Complete Care at Annapolis

In the surveyor’s words

From the most serious findings on record at Complete Care at Annapolis, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Apr 7, 2021

  Based on medical record review, the review of pertinent records from a local hospital and emergency services provider, interviews with current and former staff, and interview with residents' attending physician, it was determined that the facility failed to: 1.) Ensure the expressed wishes of Resident #1 were clearly communicated to emergency services personnel on [DATE], the day the resident became unresponsive and unable to communicate said wishes; and 2.) Ensure residents' expressed wishes for life sustaining treatment were obtained and documented in a manner that involved the resident or the resident's representative. This was evidence for 3 of 21 resident reviewed during the revisit survey (Residents #1, #3, and #14). […]

• Immediate jeopardy, isolatedF689Apr 7, 2021

  Based on facility investigation documentation and medical records; observations and interviews, it was determined the facility failed to have an effective system in place to prevent residents with cognitive impairment from leaving the facility without appropriate supervision. More specifically, the facility failed to 1) Provide adequate supervision to prevent a resident with known wandering and exit seeking behaviors from exiting the facility unsupervised on 7/19/20, 2) Provide adequate supervision to prevent the same resident from exiting the facility nine weeks later on 9/21/20, 3) Ensure all staff have been trained on how to check the functionality of the wander guard bracelets and how to obtain a new bracelet or replacement bracelet when necessary, 4) Educate all staff on the location… […]

• No harm, potential for more than minimal, widespreadF835Apr 7, 2021

  Based on review of medical records and other pertinent documentation and staff interviews, it was determined that the facility failed to conduct oversight of their social worker regarding the use of presigned Medical Orders for Life-Sustaining Treatment (MOLST) forms. This failure allowed the facility's social worker to complete presigned MOLST forms without speaking with the resident, the resident's family, or the resident's physician regarding end of life wishes. This was evidence for 3 of 21 resident reviewed during the revisit survey (Residents #1, #3, and #14). The facility's action and lack of oversight placed residents at risk of suffering injury if cardiopulmonary resuscitation (CPR) was initiated by following Physician #27 and Social Worker #23 MOLST orders. […]

• No harm, potential for more than minimal, widespreadF842Apr 7, 2021

  Based on medical record review and interview, it was determined the facility staff failed to maintain a medical record in the most accurate form. This was evident for 5 of 25 residents reviewed in the complaint survey but affected all residents in the facility (Resident #12, #6 #9, #24, and #25). The findings include: 1) On [DATE] a review of Resident #12's medical record revealed the resident was discharged from the facility on [DATE]. On [DATE], eight (8) days after discharge a Coronavirus Pre-Assessment was completed on Resident #12 and recorded in the medical record. The assessment included Resident #12's temperature, taken on [DATE] at 7:36 AM, and recorded as 97.7 degrees. The inaccurate medical record assessment was confirmed with the Administrator on [DATE] at 1:11 PM. […]

• No harm, potential for more than minimal, patternF568Mar 10, 2026

  Based on record review, interview with residents, and the facility staff, it was determined that the facility failed to ensure that quarterly resident fund account statements were provided to residents. This was evident for four residents (Residents #86, # 1, #3 and #47) out of five residents reviewed for personal funds during the facility's recertification survey.The findings include:On 03/06/2026 at 7:45 AM, during the initial tour of the facility, some residents provided statements regarding quarterly statement of account as follows.On 03/03/2026 at 9:09 AM, Resident #86 stated that he/she did not receive a quarterly statement.On 03/03/2026 at 9:42 AM, Resident#1 stated that he/she had an account with the facility but had never received statements and requested that statements be… […]