A list of the most recent deficiencies for Complete Care at Annapolis. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-04-07 | 2021-06-30 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-04-07 | 2021-06-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-07 | 2021-06-30 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-04-07 | 2021-06-03 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-04-07 | 2021-06-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-07 | 2021-06-03 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-04-07 | 2021-06-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-07 | 2021-06-03 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-04-07 | 2021-06-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-07 | 2021-06-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-07 | 2021-06-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-07 | 2021-06-03 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2021-04-07 | 2021-06-03 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-04-07 | 2021-06-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-07 | 2021-06-03 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-11-22 | 2020-01-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-11-22 | 2020-01-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-22 | 2020-01-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-11-22 | 2020-01-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-22 | 2020-01-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-22 | 2020-01-30 | N |
| Respond appropriately to all alleged violations. | Health | 2019-11-14 | 2020-01-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-11-14 | 2020-01-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-14 | 2020-01-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-11-14 | 2020-01-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-14 | 2020-01-10 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-11-14 | 2020-01-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-11-14 | 2020-01-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-11-14 | 2020-01-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-11-14 | 2020-01-10 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-11-14 | 2020-01-10 | N |
| Provide or obtain dental services for each resident. | Health | 2019-11-14 | 2020-01-10 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2019-11-14 | 2020-01-10 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-11-14 | 2020-01-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-14 | 2020-01-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-07-27 | 2018-09-14 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-07-27 | 2018-09-14 | N |
| Respond appropriately to all alleged violations. | Health | 2018-07-27 | 2018-09-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-07-27 | 2018-09-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-07-27 | 2018-09-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-07-27 | 2018-09-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-27 | 2018-09-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-07-27 | 2018-09-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-27 | 2018-09-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-07-27 | 2018-09-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-08-07 | 2018-08-22 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-08-07 | 2018-08-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-08-07 | 2018-08-20 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2018-08-07 | 2018-08-20 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2018-08-07 | 2018-08-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-04-06 | 2017-04-24 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-04-10 | 2017-04-16 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-04-10 | 2017-04-16 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-04-10 | 2017-04-16 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-04-10 | 2017-04-16 | N |
