Sterling Care Bel Air

F 0551 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

and confirmed the body was sent to the Maryland State Anatomy Board. By the time the family called the anatomy board it was too late as the body was already injected with fluid. The staff member stated that the family was upset because the state board would have the body for 2 years and the gift registry would only have the body 4 to 6 weeks. The family wanted to [NAME] the ashes with the spouse.On [DATE REDACTED] at 8:48 AM

the Director of Social Work (DSW) was interviewed and stated, the family wishes were for the resident's body to be donated to the gift registry. The DSW stated that she was aware that the resident was registered with the state anatomy board and the family was aware too, but they wanted the resident to go to the gift registry. When asked who was responsible to put on the face sheet where the body was to go once the resident passed, the DSW stated, I guess I am.On [DATE REDACTED] at 9:13 AM a second interview was conducted with the DON. Resident #2's face sheet was reviewed with her, and she confirmed the external facility (where the body was to go once deceased ) was blank. The DON stated, it is not a solid system as to who puts the information on the face sheet. It is evolving.On [DATE REDACTED] at 9:14 AM Staff #29 was interviewed and stated, I called the anatomy board. I was told later it should have been the gift registry. Staff #29 stated the information was usually on the face sheet as who to call but she got the information out of the resident's chart. She stated, I do not know whose responsibility it is to put it on the face sheet. Staff #29 stated it was

an honest mistake as she didn't know there were 2 different anatomy boards.On [DATE REDACTED] at 9:15 AM an

interview was conducted with the complainant who was also the RP. The complainant stated, they had all

the paperwork in the file to go to anatomy gifts. The complainant stated that if Resident #2 went to the state anatomy board they could have the body for up to 2 years. If the Resident went to the gift registry it would be for 4 to 6 weeks, and they would be able to get the ashes back. The complainant stated that by the time

she called the anatomy gifts it was too late because the anatomy board had already put fluid in Resident #2's body. The complainant stated, I called the anatomy board and they said it was too late. I asked them if

they had already started using the body and they said yes. The whole thing was awful. You shouldn't have to deal with all of this when you already have to deal with a loss.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sterling Care Bel Air

410 East McPhail Road Bel Air, MD 21014

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on complaint, medical record review, and staff interview, it was determined the facility staff failed to timely notify a resident's physician/nurse practitioner of a change in condition. This was evident for 1 (#6) of 9 residents reviewed for complaints during a complaint survey. The findings include: On 8/18/25 at 11:10 AM a review of complaint 302921 alleged unacceptable and negligent care provided to Resident #6 while under the care of the facility. Review of Resident #6's medical record revealed Resident #6 was admitted to

the facility in December 2024 from an acute care facility with diagnoses including but not limited to generalized weakness, peripheral artery disease, COPD, slurred speech, history of falls, and hypertension.

Review of a 1/10/25 at 8:58 AM eMar - Medication Administration Note documented, amlodipine Besylate tablet 10 mg. give 1 tablet by mouth one time a day for HTN (hypertension). Med not given due to low b/p (blood pressure). On 8/20/25 at 1:45 PM an interview was conducted with Nurse Practitioner #19 (NP). NP #19 stated that she did not see Resident #6 that morning and that she was not notified of the low blood pressure. There were no parameters as to when the nurse should have held the medication, so she would have expected to be notified. I was in the building that morning and I was not notified. I could have seen the resident and started [him/her] on IV fluids or Midodrine. They informed me at lunch that the resident's condition changed, but they did not notify me about the low blood pressure and holding the medication.

Normally I would tell all the managers that if I am at the building call me and let me know. They did not tell me until [he/she] was not arousable. I was concerned because [he/she] was a stable patient. I was concerned that [he/she] went down that quickly. I feel I could have stabilized [him/her] and [his/her] b/p. On 8/21/25 at 10:55 AM the concern was reviewed with the Director of Nursing (DON). The DON agreed that

the NP should have been notified about the low blood pressure and holding the medication.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sterling Care Bel Air

410 East McPhail Road Bel Air, MD 21014

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation and interviews, it was determined the facility staff failed to provide maintenance services necessary to maintain resident wheelchairs. This was evident for 15 (#25, #26, #27, #14, #12, #28, #29, #30, #19, #20, #13, #16, #33, #34, #8) of 37 residents reviewed during a complaint survey. The findings include:The following maintenance concerns were observed during the initial rounds of the facility

on 8/18/25 at 7:30 AM and throughout the survey until 8/21/25.Resident #25: There was no armrest on the left side of the wheelchair and the vinyl on the right side was cracked throughout.Resident #26: The vinyl on

the left wheelchair armrest was torn approximately an inch from the top of the armrest exposing yellow foam. This could be seen from the hallway.Resident #27: There was no wheelchair armrest on the right or left side of the wheelchair. Resident #27 was noted with several bruises to the resident's arms.Resident #14: There was no armrest on the left side of the wheelchair.Resident #12: The vinyl was cracked along the edge of the left wheelchair armrest, and the yellow foam padding was exposed.Resident #28: The vinyl was cracked on the left wheelchair armrest.Resident #29: There was no padding on the left wheelchair armrest as the vinyl was pulled back and there was nothing underneath.Resident #30: There was no left or right wheelchair armrest on the wheelchair.Resident #19: The vinyl was cracked on the left and right wheelchair armrests.Resident #20: There was no wheelchair armrest on the right side of the wheelchair.Resident #13:

The vinyl on the right wheelchair armrest was torn along the edges.Resident #16: The vinyl on the right and left wheelchair armrests was torn along both edges.Resident #33: There was a piece of vinyl approximately 1 inch that was missing from the left wheelchair armrest exposing the underneath foam padding.Resident #34: There was no left or right wheelchair armrest.Resident #8: The vinyl on the entire left wheelchair armrest was ripped and frayed.On 8/21/25 at 10:40 AM an interview was conducted with the Director of Maintenance, Staff #31. Staff #31 stated that most of the repair orders came through the electronic system, TELS. Staff #31 stated that all staff, including the geriatric nursing assistants (GNAs) had access to put work orders in when they saw that repairs were needed. Staff #31 stated that a lot of times staff would just tell him about the issue, and he would fix it when told about it. Staff #31 stated that they do maintenance on

the wheelchairs once a month that includes armrests and brakes. Staff #31 stated it was his expectation that staff would notify him of the issues with the wheelchairs. At that time Staff #31 and the Director of Nursing were informed of the condition of the wheelchair armrests. Staff #31stated, we have extra wheelchairs, and they (staff) can swap out the wheelchairs and can put a notification in TELS.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sterling Care Bel Air

410 East McPhail Road Bel Air, MD 21014

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

he/she is not anxious about the incident and feels safe. The Counselor documented will follow up with 1:1 therapeutic visits. During interview with the Psychiatrist on 8/19/25 at 9:02 AM, the Psychiatrist was asked why he changed the Resident's medications on 5/19/25 and he stated the Resident has a history of chronic anxiety and depression, he was aware of the Resident's allegation but can't say the medication change was related to the incident or the Resident's chronic anxiety and depression. The Psychiatrist stated he did tell

the facility the Resident should not have male care givers. The psychiatrist was asked if he was aware the Resident has not been seen by a Counselor since 2/10/25, the Psychiatrist stated no that is a third party and not sure how that works but the Resident should be followed by a counselor regularly. Review of Resident #5's medical record on 8/19/25 revealed the Resident was seen by the Primary Care Physician on 3/7/25, 4/4/25, 5/27/25, 6/17/25 and 7/26/25 who documented under Assessment and Plan for Anxiety: We are continuing to provide the patient with emotional support. We will also have psych follow up with the patient. During interview with the Counselor (Staff #23) on 8/20/25 at 1:44 PM, Staff #23 stated he/she was not aware Staff #11 had a criminal background and was charged with a crime related to the allegation of sexual abuse on 1/25/25. Staff #23 also stated she was not aware Resident #5 was going to court in September 2025. Staff #23 stated Resident #5 would need more support now since going to court and she would update the Counselor (Staff #27) so he could follow up with the Resident immediately. Interview with Director of Nursing on 8/20/25 at 1:00 PM confirmed Resident #5 made an allegation of sexual abuse by Staff #11 who has a criminal record on 1/25/25, has not been seen by the Counselor since 2/10/25 and was not on the facility's list of residents who were receiving counseling services.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sterling Care Bel Air

410 East McPhail Road Bel Air, MD 21014

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0606

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Level of Harm - Actual harm

Based on medical record review, review of facility documentation and interview it was determined the facility failed to ensure a criminal background check was completed on an agency GNA (geriatric nursing assistant) which allowed a GNA (Staff #11) with a criminal background of assault and sexual assault to care for vulnerable residents. This was evident for 1 of 4 agency GNAs reviewed for criminal background checks during a complaint survey. Resident #5 alleged Staff #11 sexually abused him/her on 1/25/25. This resulted in psychosocial harm to Resident #5. The findings include:A review was conducted on Facility Reported Incident 302934 on 8/18/25 related to Resident #5's allegation of sexual abuse by Staff #11 on 1/25/25. Resident #5 alleged on 1/29/25, to Staff #12, that Staff #11 kissed the Resident on the lips and attempted to kiss the Resident's private area during care on 1/25/25.Review of Resident #5's medical

record on 8/18/25 revealed the Resident was admitted to the facility in July 2024 with a diagnosis to include cerebral infarction (stroke). The facility staff conducted a MDS (Minimum Data Set) assessment on 8/6/25 and coded the Resident as dependent on facility staff for toileting. During interview with Resident #5 on 8/18/25 at 11:05 AM, the Resident was asked if he/she was okay telling the Surveyor what happened on 1/25/25, the Resident stated he/she was but began crying while giving his/her statement. The Resident stated on 1/25/25 Staff #11 kissed him/her on the lips and then attempted to kiss his/her private area.

Resident #5 stated he/she told Staff #11 F*** No. The Resident then stated Staff #11 put the Resident in a wheelchair and took the Resident to the bathroom where Staff #11 took the Resident's hand and put it on Staff #11's penis on top of Staff #11's clothes. Resident #5 stated he/she has to go to court in September 2025 for the incident and Staff #11 is currently in jail and has a history of the same thing. The Resident stated he/she has been interviewed by the States Attorney over the phone. Review of Staff #11's employee file on 8/18/25 provided by the Director of Nursing revealed a criminal background check that was conducted 1/12/24 and it was incomplete. The criminal background check did not indicate if Staff #11 had a criminal background or not.During an interview with Human Resources (HR) on 8/18/25 at 1:41 PM, HR stated the agency provides the agency staff's criminal background checks. HR stated she reviews all criminal background checks the agency provides prior to the agency staff working at the facility. HR stated

she missed that Staff #11's was incomplete.The Surveyor reviewed Maryland Judiciary Case Search on 8/18/25 which revealed Staff #11 was found guilty from a 5/31/19 case of 2nd degree assault and 4th degree sexual assault. Further review of Maryland Judiciary Case Search revealed on 3/18/25 Staff #11 was charged with abuse of vulnerable adult, 2nd degree rape and 4th degree sexual offense for an offense date of 1/25/25 and a hearing is scheduled for September 2025. During interview with Resident #5 on 8/19/25 at 7:28 AM, the Resident was asked if he/she could review the incident again with the Surveyor, the Resident stated no he/she can't because he/she had nightmares last night regarding the incident. The Surveyor asked the Resident if he/she is seeing a counselor, the Resident stated he/she did after the event, but that Counselor has left and has not even met the new counselor. The Resident states he/she is stressed about going to court, he/she doesn't want to mess up because he/she wants to make sure he (Staff #11) is not able to do this to someone else. The Resident stated after the incident he/she feels like he/she has become more withdrawn. During interview with HR on 8/19/25 at 7:45 AM, HR stated Staff #11 began working at the facility on 1/26/24. HR stated the facility stopped using agency staff on 7/6/25.Interview with the Director of Nursing (DON) on 8/19/25 at 8:37 AM confirmed the facility failed to have a complete background check on Staff #11 that included Staff #11's criminal record. The DON confirmed Resident #5 made an allegation of sexual abuse by Staff #11 on 1/25/25 and the Resident has no other allegations of sexual abuse by staff since admission in July 2024.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sterling Care Bel Air

410 East McPhail Road Bel Air, MD 21014

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658

2/12/25.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sterling Care Bel Air

410 East McPhail Road Bel Air, MD 21014

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

expected to be notified. “I was in the building that morning and I was not notified. I could have seen

the resident and started [him/her] on IV fluids or Midodrine. They informed me at lunch that the resident’s condition changed, but they did not notify me about the low blood pressure and holding

the medication. Normally I would tell all the managers that if I am at the building to call me and let me know.

They did not tell me until [he/she] was not arousable. I was concerned because [he/she] was a stable patient. I was concerned that [he/she] went down that quickly. I feel I could have stabilized [him/her] and [his/her] b/p.

On 8/21/25 at 10:55 AM the concern was reviewed with the Director of Nursing (DON). The DON agreed that the NP should have been notified about the low blood pressure and holding the medication and there should have been more follow-up from the nurse.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sterling Care Bel Air

410 East McPhail Road Bel Air, MD 21014

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or potential for actual harm

Based on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by administering a medication not ordered by the physician (Resident #5). This was evident for 1 of 9 residents reviewed for complaints during a complaint survey. The findings include:Review of Resident #5's medical record on 8/19/25 revealed the Resident was admitted to

the facility with diagnosis to include mood disorder, depression and anxiety.Further review of Resident #5's medical record revealed on 5/18/25 the Resident was seen by the Psychiatrist. Review of Psychiatry Progress Note on 5/18/25 stated depressed very anxious. A nurse's note on 5/18/25 at 9:15 PM states at 8:57 PM the psych doctor new medication and made change in psych dose as follow: Hydralazine 50 mg every 8 hours for anxiety for 14 days. Hydralazine is a medication that is used for hypertension (high blood pressure) and heart failure.During interview with the Psychiatrist on 8/19/25 at 9:02 AM, the Psychiatrist stated the medication should have been hydroxyzine not hydralazine. Hydroxyzine is a medication that can used to help control anxiety.Review of Resident #5's MAR (Medication Administration Record) revealed the Resident was administered Hydralazine 50 mg every 8 hours for anxiety from 5/19/25 at 10:00 PM until 5/30/25 at 10:00 PM for a total of 34 doses.Interview with the Director of Nursing on 8/19/25 at 2:45 PM confirmed Resident #5 was administered Hydralazine 50 mg instead of Hydroxyzine from 5/19/25 until 5/30/25.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sterling Care Bel Air

410 East McPhail Road Bel Air, MD 21014

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761

room at the nurses' station or other secured location.On [DATE REDACTED] at 8:30 AM the DON was informed of the

observation. The DON stated she was aware and had already started to in-service staff.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sterling Care Bel Air

410 East McPhail Road Bel Air, MD 21014

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

President called the surveyor over and gave the surveyor a list of concerns from him/her and another resident. The surveyor asked why they did not bring the concerns up in the meeting, and the response was, because they never do anything about it. The following were the concerns that were written down: Frozen and raw biscuit, English muffins not toasted, bagel not toasted, French toast cold and pancakes hard and cold. Bacon and sausage cold and raw. Meals sit at nurse's station for 10 minutes waiting to be served.

Meals are cold and are served 30 minutes late or later. Use paper plates due to dish washer not working.

One or more times a month, meals are on paper plates. Bugs on tray holder due to not being taken out to wash, silverware not clean, plate and glasses not clean. Meals are consistently late. Dining room meals are at least one-half hour to 1 hour late coming out. Trays to the floor (rooms) are then much later also.On 8/20/25 at 11:30 AM the concerns related to food were discussed with the NHA, Corporate Staff and the Director of Nursing. They were also informed of the fear of retaliation if the residents spoke up about the food as verbalized by some residents.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sterling Care Bel Air

410 East McPhail Road Bel Air, MD 21014

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

#4’s medical record revealed Resident #4 was admitted to the facility in August 2019 and was currently on Hospice care.Review of Resident #4’s August 2025 physician’s orders revealed

the order, “float bilateral heels when in bed.” On 8/19/25 at 1:55 PM observation was made of Resident #4 lying in bed. With permission from the resident, the surveyor looked at the resident’s feet and the resident’s feet were not elevated off of the mattress. The heels were lying directly on the mattress. Review of the August 2025 Treatment Administration Record (TAR) had documented the nurse had signed off for that shift that Resident #4’s heels were elevated while in bed.On 8/20/25 at 8:55 AM observation was made of Resident #4 lying in bed. There was a pillow between the resident’s knees, however the heels were not elevated and were lying directly on the mattress.On 8/20/25 at 2:55 PM

a second observation that day was made of Resident #4 lying in bed. The resident’s family was visiting, and they looked at the resident’s heels with the surveyor. The heels were lying directly on

the mattress and were not elevated. The nurse had already signed off on 8/20/25 at 2:55 PM on the TAR that the heels were elevated.On 8/20/25 at 3:00 PM the Director of Nursing (DON) went into the resident’s room with the surveyor and observed the resident’s heels. The DON confirmed the heels were not elevated and at that time placed a pillow under the resident’s heels. The DON was informed that the nurse had signed off for 2 consecutive days that the resident’s heels were elevated when they were observed not elevated.

Event ID:

Facility ID:

If continuation sheet