STERLING CARE ROCKVILLE NURSING
For profit - Limited Liability company
100 Beds
STERLING CARE
Data: November 2025
Trust Grade
70/100
#83 of 219 in MD
Photo by Steve Young
Photo by Isaac Beletskiy
Photo by Isaac Beletskiy
1 / 10 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Sterling Care Rockville Nursing has received a Trust Grade of B, indicating it is a good choice among nursing homes. With a state ranking of #83 out of 219 in Maryland, they are positioned in the top half of facilities, and they rank #16 out of 34 in Montgomery County, meaning only 15 local options are better. The facility is newly inspected, so there is no trend data available yet. Staffing is a concern with a low rating of 1 out of 5 stars, although their turnover rate is 40%, which is on par with the state average. They have no fines on record, which is a positive sign, but the RN coverage is less than 97% of Maryland facilities, potentially impacting care quality. However, there are some significant issues noted in the inspector findings. For instance, one resident was left in a soiled depend for an extended period after calling for help, and another resident lacked access to a call bell, which could hinder their ability to request assistance. Additionally, the facility's environment received criticism for having dirty and broken shower rooms, which does not contribute to a safe and comfortable living space. Overall, while there are strengths in their ranking and lack of fines, these concerns about care and environment warrant careful consideration.
- Trust Score
- B
- In Maryland
- #83/219
- Safety Record
- Low Risk
- Inspections
- Too New
- Staff Stability ○ Average
- 40% turnover. Near Maryland's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Maryland facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 25 minutes of Registered Nurse (RN) attention daily — below average for Maryland. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 21 deficiencies on record. Higher than average. Multiple issues found across inspections.
70/100
Top 37%
No red flags
0 → 21 violations
★★★★☆
4.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
: 0 issues
2025: 21 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (40%)
8 points below Maryland average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 40%
Near Maryland avg (46%)
Typical for the industry
Chain: STERLING CARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 21 deficiencies on record
Jan 2025
21 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and interview with residents and staff, it was determined that the facility failed to maintain a residents' dignity. This was found of 1 (Resident #40) resident on a random observ...
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Based on observation and interview with residents and staff, it was determined that the facility failed to maintain a residents' dignity. This was found of 1 (Resident #40) resident on a random observation.
The findings include:
On 1/16/25 at 12:01 PM, the surveyor knocked and asked to enter into Resident #40's room. Resident #40 responded, yes.
Next the surveyor observed Resident #40 with an open depends laying flat in the bed. The surveyor asked if Resident #40 needed any help. Resident #40 stated that he/she had just put on the call light to have incontinent care provided. He/she further stated that a staff member came in, turned off the light, and stated that they would get the person assigned to assist in cleaning up. Resident #40 stated that he/she had a full depends and could not get up on his/her own.
On 1/16/25 at 12:07 PM, 6 minutes later, the surveyor observed Geriatric Nursing Assistant (GNA) #25 walk right into the room without knocking or asking permission to come in. GNA #25 stated she was there to help Resident #40 with incontinent care. The surveyor asked the GNA how long it had been since Resident #40's call light was turned off and GNA#40 stated it had been 10 minutes. The surveyor asked GNA #25 if she normally knocks before entering into a resident's room. GNA #40 stated that she usually does but did not this time.
On 1/16/25 at 12:20 PM, the surveyor reviewed the observation with the 2nd floor Unit Manager #6. UM#6 confirmed the GNA #40 should have knocked before entering.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observations and staff interviews, it was determined that the facility failed to ensure residents had access to, and appropriate call bells. This was found to be evident in 2 (Resident #9 and...
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Based on observations and staff interviews, it was determined that the facility failed to ensure residents had access to, and appropriate call bells. This was found to be evident in 2 (Resident #9 and Resident #333) of 52 residents reviewed for access to the call system during the recertification survey.
The findings include:
1) On 1/7/2025 at 10:00 AM, surveyors observed Resident #333 did not have a call bell in their room. Surveyors interviewed Geriatric Nursing Assistant (GNA) #12 at 10:01 AM and asked about the call bell for the resident. GNA #12 confirmed to surveyors that the resident did not have a call bell available and informed that the room needed a splitter for the outlet that would allow for 2 call bells (Resident #333's roommate had a functioning call bell). GNA #12 stated they would update their Unit Manager about the situation to correct.
Further observations by surveyors at 11:30 AM revealed that Resident #333 had not received a call bell. GNA #12 was questioned by surveyors and stated they alerted their Unit Manager about the situation. At 11:30 AM, surveyors interviewed 3rd floor Licensed Practical Nurse (LPN) Unit Manager #9. LPN #9 stated they would alert maintenance to the situation.
At 11:43 AM, LPN #9 stated to surveyors that Resident #333 had received a call bell, and a functioning call bell was observed by surveyors to be next to the resident.
2) On 1/8/2025 at 10:05 AM, surveyors observed and interviewed Resident #9. Resident #9 stated to surveyors that staff did not answer their call bell when pushed earlier in the morning. Surveyors directed the resident to activate the call bell again and observed the resident unable to physically activate the push pad style call bell.
At 10:12 AM, GNA #11 was interviewed by the surveyors and was made aware of Resident #9's inability to activate the call bell provided to them. GNA #11 observed the resident attempting to activate without success and stated to the surveyors they would update their Unit Manager. At 10:19 AM, the facility's Maintenance Director entered the resident's room and observed the resident unable to activate their call bell. The Maintenance Director stated to surveyors that they would replace the push pad call bell with a push button.
At 10:22 AM, the Maintenance Director replaced Resident 9's push pad call bell with a push button call bell, and the surveyors observed the resident successfully activate the call bell system.
An interview was conducted with the Director of Nursing (DON) by surveyors on 1/10/2025 at 9:58 AM. The DON acknowledged the surveyors' concern with call bells and stated the facility's expectation is that call bells are accessible to residents and appropriate call bells are used based on residents' needs.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations, interviews and record reviews, it was determined that the facility failed to provide a safe, comfortable, homelike environment. 1) This was found to be evident in 2 out of 2 sho...
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Based on observations, interviews and record reviews, it was determined that the facility failed to provide a safe, comfortable, homelike environment. 1) This was found to be evident in 2 out of 2 shower rooms observed during the annual survey, and 2) An handrail was broken on the toilet. This was evident for 1 (Resident #58) out of 9 residents reviewed for environment.
The findings include:
1) During an interview with Resident #97 on 1/13/25 at 12:25 PM, the surveyor was told to investigate the showers because they were dirty and broken.
On 01/14/2025 at 10:15 AM, the surveyors observed that the second floor shower room contained 4 shower stalls, had stained ceiling tiles, a taped up vent in the ceiling with brown colored tape and tape hanging off the vent, and visible dark spots in the ceiling light covers. It appeared that 2 shower stalls had been recently used. The other 2 stalls were dry and equipment stored in the stalls. The third floor shower room stalls had one stall that appeared to be in use and 2 stalls with big perforations in the walls covered with taped on plastic, and a 4th stall that was filled with equipment.
The Nursing Home Administrator (NHA) was informed of the concerns found by the surveyors on 1/16/25 at 8:38 AM. The NHA stated the 2nd floor shower stalls hadn't worked in years and the facility was working on repairing the showers. The Maintenance Director stated that an outside company was hired to work on the pipes. That when the work was completed and he and his staff would finish the repairs. When asked when the repairs would be completed, he stated in about a month.
During an interview on 1/22/2025 at 8:15 AM, the Nursing Home Administrator stated we currently have 3 functioning showers but we are not having problems getting showers completed as scheduled. We plan to have two more up and running soon.
2) On 1/08/25 at 10:24 AM, an interview was conducted with Resident #58. They complained of a handrail attached to the toilet being broken for weeks. This surveyor observed two handrails attached to the toilet. The one on the right side was broken at the connecting piece of the toilet. Staff #4 was notified of the concern. Staff #4 stated this was the 1st time they were aware of the issue and stated that they would notify maintenance immediately.
On 1/09/25 at 12:10 PM, an observation was done on Resident #58's room. The handrail on the toilet is visualized and was still broken. This surveyor notified the Administrator (Staff #1) of the broken handrail on the toilet.
On 1/09/25 at 2:23 PM, an interview was conducted with the Maintenance Director (Staff #5). When asked how often the safety/support equipment is being checked, Staff #5 stated that monthly checks are conducted and equipment is being checked as damages are reported. When asked the average time it takes to address repairs, Staff #5 stated that repairs are prioritized by the severity of repairs and are attended to accordingly. When asked how they keep track of repairs, Staff #5 stated that they write concerns in their personal log as they come to them and write down the repair date once completed. When asked what was done to repair Resident #58's toilet handrails, Staff #5 stated that the hand rails were removed for safety and they had hand rails on the wall for the resident to use instead.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, it was determined that the facility failed to prevent resident abuse. This was found to be evident for 2 (#134 & #85) out of 9 residents investigate...
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Based on observation, record review, and interview, it was determined that the facility failed to prevent resident abuse. This was found to be evident for 2 (#134 & #85) out of 9 residents investigated for abuse during the recertification survey.
The findings include:
1) Review of facility report MD00181452 on 1/13/25 at 7:54 AM, revealed that Registered Nurse #36 and Certified Medication Aide #21 observed Resident #135 approach and slap Resident #134, who was sitting in his/her wheelchair in the hall, on the left cheek on 3/19/2021 at 11:30 AM. The residents were separated and no injuries were observed or reported. Resident #135 was placed on 1:1 observation and sent to the Emergency Department for further assessment.
The facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property was reviewed by the surveyor on 1/13/24 at 9:47 AM. The policy stated that physical abuse included slapping.
On 1/13/25 at 9:44 AM, the DON was interviewed regarding the concern for resident-to-resident abuse. She stated that although she was not able to speak about the incident, she understood the concern.
2) On 1/16/25 at 1:30 PM, the facility reported incident (FRI) #MD00197347 was reviewed. Resident #85 was diagnosed with Dementia and a Brief Interview of Mental Status (BIMS) of 0.0. BIMS is a cognitive screening tool used to assess a person's mental and cognitive health with scores ranging from 0 to 15, with higher scores indicating better cognitive function. According to the report, a staff member (Staff #26) witnessed Resident #85's family member pulling the residents hair and tapping their head. This incident was witnessed in hallway on the second floor, outside the resident lounge during lunch time, around 2:30 PM. The resident's family member stated they did not mean any malintent but was only trying to get the resident up to eat their food. The resident is unable to recall incident per report. The family member was placed on 1:1 visitor observation and a Behavioral contract was presented to the resident's family member.
On 1/16/25 at 2:00 PM, an interview was conducted with the corporate nurse (Staff #27). When asked if there was any supporting documentation for this investigation, Staff #27 stated they cannot provide any additional documentation but could explain this incident in depth. When asked what happened in this investigation, Staff #27 stated that the regional corporate team takes charge in incidents/allegations of visitor to resident abuse. we went over with behavioral contract with our conditions which the family member was not happy about. They eventually understood the purpose of the contract and our conditions for his visits.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on medical record review, internal report review and interview with resident and staff, it was determined the facility staff failed to report an allegation of abuse and an injury of unknown orig...
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Based on medical record review, internal report review and interview with resident and staff, it was determined the facility staff failed to report an allegation of abuse and an injury of unknown origin to the regulator agencies and Office of Health Care Quality (OHCQ). This was found evident in 2 (Resident #1 and #29) out of 10 residents reviewed for abuse and injuries of unknown origin.
The findings include:
1a) On 1/8/25 at 8:49 AM, the surveyor interviewed Resident #1. During the interview Resident #1 recounted an alleged abuse that occurred. Resident #1 was not able to remember the exact date or recall what the person looked like but reported that it happened in the middle of the night and that he/she woke up with someone holding his/her nose closed. Resident #1 stated that he/she felt that the person was trying to kill them.
On 1/10/25 at 9:16 AM, the surveyor reviewed Resident #1's medical record. The review revealed that on 12/12/23 a Palliative Care Physician Staff #39 evaluated Resident #1 and wrote a progress note that stated, Resident #1 noted with delusions. He/she feels someone was holding his/her nose in the night and someone stole his/her shoes. The note further stated that the shoes were on the resident and that the Resident #1 agreed the recent decrease in his/her medication may be contributing to the feeling.
On 1/14/25 at 3:32 PM, the surveyor requested the investigation into the allegation of abuse from Resident #1 in 2023 from the Director of Nursing (DON). The DON stated she was unaware of any abuse and would look into the situation.
On 1/14/25 at 3:52 PM, the surveyor conducted a follow-up interview with the DON. The DON confirmed that she would be starting an investigation into the allegation.
1b) On 1/16/25 at 7:39 AM, the surveyor reviewed Resident #29's medical record. The record revealed that on 9/3/23 Resident # 29's had x-rays done to the right arm to rule out a fracture after it was noted Resident #29 was having discomfort. No fracture was found. On 9/6/23 a result of a shoulder x-ray revealed Resident #29 had a right shoulder dislocation. Resident #29 was sent to the hospital for treatment.
On 1/16/25 at 10:16 AM, the surveyor reviewed an investigation into the injury of unknown origin. The report found that no one witnessed a fall or incident to cause the dislocation. The previous Director or Nursing Staff #41 documented the Resident #29 was noted in wheelchair with arms on flat section of armrest. No other observations could rule reason for dislocation.
On 1/27/2025 at 11:33 AM, the surveyor conducted a phone interview with the Director of Nursing (DON). During the interview the DON confirmed that the investigation into the injury of unknown origin was done internally. The surveyor reviewed the concern that facility failed to report and submit the investigation of this incident to the Office of Health Care Quality (OHCQ).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on review of the facility's investigation file and interview it was determined that the facility failed to maintain evidence that an injury of unknown origin was thoroughly investigated. This wa...
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Based on review of the facility's investigation file and interview it was determined that the facility failed to maintain evidence that an injury of unknown origin was thoroughly investigated. This was found evident in 1 (Resident #32) out of 9 residents reviewed for abuse.
The findings include:
On 1/21/25 at 8:04 AM, the surveyor reviewed the investigation file regarding the investigation into the injury of unknown origin for Resident #32. The investigation listed all of the steps taken to investigate the injury and are as follows:
1. Head to toe assessment of the resident was completed and the Resident was sent for treatment and family updated
2. Residents in the hall were interviewed and any incapable residents had a head-to-toe assessment done
3. Director of Nursing was notified
4. Ombudsman notified
5. Interviews were conducted for any staff member on the hall at the time of the event
6. Police were notified
7. Self-report filed
On review of the file no resident interviews or skin checks were in the investigation file. Statements from staff were provided, however, the statement from GNA #40, the staff that identified the injury, was not in the file.
On 1/21/25 at 1:11 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reviewed the concern that the facility reported that they performed skin checks and interviews with residents from Resident #32's hallway, however they were not part of the investigation. The DON stated skin checks were done and she had the sheets to provide, however no interviews from capable residents were completed.
On 1/22/25 at 11:10 AM the surveyor conducted a follow up interview with the DON. During the interview the DON stated that the statement was taken from GNA #40 however it was not in the investigation file but found in the concern forms documentation. The surveyor relayed the concern that the facility reported they did all the steps for a thorough investigation, however interviews from other residents were not done and two components of the investigation were not part of the investigation file.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined that the facility failed to code the resident's status acc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined that the facility failed to code the resident's status accurately on the Minimum Data Set (MDS) assessment. This was found to be evident for 1 (Resident #52) of 8 residents reviewed for accuracy during the recertification survey.
The findings include:
The MDS is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need.
Anticoagulant (AC) medication is a type of drug that helps prevent blood clots from forming or growing larger. It is important because it reduces the risk of serious conditions like strokes, heart attacks, or deep vein thrombosis, especially in people with conditions that increase the likelihood of clotting. These medications help keep blood flowing smoothly and prevent harmful blockages in the bloodstream.
On 1/13/2025 at 8:44 AM, Resident #52's medical record was reviewed by the surveyors. A physician's order for Apixaban (a type of AC medication) was placed on 7/23/2024 and the resident's care plan included they were on AC medication, initiated on 3/23/2025 and revised on 6/27/2024. Further record review revealed a quarterly MDS assessment dated [DATE] which, under section N for medication, no was documented for AC.
An interview was conducted by surveyors with the MDS Coordinator on 1/13/2025 at 10:11 AM. The MDS Coordinator was asked about the quarterly MDS assessment being documented no for AC. The MDS Director stated to surveyors that it was an error AC was incorrectly coded no and stated they would submit a modification of quarterly to MDS to correct the discrepancy.
During an interview on 1/13/2025 at 2:15 PM, the Nursing Home Administrator acknowledged concerns with MDS accuracy and provided documentation to surveyors that the resident's MDS was corrected by the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on record review and interview with a resident and staff it was determined that the facility failed to develop a comprehensive person-centered care plan. This was found evident of 1 (Resident #1...
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Based on record review and interview with a resident and staff it was determined that the facility failed to develop a comprehensive person-centered care plan. This was found evident of 1 (Resident #1) of 3 residents reviewed for care planning.
The findings include:
On 1/8/25 at 8:49 AM, the surveyor interviewed Resident #1. During the interview Resident #1 expressed that he/she was inaccurately assessed and/or diagnosed and that he/she wished to pursue looking into transfer to another facility.
On 1/10/25 at 9:16 AM, the surveyor reviewed Resident #1's medical record. The review revealed that on 8/15/24 Psychiatric Nurse Practitioner Staff #37 wrote a progress notes that stated, Resident #1's goals,I want to go to a different nursing home which is closer to a shopping center and metro access because I like to shop.
On further review, a Psychologist, Staff #38 wrote a progress note on 10/4/24 that stated, Resident #1 requested to leave the facility for several hours to go shopping. Staff #38 wrote in the note, my clinical impression, he/she is safe to do so and is generally good at following structure. However, further in the note Staff #38 expressed that Resident #1 did not have capacity at this time and that Resident #1 would be vulnerable.
On 1/13/25 at 10:11 AM, the surveyor reviewed Resident #1's care plan. The review revealed a care plan that was created on 9/22/23 that stated, Resident #1 had a variety of activity interests such as music entertainment, socials, bingo, arts and crafts, poetry and a general willingness to take part in group activity programs. The goal listed was Resident #1 will plan and choose to engage in preferred activities. No mention of request or desire to go shopping was noted in the care plan.
A care plan was created on 7/10/24 by Social Service Director #16 that stated, Resident #1's anticipates remaining in the facility long-term. The goal listed was Resident #1 will receive effective treatments throughout the review at the facility. Resident #1 will participate in his/her care decisions for my long-term stay and will be able to voice satisfaction with the care received while remaining in this facility through this review period.
On 1/4/25 at 11:04 AM, the surveyor interviewed the Social Service Director Staff #16. During the interview Staff #16 stated that Resident #1 expressed a desire to be transferred to other facilities earlier in 2024 and that she had sent in referral documents to other facilities. She also stated that Resident #1 had expressed an interest in going out shopping earlier in the summer months. She further stated that she offered for Resident #1 to go out with an escort. The surveyor asked if Staff #16 had documented these changes in the care plan or anywhere in Resident #1's medical record. She stated she would look and follow up.
On 1/14/25 at 1:15 PM, the surveyor conducted a follow-up interview with Staff #16. During the interview Staff #16 brought in email correspondence dated 7/3/24 and 9/3/24 to another facility regarding transferring and a two typed statement from the days she spoke with Resident #1 about shopping trip availability and desire dated 7/1/24 and 9/11/24. The surveyor noted that Resident #1 requested to be transferred on 7/3/24 and yet the care plan created on 7/10/24 stated Resident #1 plan was to remain in the facility in long term care.
On 1/21/25 at 12:11 PM, the surveyor conducted an interview with the Director of Nursing (DON) and Staff #16. During the interview the surveyor reviewed the concerns that Resident #1's care plan was not updated and/or person centered with Resident #1's expressed goals for his/her plan of care regarding discharge planning and activities goals and interventions.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interviews, and record review, it was determined that the facility failed to review and revise a resident's care plan after a resident's situation changed. This was found evident of 1 (Reside...
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Based on interviews, and record review, it was determined that the facility failed to review and revise a resident's care plan after a resident's situation changed. This was found evident of 1 (Resident #28) out of 3 Residents reviewed for care planning during the survey.
The findings include:
On 1/13/25 at 10:59 AM, the surveyor conducted an interview with Resident #29's family member. During the interview Resident #29's family member was concerned that it was not communicated that his/her parent was hard of hearing. When asked if Resident #29 had hearing aids, the family member stated that Resident #29 had hearing aids at one time but would constantly take them out and they had asked the facility to stop using them so they would not be lost.
On 1/16/25 at 10:53 AM, the surveyor reviewed Resident #29's medical record. The review revealed that Resident #29 had a care plan that stated Resident #29 had a hearing deficit. The care plan was revised on 3/9/21. In the interventions it stated, apply bilateral (both sides) hearing aids in the morning and out in the evening.
On further review a treatment log for January 2025 had a place to document the left and the right hearing aid placement in the morning and removal in the evening. All days in January up to the 15th were documented as completed.
On 1/17/25 at 9:44 AM, the surveyor interviewed the 2nd floor Unit Manager #6. UM#5 stated he would update a care plan if a Resident's Responsible Party (RP) requested a change in the plan of care. He further stated he was unsure if Resident #29 currently was using hearing aids but was aware that he/she wasn't using them as frequently anymore.
On 1/17/25 at 12:26 PM, the surveyor reviewed the concern with the Director of Nursing (DON) that Resident #29 hearing care plan was not revised nor the treatment sheet to reflect the change that Resident #29 was not utilizing hearing aids anymore. The DON confirmed both areas needed to be updated to reflect the residents' care.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 1/17/25 at 8:30 AM, Complaint #MD00171169 was reviewed. The complaint states that Resident #132 was discharged on 8/18/21 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 1/17/25 at 8:30 AM, Complaint #MD00171169 was reviewed. The complaint states that Resident #132 was discharged on 8/18/21 and a home health nurse did not show up to provide care until 8/26/21.
On 1/17/25 at 8:45 AM, a review of Resident#132's progress notes. On a discharge follow-up note from Social Services on 8/25/21 at 3:51 PM states, Resident was discharge to home on [DATE] with friends assistance. Resident was referred to Community home health of MD for Home health services, however during the call with community home health it was discovered resident did not have a primarily care doctor in the community. [Social Services], followed with resident's friend no answer left a message expressing for resident to be seen by the [Nurse Practitioner so services can began. Resident's friend followed back up with [Social Services] on Monday 08/23/2021 [Social Services] informed [them] about the issue [they] stated that [they] reached out the PCP in the facility and he's willing to follow resident in the community. [Social Services], provided Community home health with the number of the [Primary Care Provider] to follow resident. Next day Community home health of Maryland called and said she's can't take on the case because there request was 35 hours and that cannot be done with the company. [Social Services], reached back out to resident's friend informing [them] that community home health could not provide the hours [they have] requested and another referral was sent out to Home Call. [Social Services] followed up with home call on 08/25/2021 they have reached out to resident's friend and a nurse will be out to see resident on 08/26/2021. Resident remains stable no distress noted.
According to resident records, Resident #132 was discharged from the facility on 8/18/2021.
On 1/17/25 at 10:45 AM, an interview was conducted with Staff #28. When asked what is required prior to discharging when a resident is going home with Home Health Agency (HHA), Staff #28 stated, We send out a referral to the HHA via email or fax. Once that is done we wait for a response to see if the services are accepted by HHA and the date of the start of services. This information is then relayed to the Resident Representative and Resident. When asked if it is their practice to require to know if services are accepted by the HHA prior to the discharge, Staff #28 stated Correct.
Based on review of medical records, review of correspondences and interviews, it was determined that the facility failed to confirm and implement post-discharge care for residents requiring home health services. This was found evident in 2 (Resident #81 & #132) out of 3 residents reviewed for discharge planning.
The findings include:
1) On 1/21/25 at 9:35 AM, the surveyor reviewed Resident #81's medical record. The review revealed that Resident #81 was admitted to the facility in September of 2021 with a past medical history that included, but not limited to, aftercare following joint replacement surgery, muscle weakness, abnormal gait and osteoarthritis (a chronic disease that breaks down cartilage and bone in the joints).
On further review Physical Therapy (PT) worked with resident on 12/22/21 with therapeutic activities, therapeutic exercise and gait (walking) training. The therapist documented that therapy was indicated to help improve transfers, to address gait deviations, reduce assistance from caregivers, to improve time out of bed, and to reduce falls. The therapy noted that Resident #81 used both a rolling walker and wheelchair during therapy.
On further review the surveyor noted the discharge instructions document dated 12/21/21 that indicated Resident #81 required in home care or services. Listed as services being provided were, Nurse, Aide, Physical Therapy (PT), and Occupational Therapy (OT). The documentation named the home care agency, however, no contact name or number was provided on the discharge instructions in the dedicated areas. The discharge instructions were signed by facility staff on 12/23/21.
On 1/21/25 at 12 PM, the surveyor interviewed the Director of Nursing (DON). During the interview the surveyor asked the DON for documentation showing the facility set up home care services for Resident #81 on discharge.
On 1/21/25 at 2:28 PM, the surveyor conducted a follow up interview with the DON. During the interview the DON stated she reached out to the home health care agency and the DON provided their Client Coordination Note Report. The first page dated 12/23/21 was titled, Non-Admit Details. The note stated, no skilled nursing at this time. The next page of notes dated 1/5/22, titled, Clinical comment- intake. The notes state the following documents have been requested. History and Physical was checked off as received. Facility discharge summary, surgical notes, physical office notes including diagnosis list, current medication list from facility/physician, were all unchecked indicating the home health agency did not receive these documents. The next date on the Client Coordination Note Report was 1/6/22. The home agency's PT went to do a home visit and documented that the visit was missed by Resident #81 related to Resident #81 having a medical appointment. The home agency PT documents that Resident #81 was looking into another home care agency. The first visit from the home care agency was 13 days after Resident #81 was discharged from the facility. The surveyor relayed the concern that the facility discharged a resident without establishing an initial appointment within the first few days of being discharged after the facility indicated home health care was needed on discharge.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, observations, record review and staff interview, it was determined that the facility failed to ens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, observations, record review and staff interview, it was determined that the facility failed to ensure the residents had safety equipment in working condition. This was evident for 1 (Resident #58) of 9 residents reviewed for accidents and hazards.
The findings include:
On 1/08/25 at 10:24 AM, an interview was conducted with Resident #58. Resident #58 stated they fell recently and stated that they believe it was due to a handrail on the toilet being broken. In an observation during the interview, there was a handrail on each side of the wall and handrails attached to each side of the toilet. The handrail attached to the left side of the toilet was broken. Staff #4 was notified of the concern and stated this was the 1st time notified of the issue and maintenance would be notified immediately.
On 1/09/25 at 12:10 PM, an observation was conducted with Resident #58's room. The handrail on the toilet was visualized and was still broken. This surveyor notified the Administrator of the broken handrail attached to the toilet in room [ROOM NUMBER]. The Administrator stated that the handrail would be taken care of immediately.
On 1/09/25 at 12:23 PM, a review of Resident #58's records was conducted. A change of condition assessment from 12/14/24 showed that the resident's last fall was 12/13/2024. Under the summary section for the assessment stated that Resident #58 had stated they fell when attempting to use the restroom the day prior. An Xray was ordered on 12/14/2024 and no fracture was revealed.
On 1/09/25 at 1:14 PM, a review of Resident #58's care plans were conducted. The resident has a care plan for falls and it was revised on 12/16/24 with an intervention to anticipate the needs of the resident.
On 1/09/25 at 2:23 PM, an interview was conducted with the Maintenance Director (Staff #5). When asked how often the safety/support equipment is being checked, Staff #5 stated that monthly checks are conducted and equipment is being checked as damages are reported. When asked the average time it takes to address repairs, Staff #5 stated they Prioritize the severity of repairs and attend to them accordingly. When asked how they keep track of repairs, Staff #5 stated that they write concerns in their personal log as they come to them and write down the repair date once completed. When asked what was done to repair Resident #58's toilet handrails, Staff #5 stated that the handrails were removed for safety and they had hand rails on the wall for the resident to use instead.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observations, record reviews, and interviews, it was determined that the facility administered oxygen to a resident without an order. This was found to be evident in 1 (Resident #9) of 2 resi...
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Based on observations, record reviews, and interviews, it was determined that the facility administered oxygen to a resident without an order. This was found to be evident in 1 (Resident #9) of 2 residents reviewed for oxygen administration during the recertification survey.
The findings include:
On 1/10/2025 at 8:17 AM, surveyors observed Resident #9 to be on oxygen through nasal cannula via an oxygen concentrator in their room. Previous observations of Resident #9 on 1/8/2025 did not reveal the resident to be on oxygen.
Resident #9's medical record was reviewed by surveyors at 8:30 AM. A Change of Condition assessment note dated 1/9/2025 at 11:00 PM documented that Resident #9 had low oxygen saturations and the Nurse Practitioner (NP) #33 on duty was contacted by staff. The assessment note stated that Resident #9 was to be started on oxygen at 3 liters via nasal cannula per NP #33. Further review of Resident #9's record did not reveal an order in their chart for oxygen administration.
Surveyors interviewed Licensed Practical Nurse (LPN) #10 on 1/10/2025 at 8:47 AM and asked about the oxygen administration for Resident #9. LPN #9 stated they were not sure when the resident was placed on oxygen and that their expectation is that residents on oxygen should have an order in their Electronic Health Record (EHR). LPN #9 confirmed to surveyors that they did not see an order for oxygen for Resident #9 in the EHR.
At 8:52 AM, 3rd floor Licensed Practical Nurse (LPN) Unit Manager #9 was interviewed by surveyors. LPN #9 could not find an order for oxygen administration in Resident #9's EHR and stated it is their expectation that there should be an order in residents EHR if they are on oxygen.
Surveyors interviewed the Assistant Director of Nursing (ADON) at 8:56 AM about Resident #9 being on oxygen. The ADON stated that the oxygen was likely verbally ordered by NP #33 and that it is the nursing staff's responsibility to place the order in the EHR. The ADON stated to surveyors that they would update the oxygen order for Resident #9.
Further review of Resident #9 medical records by surveyors on 1/10/2025 at 9:36 AM revealed an updated order to administer continuous oxygen at 3 liters via nasal cannula for shortness of breath/low oxygen saturation.
On 1/10/2025 at 9:58 AM, surveyors interviewed the Director of Nursing (DON) addressed concerns of Resident #9 receiving oxygen without an order in their EHR. The DON acknowledged the concern and stated that they were having the nurse responsible for placing the verbal orders for oxygen by NP #33 come into the facility for a teaching conference.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0710
(Tag F0710)
Could have caused harm · This affected 1 resident
Based on interviews and record review it was determined that the facility physician failed to acknowledge review of laboratory (lab) results of a resident. This was found to be evident in 1 (Resident ...
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Based on interviews and record review it was determined that the facility physician failed to acknowledge review of laboratory (lab) results of a resident. This was found to be evident in 1 (Resident #81) out of 2 residents reviewed for lab and radiology services.
The findings include:
On 1/21/25 at 9:35 AM, the surveyor reviewed Resident #81's medical record. The review revealed that Resident #81 was admitted to the facility in September of 2021 with a past medical history that included, but not limited to, elevated white blood cell count (indicating infection), over active bladder, pyelonephritis (inflammation or infection in the kidney) and Urinary Tract Infections (UTIs) and Hydronephrosis (swelling of the kidneys due to urine build up).
On further review of Resident #81's medical records the surveyor noted that on 10/28/21 a urinalysis (UA) was obtained and a culture and sensitivity (C&S) was completed related to an order placed by the provider on 10/2721 and again on 10/28/21. Both of these laboratory tests are ordered to assess the health of the urinary tract. A UA is a test that analyzes the chemical composition of urine, and a C&S is completed only if bacteria is suspected from the UA. The C&S urine sample is completed in order to grow and identify the cause of infection and give treatment options for the infection. Resident #81's C&S resulted on 11/2/21 with results of 10,000-49,00 CFU/ml of the bacteria Escherichia coli (E coli). A paper copy of these results had an initial to indicate they were reviewed. The laboratory test was done again on 11/2/21 and the C&S results were reported on 11/6/21 with a note that indicated the lab was abnormal with greater than 100,000 CFU/ml of the bacteria of the same bacteria E coli. Resident #81 was prescribed an antibiotic by the provider to treat the infection on 11/4/21.
Additionally Resident #81 had a UA obtained on 11/22/21 that was sent for a C&S and resulted on 11/26/21 at 1:27 AM. The results indicated the lab was abnormal and again resulting with greater than 100,000 CFU/ml of the bacteria but this time the bacteria was Pseudomonas Aeruginosa. However, there was no treatment ordered or an initial on the printed lab results.
The surveyor reviewed the progress notes written by Resident #81's providers following the C&S results. On 11/26/21 Nurse Practitioner NP #33 wrote a follow-up progress note and that the primary care provider was working on a Urology (medical specialty that focuses on the urinary system and reproductive organs) consult. NP #33 documented that Resident #81 had no abdominal pain, no flank pain, no fever or chills, or nausea or vomiting. In the assessment and plan section of the note NP #33 wrote, labs, previous imaging, old records and therapy notes were reviewed in detail. She further writes, blood noted in urine, ultrasound sonography shows right renal cyst and urology will be consulted by primary provider. No where in the note indicated the results of the abnormal lab were reviewed or rational for non treatment.
Next Resident #81's Primary Care Provider MD#34 wrote a progress note following a visit on 11/29/21. MD #34 wrote that the Resident #81 was seen and examined per nursing's request related to hematuria (blood in the urine). MD #34 further stated that the results of the ultrasound showed hydronephrosis and that a foley catheter was placed with continued hematuria. The repeated ultrasound showed a kidney stone and for the foley catheter to be flushed and monitored closely. MD #34 indicated that a urologist appointment was scheduled for Resident #81, and that lab and nursing documentation was reviewed. Further in the note, MD#34 stated Resident denies urinary urgency, frequency, dysuria, nocturia or difficulty voiding, however Resident #81 had a foley in place at this time. There was no mention or indication that the abnormal S&C was reviewed and that non treatment was indicated.
On 1/22/25 at 12:35 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview, the surveyor asked the DON for the rationale as to why there was no treatment from the C&S that resulted on 11/26/21 when similar C&S was treated from the C&S that resulted on 11/2/21. The DON stated she would look into the concern and was aware that the Medical Director had conducted a review of Resident #81's medical record and would provide the report.
Next the surveyor reviewed the report. The Medical Director wrote in regards to the urine culture that resulted on 11/26 that treatment would be out of caution, but not necessary per Center for Disease Criteria. There was no date on the review to indicate when the review was made.
On 1/22/25 at 1:42 PM, the surveyor conducted a follow-up interview with the DON along with the Regional Clinical Nurse Staff #27. During the interview, Staff #27 stated the review by the Medical Director was conducted on 11/5/24 related to a medical records release. The surveyor relayed the concern that there was no documentation at the time that indicated the rationale for non-treatment or acknowledgement of abnormal laboratory results. The surveyor asked how lab results were validated as reviewed. The DON stated that electronically labs are marked as reviewed in the electronic health record or if the results are on paper that they would be initialed. When asked why the culture results on 11/2/21 were initialed but the results on 11/26/21 were not. The DON stated she had to print the lab results because the lab results were not in the paper record. The surveyor reviewed the concern that there was no documentation in the medical record to confirm the provider reviewed and/or acknowledged the abnormal labs and that there was no rationale for non treatment of the abnormal labs that resulted on 11/26/21.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on staffing record review and staff interviews, it was determined that the facility failed to provide a Registered Nurse (RN) for 8 consecutive hours. This was found to be evident for 1 of 21 da...
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Based on staffing record review and staff interviews, it was determined that the facility failed to provide a Registered Nurse (RN) for 8 consecutive hours. This was found to be evident for 1 of 21 days reviewed for RN staffing during the recertification survey
The findings include:
Prior to the recertification survey, review of the Payroll Based Journal (PBJ) by the surveyors did not identify any staffing waivers. During the entrance conference on 1/7/2025 at 9:47 AM, it was confirmed to surveyors by the Nursing Home Administrator (NHA) that the facility did not currently have any staffing waivers in place.
On 1/15/2024 at 11:30 AM, surveyors reviewed the daily nursing staffing sheets provided by the facility from 12/24/2024 to 1/13/2025. It was revealed that on 1/1/2025, there was no RN scheduled for the night, day, or evening shifts.
The Director of Nursing (DON) was interviewed by surveyors on 1/15/2025 at 12:45 PM. The DON stated that they were not aware of any staffing issues since they have been at the facility, and it is the DON and Assistant Director of Nursing (ADON) who are responsible for RN coverage if a scheduled RN calls out or there is an RN shortage. Surveyors addressed concern to the DON about no RN coverage on 1/1/2025 and requested 24-hour staff and agency punch in sheets dated 1/1/2025. The DON stated they would supply these documents.
On 1/16/2025 at 9:20 AM, the ADON was interviewed by surveyors. The ADON stated that they were the RN on call on 1/1/2025 and available by phone but were not physically present in the facility on that day. Review of 24-hour staff punch in sheets did not show a RN was clocked in on 1/1/2025.
The facility's Staffing Coordinator was interviewed by surveyors on 1/16/2025 at 11:07 AM who stated that it is the facility's expectation to have an RN in the building for 8 consecutive hours a day. Surveyors asked about RN staffing on 1/1/2025 and the Staffing Coordinator confirmed there was no RN scheduled for 8 consecutive hours on that day, and that the ADON was on call and available through the phone.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on review of the medical record, and interview, it was determined that the facility failed to provide a resident with routine medications as ordered. This was evident of 2 (Resident #82 & #99) o...
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Based on review of the medical record, and interview, it was determined that the facility failed to provide a resident with routine medications as ordered. This was evident of 2 (Resident #82 & #99) out of 8 residents reviewed for medications.
The findings include:
1) On 1/22/25 at 8:32 AM, the surveyor reviewed Resident #82's medical record. The review revealed that Resident #82 had a past medical history of diabetes mellitus type 2.
Next the surveyor reviewed the May 2022 Medication Administration Record (MAR) for Resident #82. The review revealed that the medication Sitagliptin Phosphate, a medication indicated for Diabetes Mellitus, was marked as see progress notes on 5/4/22, 5/8/22 and 5/9/22. On 5/4/22 the progress notes stated, reordered from pharmacy, on 5/8/22 and 5/9/22 the notes stated, awaiting delivery from pharmacy.
On 1/22/25 at 12:18 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor asked the DON why on three occasions, within a week, Resident #82's mediation not available from pharmacy. The DON stated she would look to see if an alternative medication was given and if the physician was aware and okay with the missing doses.
On 1/22/25 at 12:35 PM, the surveyor conducted a follow-up interview with DON. The DON stated she was unaware of the reason and would reach out to the pharmacy to find out the reason. At the time of exit no additional documents were provided to explain why Resident #82's medications were not available.
2) On 1/17/25 at 8:16 AM, a review of complaint #MD00170557 was conducted. The complainant stated that many residents' medications have not been administered specifically for Resident #99.
On 1/17/25 at 9:30 AM, a review of Resident #99's progress notes was conducted. A care plan note from 8/10/21 stated, Resident missed 3 doses of Keppra [an anticonvulsant] and Latanoprost [eye drops to treat glaucoma and ocular hypertension] due to pending pharmacy delivery. Pharmacy was notified medications has been delivered. No seizure activities noted or any changes noted to resident. MD [Medical Doctor] and RR [Resident Representative] made aware
On 1/17/25 at 9:45 AM, an interview was conducted with the Director of Nursing (Staff #2). When asked if there was an incident report regarding the missed doses of Keppra and Latanoprost, Staff #2 stated that she would check facility records. At 11:15 AM, Staff provided this surveyor with an incident report that included 2 nurses who did not administer the Keppra and Latanoprost over 2 shifts. Staff at the time received education on how to order medication from pharmacy if not available in the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on record review and staff interviews, it was determined that the facility failed to ensure that physicians document that they reviewed the pharmacist's identified the irregularities and failed ...
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Based on record review and staff interviews, it was determined that the facility failed to ensure that physicians document that they reviewed the pharmacist's identified the irregularities and failed to ensure that physicians documented the action taken or not taken to address the irregularities. This was evident for 2 (Resident #38 and #51) out of 5 residents reviewed for unnecessary medications.
The findings include:
On 1/10/25 at 9:22 AM, a review of Resident #38 and #51's records was conducted. Resident #38 was ordered Trazodone, an antidepressant, to be given for Depression. According to records, there was a pharmacist review with recommendations to Resident #38's medication regimen on 9/20/24, 6/14/24, and 5/7/24. Resident #51 was ordered Sertraline, a Selective Serotonin Reuptake Inhibitor (used to treat depression), and Mirtazapine, an antidepressant.
On 1/9/25 at 9:25 AM, This surveyor requested the pharmacist medication recommendation for Resident #38 conducted on 9/20/24, 6/14/24, and 5/7/24; and requested pharmacist medication recommendation for Resident #51 conducted on 9/20/24 and 6/14/24 from the Director of Nursing (DON).
On 1/10/25 at 11:45 AM, an interview was conducted with the DON. The DON stated that the Physician failed to document that they reviewed the pharmacist's identified irregularities and failed to document the action taken or not taken to address the irregularities.
On 1/14/2025 at 12:46 PM, An interview was conducted with Medical Director (Staff #35). When asked what his expectations were for reviewing and implementing changes to the medication regimen after a pharmacist reviews and/or recommends changes, Staff #35 stated that this should be done in a timely fashion. When asked what a reasonable time is, Staff #35 stated that within a week or so is a reasonable amount of time. Providers are in the building weekly so they should be reviewing the pharmacy reviews on their visits. The nursing staff will also be called and notified, and providers can give verbal orders for the recommendations. When asked where the providers can document that the pharmacist reviews were reviewed; Staff #33 stated that if the doctor did not agree with the pharmacist recommendation, Staff #33 doesn't know that there is a specific place where they would document it. When asked that if a MD does not document rationale, how is the facility to know that the recommendation was just not ignored vs not agreed with; Staff #33 stated, I do see the sheets that are printed with the recommendation and decision made.
On 1/15/25 at 10:15 AM, an interview was conducted with Staff #33. When asked how the providers in the facility review the pharmacist review of each resident's medication regimen, Staff #33 stated the DON sends the recommendations to the providers to review them. Once reviewed there is a PDF document from the pharmacy that the providers document whether they agree or disagree with their recommendations. The provider would then sign the document and send it to the DON for follow-up. When asked if this document is placed in the residents' hard chart or uploaded to the residents' electronic chart or is the review documented in the resident's chart; Staff #33 stated that if a change is recommended and agreed on, they will add or change the orders and write notes to coincide, but if no changes then no notes or documentation would be made in the resident's chart.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication. This was found...
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Based on medical record review and staff interview, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication. This was found evident in 1 (Resident #1) out of 8 residents reviewed for medications.
The findings include:
On 1/8/25 at 8:49 AM, the surveyor interviewed Resident #1. During the interview Resident #1 expressed that he/she was not getting the correct doses of medications.
On 1/13/25 at 9:45 AM, the surveyor reviewed the May 2024 Medication Administration Record. On May 1st, 2nd, 3rd, and 4th it was documented that Resident #1 received 88 micrograms of levothyroxine Sodium (a medication used to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone) at 6:30 AM. On further review it was noted an additional dose of Levothyroxine Sodium 88 micrograms was given on May 1st, 2nd, 3rd, and 4th at 9 AM, the combined dose was 188 micrograms for those 4 days.
On 1/14/25 at 1:20 PM, the surveyor interviewed the Director of Nursing (DON). During the interview the surveyor asked if Resident #1 was intended to get two different administrations of the same medication, levothyroxine May 1st-4th. The DON confirmed that the two administrations were given in error and education would be provided to the staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0776
(Tag F0776)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, it was determined that the facility failed to ensure that radiology services were set up to meet the resident's needs and scheduled in a timely manner. This...
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Based on record review and staff interview, it was determined that the facility failed to ensure that radiology services were set up to meet the resident's needs and scheduled in a timely manner. This was evident for 1 (Resident #88) out of 1 resident reviewed for radiology services.
The findings include:
On 1/21/25 at 10:30 AM, a review of Complaint #MD00199976 was conducted. The complaint stated that Resident #88's discharge was delayed due to poor coordination of staff to plan transportation and appointments prior to discharge.
On 1/22/25 at 10:36 AM, a review of Resident #88's progress notes were conducted. According to physicians and nursing notes, the resident had complained of left knee pain on 10/10/23. An Xray was completed on 10/10/23 to rule out a fracture, and the Xray did not show any signs of fractures but did show left knee joint effusion. On 10/13/23, a physician's note stated that the resident would need an orthopedic surgery consultation. After the orthopedic surgery consult appointment on 10/23/23, an ultrasound of the knee was ordered for 11/20/23. On 11/7/23, an Magnetic Resonance Imaging (MRI) of the knee was ordered for 11/20/23. On 11/20/23, the ultrasound and MRI were not done due to improper sling on the resident's wheelchair. The rescheduled appointment for MRI and ultrasound was set for 12/1/23. On a nursing note on 11/30/23, the resident's MRI and ultrasound was canceled because the Doctor had an order in place stating the resident would not be able to tolerate an MRI and the radiology provider stated they do not offer ultrasounds as a service. On 12/8/23, nursing noted that they are still looking to create an appointment for the resident's ultrasound. On 12/11/23, the MRI was conducted.
On 1/21/25 at 9:50 AM, an interview with Staff #32 was conducted. When asked when they review orders for transportation how do you know the type of transportation needed for a resident, they stated that they will verbally communicate with the unit managers to find out what the needs for the resident are. When asked if it is their expectation that the information provided by the unit managers is accurate, Staff #32 stated, yes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview it was determined that the facility failed to maintain accurate orders in a resident's medical record. This was evident for 1 (Resident #380) of 52 r...
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Based on observation, record review, and interview it was determined that the facility failed to maintain accurate orders in a resident's medical record. This was evident for 1 (Resident #380) of 52 residents reviewed during the annual survey.
The findings include:
Medical records must be maintained for accuracy in a manner that is consistent with resident's needs, medical history and physical.
On 1/08/25 at 9:30 AM, surveyors observed Resident #380 in bed with bilateral below the knee amputations (BKA).
On 1/15/25 at 9 AM the surveyor conducted a record review which revealed a history and physical progress note dated 1/05/25 that stated the resident was admitted to the facility with bilateral BKAs.
Further review of the medical record showed an active physician's order to Float heels when in bed as tolerated every shift for Preventative Skin Measures. Review of the treatment administration record revealed that facility staff documented this order as performed three times daily from 1/03/25-1/14/25.
On 1/15/25 at 09:54 AM surveyors and a licensed practical nurse (LPN), LPN #19, reviewed Resident #380's treatment administration record. Surveyors asked LPN #19 if the order to float heels was accurate. LPN #19 disagreed and stated, no it is not accurate Resident #380 does not have heels. The surveyors asked LPN #19 if the order will remain in the resident's chart and LPN #19 replied no, the order will be discontinued immediately.
During exit conference on 1/22/25 at 2 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were made aware of the concern that the medical record was inaccurate.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observations and interviews it was determined that the facility failed to provide a safe, functional sanitary environment for a resident. This was found in 1 of 18 resident rooms reviewed in ...
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Based on observations and interviews it was determined that the facility failed to provide a safe, functional sanitary environment for a resident. This was found in 1 of 18 resident rooms reviewed in the initial sample.
The findings include:
On 1/8/25 at 8:37 AM, the surveyor conducted an interview with Resident #1. During the interview Resident #1 stated that the floors were not cleaned regularly in the back corner of his/her room due to a fall mat that ran alongside the bed. The surveyor observed debris on the floor at the back wall at the end of the fall mat. On further observation the surveyor observed a dark substance noted on the privacy curtain that appeared to have been left by finger impression. Also noted was the ceiling tile removed from above the unoccupied bed in the room, chair rail falling down from behind Resident #1's bed, the edge of the foot board sticking out, the top drawer to Resident #1's bedside night stand falling out when pulled out and a brown staining along the side of Resident #1's toilet.
On 1/9/25 at approximately 12:30 PM, the surveyor observed the same conditions in Resident #1's room.
On 1/9/25 at 12:44 PM, the surveyor conducted an interview with Licensed Practical Nurse (LPN) #4 and she confirmed the rooms were cleaned earlier in the morning. The surveyor showed LPN #4 the concerns noted in Resident #1's room. She stated she would address the issues.
On 1/10/25 at 9:38 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the interview the NHA stated that the facility was working on fixing the identified concerns.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
Based on record review and interviews it was determined that the facility failed to have an effective pest control program. This was found evident on 1 of 3 floors.
The findings include:
On 1/8/25 at ...
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Based on record review and interviews it was determined that the facility failed to have an effective pest control program. This was found evident on 1 of 3 floors.
The findings include:
On 1/8/25 at 8:37 AM, the surveyor conducted an interview with Resident #1. During the interview Resident #1 reported that he/she had observed cockroaches in his/her drawer a few months back and the facility had to have someone come in to take care of them.
On 1/10/25 at 9:38 AM, the surveyor interviewed the Nursing Home Administrator (NHA). During the interview the NHA confirmed that in late October or November an exterminator came to the facility to treat rooms for cockroaches. The surveyor asked for the facility's pest management log and reports.
On 1/13/25 at 10:59 AM, during an interview with Resident #29's family member it was reported that the family member saw a cockroach in their father/mother's room.
On review of the documents provided by the NHA, a Special Service Record was given and the description on the forms stated, this form [should be used] to reported problems which occur between routine scheduled service visits. The form had serviced dates of 9/16/24, 10/10/24, 10/28/24, 11/4/24, 12/2/24, and 12/17/24. 5 out of the 6 dates mentioned roaches as the problem. Additionally, the NHA gave a special agreement document, without a date or signature, that described treatment as, roach flashout service for 48 rooms with 5 times service. No additional documents were provided.
On 1/15/25 at 11:44 PM, the surveyor conducted an interview with the NHA. During the interview the NHA stated he had no additional documentation of the routine pest control visits. He confirmed that he was unaware of additional reports or as to what was completed, found or recommended the facility should do after or between each visit.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Maryland facilities.
- • 40% turnover. Below Maryland's 48% average. Good staff retention means consistent care.
Concerns
- • 21 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.
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About This Facility
What is Sterling Care Rockville Nursing's CMS Rating?
CMS assigns STERLING CARE ROCKVILLE NURSING an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Maryland, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Sterling Care Rockville Nursing Staffed?
CMS rates STERLING CARE ROCKVILLE NURSING's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 40%, compared to the Maryland average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Sterling Care Rockville Nursing?
State health inspectors documented 21 deficiencies at STERLING CARE ROCKVILLE NURSING during 2025. These included: 21 with potential for harm.
Who Owns and Operates Sterling Care Rockville Nursing?
STERLING CARE ROCKVILLE NURSING is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by STERLING CARE, a chain that manages multiple nursing homes. With 100 certified beds and approximately 88 residents (about 88% occupancy), it is a mid-sized facility located in ROCKVILLE, Maryland.
How Does Sterling Care Rockville Nursing Compare to Other Maryland Nursing Homes?
Compared to the 100 nursing homes in Maryland, STERLING CARE ROCKVILLE NURSING's overall rating (4 stars) is above the state average of 3.0, staff turnover (40%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Sterling Care Rockville Nursing?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Sterling Care Rockville Nursing Safe?
Based on CMS inspection data, STERLING CARE ROCKVILLE NURSING has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Maryland. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Sterling Care Rockville Nursing Stick Around?
STERLING CARE ROCKVILLE NURSING has a staff turnover rate of 40%, which is about average for Maryland nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Sterling Care Rockville Nursing Ever Fined?
STERLING CARE ROCKVILLE NURSING has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Sterling Care Rockville Nursing on Any Federal Watch List?
STERLING CARE ROCKVILLE NURSING is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.