Sterling Care Rockville Nursing

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,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.