Deficiencies (last 4 years)
Deficiencies (over 4 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% better than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 6
Dec 19, 2025
Visit Reason
The inspection was conducted based on complaints regarding medication administration errors, pharmaceutical service deficiencies, medication error rates, medication labeling, call light system failures, and unsafe, unsanitary, and uncomfortable living conditions in the facility.
Findings
The facility failed to provide medication administration that met professional standards for multiple residents, resulting in medication errors and unlabeled insulin pens. The medication error rate was 11%, exceeding the acceptable threshold. The call light system was nonfunctional in several resident rooms, and the facility failed to maintain a safe, sanitary, and comfortable environment, including unresolved plumbing issues and unsanitary resident rooms.
Complaint Details
The complaint investigation was triggered by allegations of medication administration errors, pharmaceutical service deficiencies, high medication error rates, unlabeled medication storage, nonfunctional call light systems, and unsanitary and unsafe living conditions affecting multiple residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide medication administration meeting professional standards for 5 of 8 sampled residents, including improper use of insulin syringes with insulin pens and unlabeled insulin pens. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer medications as ordered for 3 of 8 sampled residents, including missed doses and unavailable medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain medication error rates below 5%, with 5 errors out of 43 opportunities (11% error rate). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to label opened insulin pens with patient name, physician name, and date used for 1 of 3 medication carts reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a working call system in each resident's bathroom and bathing area for three residents; multiple call lights were broken and not repaired. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a safe, clean, comfortable, and sanitary environment for three residents, including failure to replace damaged and leaking commode toilets and failure to maintain sanitary conditions in resident rooms. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication errors observed: 5
Residents affected by medication administration deficiency: 5
Residents affected by pharmaceutical services deficiency: 3
Residents affected by call light deficiency: 3
Facility census: 78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Nurse #6 | Observed using insulin syringes to extract insulin from insulin pens and administering insulin without proper labeling. | |
| Staff Nurse #5 | Observed failing to administer prescribed medication Biofreeze to Resident #23. | |
| Staff Nurse #11 | Observed failing to administer multiple medications to Residents #28, #29, and #30 and improper medication handling. | |
| Staff Nurse #23 | Confirmed use of insulin syringes to extract insulin from pens due to lack of proper needles. | |
| Staff Nurse #13 | Reported being trained to use insulin syringes for insulin pens and confirmed ongoing improper practice. | |
| Pharmacist | Confirmed that insulin syringes should not be used with insulin pens and that medications should be administered as ordered. | |
| Director of Nursing (DON) | Director of Nursing | Acknowledged medication administration deficiencies and lack of awareness of improper insulin syringe use; stated nurses will be retrained. |
| Maintenance Director (MD) 17 | Maintenance Director | Acknowledged call light system issues and plumbing problems affecting resident bathrooms. |
| Housekeeping Director (HKD) 18 | Housekeeping Director | Reported unsanitary conditions in resident rooms and bathrooms and ongoing efforts to clean and maintain environment. |
| Administrator | Administrator | Acknowledged some facility issues and stated plans for monitoring and repair. |
Inspection Report
Annual Inspection
Deficiencies: 3
Mar 14, 2025
Visit Reason
The inspection was conducted as part of an annual and complaint survey to evaluate compliance with care planning, medication administration, and dietary services at the facility.
Findings
The facility failed to develop and implement a comprehensive care plan for a resident with hearing and vision deficits, failed to ensure medications were administered as ordered to multiple residents, and failed to honor a resident's food preferences.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to develop and implement a complete care plan that meets all the resident's needs, specifically for hearing and vision deficits for Resident #85. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medications were administered as ordered, including delayed administration and missing medications for 6 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide each resident with a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, including failure to honor food preferences for Resident #9. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for care planning: 19
Residents affected by care plan deficiency: 1
Residents reviewed for medication regimen: 14
Residents affected by medication administration deficiency: 6
Residents reviewed for food/nutrition: 38
Residents affected by food preference deficiency: 1
Medication administration delay: 60
Medication administration delay: 33
Medication doses missed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #14 | Licensed Practical Nurse | Observed preparing and administering medications late and missing medications for Residents #77 and #7 |
| LPN #15 | Licensed Practical Nurse | Observed preparing medication for Resident #38 |
| LPN #13 | Licensed Practical Nurse | Interviewed regarding failure to flush Resident #38's tube with water after medication administration |
| RN #19 | Registered Nurse | Observed preparing and administering medications late and missing medications for Resident #48 |
| LPN #16 | Licensed Practical Nurse | Interviewed and observed preparing and administering medications late and missing medications for Resident #90 |
| Acting Director of Nursing | Director of Nursing | Interviewed regarding care plan deficiencies and medication administration issues |
| Administrator | Administrator | Interviewed regarding food preference deficiency |
| Kitchen Manager | Kitchen Manager | Acknowledged error in food service related to Resident #4's meal |
Inspection Report
Routine
Deficiencies: 5
Dec 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations related to abuse reporting, investigation of neglect allegations, pressure ulcer care, fall prevention, and medical record maintenance at Complete Care at Springbrook.
Findings
The facility failed to timely report abuse allegations for three residents, did not conduct thorough investigations into neglect allegations, failed to provide appropriate pressure ulcer care for two residents, failed to consistently implement physician-ordered bed rails for one resident, and failed to maintain complete medical records for two discharged residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to timely report allegations of abuse for Residents #13, #27, and #32 within the required timeframe. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct a thorough investigation into an allegation of neglect for Resident #13 by not interviewing staff assigned to care for the resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure necessary treatment and services were provided to promote healing of pressure ulcers for Residents #3 and #21, including failure to complete weekly wound assessments and provide wound treatments as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a physician-ordered intervention for bed rails was consistently implemented to assist Resident #4 with safe bed mobility and minimize fall risk. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the complete medical record was retained for a minimum of five years from the date of discharge for Residents #33 and #34. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for abuse allegations: 19
Residents reviewed for pressure ulcers: 13
Residents reviewed for falls: 5
Residents whose medical records were reviewed: 45
Residents affected by abuse reporting deficiency: 3
Residents affected by neglect investigation deficiency: 1
Residents affected by pressure ulcer care deficiency: 2
Residents affected by bed rail deficiency: 1
Residents affected by medical record retention deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator (ADM) | Named in relation to late abuse reporting and bed rail implementation. |
| Director of Nursing | Director of Nursing (DON) | Named in relation to abuse reporting, neglect investigation, wound care oversight, and bed rail implementation. |
| RN #17 | Registered Nurse | Named in relation to wound care for Resident #21. |
| Geriatric Nurse Aide #13 | Geriatric Nurse Aide | Named in relation to wound care for Resident #21. |
| Wound Nurse Practitioner #38 | Wound Nurse Practitioner | Named in relation to wound care consultation. |
| Medical Director #31 | Medical Director | Named in relation to wound care orders. |
| RN #21 | Registered Nurse | Named in relation to wound care and wound NP rounding. |
| LPN #6 | Licensed Practical Nurse | Named in relation to wound care and wound assessment. |
| LPN #12 | Licensed Practical Nurse | Named in relation to wound care for Resident #3. |
| Primary care NP #32 | Primary Care Nurse Practitioner | Named in relation to wound care oversight. |
| LPN #39 | Licensed Practical Nurse | Named in relation to wound care documentation. |
| LPN #20 | Licensed Practical Nurse | Named in relation to bed rail documentation. |
| RN #36 | Registered Nurse | Named in relation to bed rail ordering and documentation. |
| Maintenance Director | Maintenance Director | Named in relation to bed replacement and bed rail installation. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Named in relation to bed rail consent and installation. |
| Director of Rehabilitation | Director of Rehabilitation (DOR) | Named in relation to therapy records for Resident #34. |
Inspection Report
Annual Inspection
Deficiencies: 7
Sep 16, 2020
Visit Reason
The inspection was conducted as part of the annual survey of Complete Care at Springbrook nursing home to assess compliance with regulatory standards and quality of care.
Findings
The facility was found deficient in multiple areas including failure to safeguard residents' medical information, failure to assist residents in filing grievances, failure to meet professional standards of care, failure to follow physician orders for medication administration, failure to provide appropriate care to maintain range of motion, failure to label and store drugs and biologicals properly, and failure to implement adequate infection prevention and control practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to safeguard the disclosure of medical information for 1 resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assist resident to file a grievance on missing personal belonging. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to meet professional standards of care related to medication reconciliation and communication with psychiatrist. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow physician order to administer insulin medication as prescribed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate care to maintain and/or improve range of motion by not applying prescribed splints. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to label drugs and biologicals properly and stored expired medications and supplies. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement infection prevention and control practices including improper storage and changing of oxygen and nebulizer tubing and improper sterile technique during central venous catheter dressing change. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 25
Residents affected: 1
Medication storage room inspected: 1
Expired syringes: 100
Expired phlebotomy tubes: 3
Phlebotomy tubes per case: 50
Additional expired red top tubes: 6
Expired purple tubes: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse | Named in failure to assist resident to file grievance and failure to communicate medication status with psychiatrist |
| LPN #5 | Licensed Practical Nurse | Named in failure to administer insulin and improper sterile technique during central venous catheter dressing change |
| LPN #6 | Licensed Practical Nurse | Named in failure to administer insulin |
| Staff #3 | Acknowledged improper posting of resident medical information | |
| Staff #2 | Pinned medical information poster in wrong room | |
| Staff #8 | Failed to apply prescribed splints for resident | |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding findings |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding infection control practices |
Inspection Report
Complaint Investigation
Deficiencies: 8
Sep 12, 2019
Visit Reason
The inspection was conducted to investigate complaints and review compliance with regulatory requirements related to resident care, medication administration, care planning, respiratory care, and documentation at Complete Care at Springbrook.
Findings
The facility was found deficient in multiple areas including failure to timely notify responsible parties of Medicare non-coverage, incomplete care plans, failure to conduct timely interdisciplinary care conferences, improper medication administration practices, failure to follow physician orders, lack of current physician orders for oxygen use, and inaccurate documentation of responsible parties.
Complaint Details
The visit was complaint-related, triggered by allegations concerning failure to provide timely Medicare non-coverage notices, incomplete care plans, medication administration errors, failure to follow physician orders, and inadequate respiratory care. Substantiation status is not explicitly stated.
Severity Breakdown
Level of Harm - Potential for minimal harm: 2
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to provide resident #23's responsible party with Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage in a timely manner. | Level of Harm - Potential for minimal harm |
| Failed to develop a complete baseline care plan for resident #9 regarding medication use and monitoring. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop a comprehensive care plan specific to the use of psychotropic medication for resident #61. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct timely interdisciplinary care plan conferences after MDS assessments for residents #55, #20, and #21. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure nursing standards of practice during medication administration for residents #23 and #68. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow physician's orders for blood sugar monitoring and notification for resident #72. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure current physician's orders and respiratory assessments for oxygen use for residents #37 and #55. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately document resident #28's responsible party on the face sheet. | Level of Harm - Potential for minimal harm |
Report Facts
Residents selected for review: 25
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration finding for resident #23 |
| LPN #2 | Licensed Practical Nurse | Named in medication administration and documentation finding for resident #68 |
| Director of Nursing | Interviewed regarding multiple findings including medication administration, care planning, and respiratory care | |
| Director of Social Work | Interviewed regarding care plan conference scheduling | |
| Nurse Practitioner | Interviewed regarding blood sugar monitoring for resident #72 |
Inspection Report
Complaint Investigation
Deficiencies: 10
Mar 27, 2019
Visit Reason
The inspection was conducted based on a complaint investigation related to resident care, including issues with court appointed guardianship documentation, notification of rights, significant changes in care, and other care deficiencies.
Findings
The facility failed to maintain proper documentation of a court appointed guardian for resident #127, failed to notify the guardian of resident rights and significant care changes, failed to revise care plans timely for residents at risk of elopement, failed to provide adequate activities of daily living assistance, failed to maintain a safe environment preventing elopement, failed to provide timely behavioral health services, failed to reconcile controlled substance medications accurately, failed to label opened medications properly, and failed to coordinate outside professional services effectively.
Complaint Details
The complaint investigation focused on multiple issues including failure to document court appointed guardianship, failure to notify guardians of resident rights and significant changes, failure to revise care plans, failure to provide adequate care and supervision, medication management issues, and failure to coordinate outside professional services.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure documentation to verify a court appointed guardian was located in resident #127's clinical record. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify resident #127's court appointed guardian of the resident's rights and services including admission paperwork. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely notify resident #127's court appointed guardian of significant changes in care/treatment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to revise residents' care plans in a timely and accurate manner to reflect current clinical status for residents #54 and #76. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide activities of daily living to promote the dignity of resident #19. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a safe environment for resident #76, resulting in elopement and immediate jeopardy to resident health or safety. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to provide necessary behavioral health care services to resident #127 on a timely basis. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate reconciliation of a controlled substance medication for resident #25. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to label dates of opened medications and biologicals in accordance with professional principles. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to coordinate care of outside professional resources for residents #31 and #17. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents selected for Hospitalization care area review: 5
Residents selected for care plan review: 30
Residents reviewed for accidents: 13
Residents selected for Mood/Behavior care area review: 2
Medication carts selected for medication storage review: 4
Medication storage rooms selected for medication storage review: 2
Residents reviewed during survey: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| GNA #1 | Geriatric Nursing Assistant | Observed resident #76 outside the building unattended and reported to charge nurse. |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding various deficiencies including medication reconciliation and behavioral health services. |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided training to staff regarding elopement and leave of absence policy. |
| Social Services Manager | Social Services Manager | Unaware of resident #127's court appointed guardian until surveyor intervention; interviewed about behavioral health services. |
| Facility Administrator | Facility Administrator | Interviewed regarding court appointed guardian and behavioral health services. |
| Charge Nurse | Charge Nurse | Observed resident #76 last on 12-19-18 morning; unavailable for interview. |
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