Sterling Care Bel Air
STERLING CARE BEL AIR in BEL AIR, MD — inspection on August 21, 2025.
Found 11 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
spouse.On [DATE] at 8:48 AM the Director of Social Work (DSW) was interviewed and stated, the
too, but they wanted the resident to go to the gift registry.
When asked who was responsible to put on
[DATE] 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] 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] 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.
215312 08/21/2025
Sterling Care Bel Air 410 East McPhail Road Bel Air, MD 21014
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.
215312 08/21/2025
Sterling Care Bel Air 410 East McPhail Road Bel Air, MD 21014
limited to receiving treatment and supports for daily living safely.
maintenance services necessary to maintain resident wheelchairs.
This was evident for 15 (#25, #26,
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.
215312 08/21/2025
Sterling Care Bel Air 410 East McPhail Road Bel Air, MD 21014
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.
215312 08/21/2025
Sterling Care Bel Air 410 East McPhail Road Bel Air, MD 21014
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.
215312 08/21/2025
Sterling Care Bel Air 410 East McPhail Road Bel Air, MD 21014
Review of Resident #7's medical record on 8/18/25 revealed the Resident was admitted to the facility in April 2025 for rehabilitation following a hospitalization with a diagnosis to include muscle weakness.
Review of Resident #7's medical record revealed a Change in Condition Assessment on 5/10/25 at 3:35 AM that stated During rounds around 2 AM patient was found in the bathroom on the floor lying on his/her right side.
Patient was assisted back to bed with the help of the nursing supervisor, nursing aide and another nurse on duty.
Patient vitals was assessed blood pressure 135/76, temperature 97.2, oxygen saturation 98 %, respirations 18, heart rate 89.
Neuro checks was assessed and range of motion was performed, patient was noted with weakness to the right hand and was unable to talk, patient was also noted with the mouth switch to the side. On call APN (Advanced Practice Nurse) was made aware and order given to transfer to ER.
After the fall, Resident #7 was transferred to the emergency room on 5/10/25 at an unknown time and the Resident did not return to the facility.
Further review of Resident #7's medical record revealed on 5/11/25 the following assessments were completed by Staff #13 even though the Resident had been discharged from the facility: Change in Condition Follow up, Neurological Check List, Pain Assessment, and Nursing Skilled Charting.
Review of Resident #7's May 2025 Medication Administration Record revealed on 5/11/25 Staff #13 documented he administered the following medications on 5/11/25 to the Resident even though the Resident had been discharged from the facility: Albuterol Inhaler 12 AM and 4 AM, Levothyroxine 175 mcq at 6 AM, Calcium Carbonate 500 mg at 6 AM and Sevelamer Carbonate at 6 AM.
Interview with the Director of Nursing on 8/19/25 at 2:45 PM confirmed Staff #13 inaccurately documented nursing assessments and administration of medications to Resident #7 on 5/11/25. 2.The facility staff documented medication and treatment administration for Resident #9 even though the Resident was not in the facility.
Review of Resident #9's medical record on 8/19/25 revealed the Resident was admitted to the facility in October 2024.Further review of Resident #9's medical record revealed a nurse's note on 2/11/25 at 3:06 PM that stated the Resident was transferred to the hospital.
The Resident did not return to the facility.
Review of Resident #9's February 2025 Medication Administration Record revealed Staff #18 documented she administered Aspirin 81 mg, Clopidogrel Bisulfate 75 mg, Metoprolol 100 mg, Prednisone 5 mg, Cyclosporine 5 ml, Levetiracetam 5 ml, flushed the Resident's tube feeding with 200 ml water on 2/12/25 when the Resident was not in the facility.
Review of Resident #9's February 2025 Treatment Administration Record revealed Staff #18 documented they cleansed the Resident's gastric tube site, did a left buttock wound treatment, did a sacrum wound treatment, applied betadine to the Resident's right great toe, applied skin prep to the Resident's heels, elevated the Resident's heels and provided catheter cleaning on 2/12/25 when the Resident was not in the facility.
Interview with the Director of Nursing on 8/21/25 at 11:54 AM confirmed Staff #18 inaccurately documented administration of medications and treatments to Resident #9 on 2/12/25.
215312 08/21/2025
Sterling Care Bel Air 410 East McPhail Road Bel Air, MD 21014
that she did not see Resident #6 that morning and that she was not notified of the low blood pressure.
seen the resident and started [him/her] on IV fluids or Midodrine.
They informed me at lunch that the
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.
215312 08/21/2025
Sterling Care Bel Air 410 East McPhail Road Bel Air, MD 21014
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.
215312 08/21/2025
Sterling Care Bel Air 410 East McPhail Road Bel Air, MD 21014
The surveyor proceeded to walk around the corner of the nurse's station and saw an unlocked and unattended medication cart sitting in the hallway outside of room [ROOM NUMBER]. Resident #21 was standing at the medication cart looking at the computer that was sitting on top of the cart.
The surveyor walked up to the cart and Resident #21 proceeded to walk down the hallway.
There were no nursing staff in the hallway.
The surveyor opened the top drawer of the medication cart and observed insulin pens, syringes, and a cell phone.Resident #23's insulin vial was opened with no date opened along with an opened Insulin Aspart Pen that was dispensed on 6/2 7/25.
The insulin pen was not dated.
There was another opened insulin flex pen for Resident #23 that was not dated when it was opened.
According to the manufacturer's directions, the insulin is only good for 28 days once it is opened.Resident #22's Lyumjev Kwick Pen was opened and dispensed on [DATE].
There was no date open on the Kwick Pen. Resident #21's Insulin pen was opened with no date opened.
According to the manufacturer's directions, the insulin is only good for 28 days once it is opened.There were other insulin pens in the top drawer that were not opened; however, they were in a plastic bag that stated to refrigerate until opened.After a couple of minutes of going through the unlocked medication cart, licensed practical nurse (LPN) #4 walked up to the surveyor.
The surveyor asked which nurse was using the medication cart and she stated LPN #5.
The surveyor informed LPN #4 that the cart was unlocked and unattended with Resident #21 standing at the cart. LPN #4 was also shown the undated insulin pens.
At 12:25 PM, which was 11 minutes after the initial observation, LPN #5 walked up to the medication cart. LPN #5 stated she didn't realize she left the cart unlocked.
The surveyor showed her the insulin pens, and she said she just came on duty that morning.
The surveyor asked about refrigeration of the insulin pens, and she stated that they were there when she got there in the morning.
The surveyor asked why the insulin pens were not refrigerated after LPN #5 took possession of the medication cart for the day. LPN #5 did not have any answer for the surveyor.On [DATE] at 1:30 PM a review of the Storage of Medications Policy, that was given to the surveyor from the Director of Nursing (DON), revealed Number 7; compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.
Number 9 documented, medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location.On [DATE] 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.
215312 08/21/2025
Sterling Care Bel Air 410 East McPhail Road Bel Air, MD 21014
at least one-half hour to 1 hour late coming out.
Trays to the floor (rooms) are then much later also.On
about the food as verbalized by some residents.
215312 08/21/2025
Sterling Care Bel Air 410 East McPhail Road Bel Air, MD 21014
Review of the August 2025 Treatment Administration Record (TAR) had documented the
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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.