TIMONIUM, MD - Federal inspectors documented multiple serious safety violations at Stella Maris nursing home following an April 2025 complaint investigation that revealed systematic failures in abuse investigations, medication management, and food safety protocols.
Incomplete Abuse Investigations Put Residents at Risk
The most significant findings centered on the facility's failure to conduct thorough investigations when residents reported mistreatment by staff members. In multiple instances spanning several months, administrators failed to interview other residents or staff who might have witnessed problematic behavior or experienced similar treatment.
One case involved a resident with spastic cerebral palsy and multiple contractures who reported that a nursing assistant "was rough" and "pulled the resident's clothes hard" while helping with bedtime care. The resident provided a written statement saying "I do not want her again. She was rough." Despite this serious allegation, facility staff only obtained the victim's statement and conducted no interviews with other residents on the unit or staff members who worked with the accused employee.
In another incident, a resident alleged a nursing assistant gripped them "too hard and was rough" during transfers. The resident's daughter reported she would "call the police if incidents continue." Yet again, investigators failed to interview other residents on the unit to determine if they felt safe or had experienced similar treatment.
The facility also inadequately investigated three unexplained injuries on a resident with dementia over a one-month period, including bruises to the neck, lip, and eye area. Medical records documented a 1.2 cm by 6 cm bruise on the neck, a 0.2 cm bruise on the bottom lip, and a 1.5 cm by 1.0 cm bruise around the left eye. Administrators confirmed they had no evidence these injuries of unknown origin were thoroughly investigated.
Critical Assessment and Documentation Failures
Federal inspectors found significant errors in resident assessments that directly impact care planning and Medicare reimbursement. Staff failed to accurately document falls with injury, medication treatments, and mental health symptoms in required federal assessments.
In one case, a resident who experienced an unwitnessed fall resulting in head bleeding and scalp staples had the fall documented but the injury component was completely omitted from federal assessment records. Another resident receiving antifungal treatments for skin rashes had those medications excluded from mandatory documentation.
Assessment errors also affected mental health care. A resident experiencing visual hallucinations and "seeing snakes intermittently" according to physician notes had this critical symptom completely absent from nursing assessments designed to identify care needs.
These documentation failures mean the federal government's quality measurement systems and care planning tools lack accurate information about residents' actual conditions and needs.
Medication Security and Management Breakdowns
Inspectors observed multiple serious medication security violations that could enable theft or accidental poisoning. On three separate nursing units, medication carts containing controlled substances and insulin were left unlocked and unattended.
During one observation, an inspector was able to open medication drawers and handle a Heparin vial while staff worked nearby without noticing. In another instance, keys were left sitting on top of an unlocked cart containing insulin pens. Four insulin pens for different residents were missing required opening dates, meaning staff couldn't determine if the medications had expired their 28-day safety window.
The facility also failed to provide timely medications to residents. One resident experienced repeated delays getting prescribed skin protection ointment, with medication records showing the treatment was unavailable for days at a time due to ordering and delivery issues. Staff documented "re-ordered," "to be delivered," or "awaiting delivery" instead of ensuring continuous availability of prescribed treatments.
Food Safety Violations Threaten Health
Kitchen observations revealed multiple food safety violations that could lead to foodborne illness. Temperature testing showed hot foods served to residents at dangerously low temperatures, including soup at 119 degrees, fried chicken at 119 degrees, and broccoli at 100 degrees - all well below the 135-degree minimum required for safety.
In kitchen storage areas, inspectors found chicken nuggets and hot dogs with no expiration dates, ground meat and mashed potatoes without date labels, and an uncovered hamburger exposed to air in the freezer. Food service staff incorrectly claimed items didn't require dating if they were being used the same day.
Additional violations included personal items like cell phones placed on food service counters, unlabeled drinks in dining room refrigerators, and warm yogurt and nutritional drinks left on hallway handrails.
Medical Care and Treatment Deficiencies
The facility failed to provide several critical medical treatments ordered by physicians. A legally blind resident never received eye drops and ointment prescribed by an ophthalmologist for glaucoma, dry eye, and eyelid problems despite the medications being ordered in February 2025.
Staff also performed incomplete neurological assessments after resident falls, missing required components like consciousness scales, vital signs, and grip strength testing. These assessments are crucial for detecting potential brain injuries following head trauma.
Another resident waited nearly three weeks for facility staff to follow up on a request for specialized kidney tube care, and the procedure was eventually performed without proper physician orders specifying the technique and frequency.
Systemic Quality Oversight Problems
The violations reveal broader quality management failures affecting infection control, pest management, and medical record maintenance. Inspectors found extensive mouse infestations across multiple nursing units and the kitchen, with residents reporting mice in their rooms and wheelchairs. Pest control logs documented dozens of dead mice found throughout the facility over several months.
Clean linens were stored uncovered in hallways, creating infection risks, while medical records lacked required documentation from hospice providers and other specialists.
The facility's own social worker acknowledged the inconsistent approach to investigations, stating: "To be honest, unless I am directed to do it, I am not involved."
These systemic deficiencies demonstrate the need for comprehensive quality improvement measures to ensure resident safety and proper care coordination at the 71-bed facility. The Maryland Department of Health and federal regulators will monitor the facility's corrective actions to address these serious violations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stella Maris, Inc. from 2025-04-09 including all violations, facility responses, and corrective action plans.
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