failure to maintain accurate medical records.
Deficiencies (13)
Failure to follow resident representative's wishes regarding body donation after death.
Failure to timely notify resident's physician/nurse practitioner of a change in condition (low blood pressure).
Failure to provide maintenance services necessary to maintain resident wheelchairs.
Failure to prevent abuse of a resident resulting in psychosocial harm.
Failure to ensure a criminal background check was completed on an agency GNA with a criminal background.
Licensed nursing staff documented assessments and medication administration when resident was not in the facility.
Failure to properly perform and document neuro checks after a fall for residents.
Failure to accurately assess resident during a change in condition.
Failure to provide care to meet the needs of residents' physical, mental, and psychosocial health.
Administration of medication not ordered by physician (Hydralazine instead of Hydroxyzine).
Failure to keep treatment and medication carts locked when unattended, failure to date medications when opened, discard expired medications, and refrigerate medications requiring refrigeration.
Failure to serve food that was attractive, palatable, matched tray ticket, timely, and at proper temperature.
Failure to maintain complete and accurate medical records in accordance with accepted professional standards.
Report Facts
Residents reviewed for death: 3
Residents reviewed for complaints: 9
Residents reviewed for abuse: 3
Residents reviewed for criminal background checks: 4
Residents reviewed for documentation: 9
Residents reviewed for care: 9
Residents affected by wheelchair maintenance deficiency: 15
Medication doses administered in error: 34
Residents affected by food service deficiency: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #11 | Agency GNA | Named in sexual abuse allegation and criminal background check deficiency |
| Staff #13 | Documented assessments and medication administration for discharged Resident #7 | |
| Staff #18 | Documented medication and treatment administration for discharged Resident #9 | |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including notification, documentation, and medication errors |
| Nurse Practitioner #19 | Nurse Practitioner | Interviewed regarding failure to be notified of low blood pressure and medication hold |
| Staff #31 | Director of Maintenance | Interviewed regarding wheelchair maintenance |
| Staff #23 | Counselor | Provided counseling to Resident #5 after abuse allegation |
| Staff #27 | Counselor | New counselor for Resident #5 |
| Human Resources | Human Resources | Interviewed regarding background check process |
| Licensed Practical Nurse #4 | LPN | Observed medication cart unlocked and unattended |
| Licensed Practical Nurse #5 | LPN | Observed medication cart unlocked and unattended |
| Nurse #29 | Interviewed regarding anatomy board and gift registry confusion | |
| Director of Social Work | Director of Social Work | Interviewed regarding responsibility for body donation documentation |
| Staff #35 | RN Supervisor | Interviewed regarding resident face sheet and body donation |
| Resident Council President | Provided information on food service complaints and resident concerns | |
| Psychiatrist | Psychiatrist | Interviewed regarding Resident #5's medication and counseling |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Dec 13, 2024
Visit Reason
The inspection was conducted as a recertification/complaint survey reviewing multiple complaints related to resident care, documentation, and infection control at Sterling Care Bel Air.
Complaint Details
The visit was complaint-related, triggered by multiple complaints including failure to execute admission agreements, incomplete discharge summaries, inadequate neuro checks, skipped feedings, delayed lab tests, incomplete medical records, and infection control breaches. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to review and document admission agreements, incomplete discharge summaries, inadequate neuro checks after falls, inaccurate medication orders and administration, failure to maintain adequate nutrition and hydration, delayed laboratory testing, incomplete medical records, and failure to implement infection prevention and control protocols including appropriate use of enhanced barrier precautions.
Deficiencies (10)
Failed to review and document the admission agreement including resident's rights for Resident #906.
Failed to complete a resident's discharge summary for Resident #913.
Failed to properly perform neuro checks after a fall for Residents #914 and #918.
Failed to order antibiotic eye drops accurately for Resident #904, causing a 3-day delay in administration.
Skipped tube feedings and meals for Resident #901 and failed to document feedings properly.
Failed to document water flushes and enteral feedings accurately for Resident #910.
Failed to timely assess and evaluate nutrition needs for Residents #901, #902, #904, #906, #911, and #910.
Failed to ensure timely completion of STAT laboratory tests for Resident #40.
Failed to maintain complete and accurate medical records for Residents #51 and #901.
Failed to implement infection prevention and control program including appropriate use of enhanced barrier precautions for Residents #13 and #51.
Report Facts
Residents reviewed: 33
Neuro check times: 7
Neuro check times: 7
Weight loss: 15
Weight loss: 14.3
Enteral feedings per day: 6
Water flush amount: 75
BIMS score: 10
BIMS score: 15
Wound size: 8.5
Wound size: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN5 | Licensed Practical Nurse | Did not wear gown during trach care for Resident #13 despite access to PPE |
| LPN1 | Licensed Practical Nurse | Stated all staff are to wear PPE for residents on enhanced barrier precautions |
| Assistant Director of Nursing | ADON | Confirmed LPN5 should have worn gown during trach care and described facility education on enhanced barrier precautions |
| Director of Nursing | DON | Confirmed multiple deficiencies including incomplete discharge summaries, nutrition assessments, and infection control practices |
| Corporate Nurse | Confirmed missing documentation of feedings for Resident #901 | |
| Registered Dietician #9 | RD | Stated expectation for documentation of tube feedings and water flushes for Resident #910 |
| LPN3 | Licensed Practical Nurse | Assisted Resident #51 without wearing gown |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Dec 13, 2024
Visit Reason
The inspection was conducted as a recertification/complaint survey triggered by multiple complaints regarding failure to review and document admission agreements, inadequate housekeeping and maintenance, failure to provide needed showers, medication monitoring issues, lack of snacks availability, kitchen sanitation concerns, garbage disposal problems, and infection control deficiencies.
Complaint Details
The complaint investigation included allegations of failure to execute admission agreements, inadequate housekeeping and maintenance, failure to provide showers to dependent residents especially during a COVID outbreak, medication monitoring failures, lack of snacks availability, unsanitary kitchen conditions, improper garbage disposal, and infection control breaches including failure to use PPE appropriately for residents on enhanced barrier precautions.
Findings
The facility was found deficient in multiple areas including failure to obtain signed admission agreements, inadequate maintenance of a sanitary environment, failure to provide showers to dependent residents especially during a COVID outbreak, failure to monitor vital signs before administering medication, lack of availability of snacks to residents, unsanitary kitchen conditions, improper garbage disposal, and failure to implement infection prevention and control protocols including appropriate use of enhanced barrier precautions.
Deficiencies (8)
Failed to review and obtain signed admission agreement including notice of resident's rights for Resident #906.
Failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on 2 of 3 nursing units.
Failed to provide needed showers for residents dependent on assistance (#907, #912) during a COVID outbreak.
Failed to monitor blood pressure and heart rate prior to administering Lisinopril as ordered for Resident #901.
Failed to ensure snacks were available to eight residents who desired snacks; snacks were only provided at bedtime and not during the day.
Failed to maintain kitchen in a sanitary manner including accumulated food residue, unlabeled food items, unclean cups and bowls, and black/grey substance on wall above dishwasher.
Failed to maintain garbage dumpster area in a sanitary manner with garbage strewn around the dumpster on multiple days.
Failed to implement infection prevention and control program including failure to wear appropriate PPE for residents on enhanced barrier precautions and improper storage of bedpans and urinals.
Report Facts
Residents reviewed for complaints: 33
Residents affected by admission agreement deficiency: 1
Residents affected by housekeeping deficiency: 2
Residents affected by shower deficiency: 2
Residents affected by medication monitoring deficiency: 1
Residents affected by snack availability deficiency: 8
Residents affected by kitchen sanitation deficiency: 105
Residents affected by garbage disposal deficiency: 117
Residents affected by infection control deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #13 | Admissions Coordinator | Interviewed regarding missing admission agreement for Resident #906 |
| Staff #23 | Maintenance Director | Interviewed regarding maintenance and wheelchair audits |
| GNA #14 | Geriatric Nursing Assistant | Interviewed regarding shower provision and documentation |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies including admission agreements, showers, medication monitoring, infection control |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding showers, medication monitoring, infection control |
| LPN5 | Licensed Practical Nurse | Observed and interviewed regarding failure to wear gown during trach care for Resident R13 |
| LPN1 | Licensed Practical Nurse | Interviewed regarding infection control practices for Resident R51 |
| LPN3 | Licensed Practical Nurse | Observed assisting Resident R51 without gown |
| Dietary Aide 1 | Dietary Aide | Interviewed regarding preparation and delivery of bedtime snacks |
| Dietary Manager | Dietary Manager | Interviewed regarding snack availability and kitchen sanitation |
| Registered Dietitian | Registered Dietitian (RD) | Interviewed regarding snack availability |
| Administrator | Facility Administrator | Interviewed regarding snack availability |
| Housekeeping/Laundry Director | Housekeeping/Laundry Director (HKSD) | Interviewed regarding garbage dumpster area sanitation |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Jul 2, 2019
Visit Reason
The inspection was conducted to investigate complaints related to resident care, medication administration, pain management, and staff competency at Sterling Care Bel Air nursing home.
Complaint Details
The visit was complaint-related, investigating multiple resident care issues including communication, medication errors, pain management, personal care delays, and staff competency. Substantiation status is not explicitly stated.
Findings
The facility was found to have multiple deficiencies including failure to accommodate resident communication needs, medication errors exceeding acceptable rates, inadequate lighting, incomplete pain care plans, delayed personal care, failure to respond to medical consultant recommendations, improper administration of pain medication, lack of nursing staff competency evaluations, and insufficient nurse aide training.
Deficiencies (9)
Facility staff failed to provide Resident #115 with the means to communicate to nursing when the Resident is in the room due to improper placement of the call bell.
Facility failed to ensure medication error rate was less than 5%; two administration errors noted for Resident #102.
Facility failed to maintain adequate lighting for Resident #33; over bed light cord was too short to be used.
Facility failed to develop comprehensive pain care plans including non-pharmacologic interventions for Resident #76.
Facility failed to ensure dependent Resident #96 received personal care in a timely manner.
Facility staff failed to respond to a consultant's recommendation to change Resident #115's catheter every 2-3 weeks; physician maintained monthly change order without documentation.
Facility failed to ensure Resident #76 received as-needed pain medication according to prescribed parameters; medication given for pain scores less than 6, including times with no pain.
Facility failed to have a process to ensure nursing staff received competency evaluations; 8 of 10 employee records lacked documentation.
Facility failed to ensure nurse aides received education corresponding with annual performance evaluations; 3 of 3 records reviewed lacked evidence.
Report Facts
Medication error rate: 7.14
Medication error opportunities: 28
Medication errors: 2
Pain medication doses: 93
Pain medication doses: 36
Pain management consultations: 9
Employee records reviewed: 10
Employee records lacking competency documentation: 8
Nurse aide records reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager #1 | Witnessed finding related to delayed personal care for Resident #96. | |
| Staff nurse #1 | Observed administering medications incorrectly to Resident #102. | |
| Licensed Practical Nurse #26 | LPN | Interviewed regarding pain medication administration practices. |
| Licensed Practical Nurse #27 | LPN | Interviewed regarding pain medication administration practices. |
| Director of Nursing | DON | Interviewed about pain medication administration errors and catheter care decisions. |
| Administrator | Interviewed about staff competency evaluations and catheter care decisions. |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Mar 26, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including honoring residents' rights, medication administration, care planning, laboratory services, and medical record maintenance.
Findings
The facility failed to honor a resident's right to forego CPR and maintain accurate MOLST forms, failed to ensure proper power of attorney documentation, did not provide adequate supervision and care planning for residents with behavioral issues and hospice care, failed to administer medications and laboratory tests as ordered, and failed to maintain accurate medical records.
Deficiencies (13)
Failure to honor resident's right to refuse CPR and maintain consistent MOLST forms.
Failure to ensure proper Power of Attorney documentation for Resident #110.
Evidence of unattended maintenance and housekeeping needs in resident rooms.
Failure to provide two caregivers for a resident with behavioral issues and failure to initiate hospice care plan.
Failure to administer medication according to nursing standards and failure to monitor/document orthostatic vital signs.
Failure to obtain ordered x-ray, act on SLP recommendations, implement medication adjustments, and schedule diagnostic exams and follow-ups.
Failure to provide dietary supplements in a timely manner to maintain proper temperature.
Physician failed to intervene to ensure end of life wishes for Resident #117 were honored.
Failure of Social Worker to intervene and ensure end of life wishes for Resident #117 were honored.
Failure to maintain accurate medical records for Residents #130 and #81.
Failure to follow physician's order for weekly lab work and failure of Consultant Pharmacist to identify missing labs.
Failure to document/obtain blood pressure as ordered, delayed response to pharmacy recommendation, and failure to implement behavior monitoring for resident on anti-psychotic medication.
Failure to obtain laboratory tests as ordered for multiple residents.
Report Facts
Residents reviewed: 54
Deficiency pages: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD # 1 | Physician | Reviewed and ordered changes to Resident #117's MOLST and code status |
| MD # 2 | Psychiatrist | Provided psychiatric consults and medication recommendations for Resident #86 |
| Social Worker # 1 | Failed to follow up on MOLST and end of life wishes for Resident #117 | |
| Social Worker # 2 | New social worker unfamiliar with Resident #117 case and failed to follow through | |
| Director of Nursing | Director of Nursing | Interviewed multiple times confirming failures in care and documentation |
| Geriatric Nursing Assistant # 1 | Involved in care of Resident #33 and Resident #86; interviewed regarding care provision and incidents |
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