A list of the most recent deficiencies for Complete Care at Severna Park LLC. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-17 | 2023-12-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-17 | 2023-12-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-17 | 2023-12-25 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-17 | 2023-12-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-17 | 2023-12-25 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-17 | 2023-12-25 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-17 | 2023-12-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-17 | 2023-12-25 | 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 | 2021-07-26 | 2021-09-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-07-26 | 2021-09-10 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-07-26 | 2021-09-10 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-07-26 | 2021-09-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-07-26 | 2021-09-10 | 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 | 2021-07-26 | 2021-09-10 | N |
| Provide activities to meet all resident's needs. | Health | 2021-07-26 | 2021-09-10 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-07-26 | 2021-09-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-07-26 | 2021-09-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-07-26 | 2021-09-10 | N |
| Post nurse staffing information every day. | Health | 2021-07-26 | 2021-09-10 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-07-26 | 2021-09-10 | 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 | 2021-07-26 | 2021-09-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-26 | 2021-09-10 | 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 | 2021-07-26 | 2021-09-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-26 | 2021-09-10 | N |
| Keep all essential equipment working safely. | Health | 2021-07-26 | 2021-09-10 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2021-07-26 | 2021-09-10 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-07-26 | 2021-09-10 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-26 | 2021-09-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-26 | 2021-09-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-26 | 2021-09-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-26 | 2021-09-10 | 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 | 2021-07-13 | 2021-08-20 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-07-13 | 2021-08-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-07-13 | 2021-08-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-13 | 2021-08-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-13 | 2021-08-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-13 | 2021-08-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-13 | 2021-08-20 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-08-22 | 2018-10-01 | 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 | 2018-08-22 | 2018-10-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-22 | 2018-10-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-22 | 2018-10-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-22 | 2018-10-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-22 | 2018-10-01 | N |
| 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 | 2018-08-23 | 2018-09-10 | 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 | 2018-08-23 | 2018-09-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-08-23 | 2018-09-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-23 | 2018-09-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-05-18 | 2017-07-15 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-05-18 | 2017-07-15 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-05-18 | 2017-07-15 | N |
| Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2017-05-18 | 2017-07-15 | N |
| Provide housekeeping and maintenance services. | Health | 2017-05-18 | 2017-07-15 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-05-18 | 2017-07-15 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-05-18 | 2017-07-15 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-05-18 | 2017-07-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-05-11 | 2017-07-07 | 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 | 2017-05-11 | 2017-07-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-05-11 | 2017-07-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-05-11 | 2017-07-07 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2017-05-11 | 2017-07-07 | N |
