Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Annapolis during CMS and state inspections, most recent first.
Failure to provide quarterly resident fund statements: several residents reported not receiving account statements for personal funds held by the facility. The BOM said statements were given monthly on request and quarterly otherwise, with signed acknowledgments kept, but record review found no proof that the affected residents received their statements. The NHA said statements were provided in person to capable residents and mailed or emailed to residents with responsible parties, but acknowledged the concern.
A deaf resident with a communication-sensory impairment had a VRI tablet available in the room and a posted sign indicating deafness, but staff primarily relied on written notes, facial expressions, and gestures instead of using the VRI system. The resident reported that written communication was not the preferred method and that staff rarely used the VRI device. When asked by surveyors, a GNA and an LPN were unable to obtain an interpreter through the VRI system because they did not know how to operate it, despite the DON’s stated expectation that VRI be used throughout the day for this resident.
Failure to timely revise and implement fall care plans affected two residents. One resident with a history of multiple falls had a post-fall care plan that included neuro-checks, but the DON stated there was no evidence they were completed, and the resident’s bed was observed in a high position despite fall-risk interventions. Another resident who had an unwitnessed fall, was on Plavix, and later reported a hip fracture had care plan revisions made 3 days after the fall, but the facility could not provide evidence that ordered neuro-checks were completed.
Failure to provide oral hygiene and showers to dependent residents. One resident required partial/moderate assist with oral care, had an ADL self-care deficit related to fatigue and tremors, and was documented as not receiving oral hygiene on multiple days despite the facility’s twice-daily protocol. Another resident with limited mobility and dependence for showers reported not having a shower for 5 weeks; records showed only one shower in the prior 30 days, despite a schedule for twice-weekly showers and a preference for shower vs bed bath.
Oxygen tubing was not dated or labeled for two residents receiving O2 via nasal cannula. One resident had continuous O2 for COPD and the other had O2 PRN for SOB; both had orders for weekly tubing and humidifier changes with labeling after each change. During observations, an LPN, RN, and DON confirmed the expectation that tubing should be changed weekly and dated.
Late Administration of Time-Sensitive Seizure Medications: A resident reported that seizure medications were being given late, and audit findings confirmed multiple late administrations of Levetiracetam and Lamotrigine by nursing staff. The DON reviewed the findings and confirmed that staff are expected to administer medications within a 1-hour window before to 1-hour after the due time.
Failure to Follow Resident Meal Preferences: Two residents were observed receiving meals that did not match their meal tickets. One resident was served regular portions despite a ticket for large portions, and the resident said this mismatch happened many times. Another resident was served peas and carrots even though the ticket specified green beans and no peas. The Food Director and staff confirmed the discrepancies, and the DON was notified of the meal preference concerns.
Food Storage and Labeling Deficiencies: During a kitchen tour, multiple food items were found without expiration dates, including non-perishable and perishable products, and several expired items were observed in storage. In the fridge, 6 containers of cooked foods lacked labels identifying the items and had no discard dates, despite the FSD stating that cooked foods should be labeled with the item name and use-by date.
The facility failed to report an elopement and an abuse allegation within the required timeframes. A resident with severe cognitive impairment eloped and was missing for a short period, but the incident was reported to the OHCQ much later than required. Additionally, an abuse allegation was reported to the State Agency several hours after it was made. The DON confirmed the reporting delays, and the staff involved are no longer employed at the facility.
Two residents with severe cognitive impairment eloped from the facility due to inadequate supervision. One resident left through a window, while another exited through a malfunctioning door. Both incidents occurred despite functioning wander guards and door alarms, highlighting a failure in monitoring and security measures.
The facility did not follow up on pharmacy recommendations for two residents, leading to delays in necessary evaluations and tests. One resident on Quetiapine did not receive an AIMS evaluation as recommended, and another on Atorvastatin did not have a fasting lipid panel conducted in a timely manner. The facility's process for addressing pharmacy recommendations was not effectively followed, resulting in these deficiencies.
A resident was transferred to the hospital for altered mental status, but the facility failed to provide written notification of the transfer reason to the resident and their representative. Staff confirmed that the reason was communicated verbally, but not documented in writing, and the transfer form was not mailed as the resident returned within 24 hours.
A facility failed to provide a resident and their representative with written notification of the bed-hold policy upon the resident's transfer to a hospital. Although the policy was included in the transfer packet sent to the hospital, it was not given to the resident or their representative. Interviews with LPNs and the DON confirmed the lack of written notification, and the DON could not find documentation to show that the policy was mailed to the resident's representative.
A facility failed to provide and document an activities program for a resident with physical limitations, as outlined in the care plan. The resident's care plan included music therapy and in-room activities, but there was no documentation of these activities in the electronic record. Interviews revealed inconsistencies in performing and documenting the activities, with the Activities Director admitting to lapses in maintaining records.
An LPN failed to instruct a resident with COPD to rinse their mouth after administering Trelegy inhalation, as per the physician's order. This oversight was identified during a medication observation, and the Director of Nursing confirmed the error.
A facility failed to provide necessary respiratory care for a resident with a tracheostomy by not implementing a physician's order for a speaking valve replacement. The resident reported that their Passy-Muir valve had not been changed since their arrival, despite having prescriptions from an ENT physician. The unit manager was aware of the prescriptions but believed the respiratory therapist would supply the equipment. The DON was unaware of the issue, and the Administrator only learned of the prescriptions on the survey day.
Failure to Provide Quarterly Resident Fund Statements
Penalty
Summary
The facility failed to ensure that quarterly resident fund account statements were provided to residents for personal money deposited with the nursing home. During resident interviews, four residents stated they did not receive statements or did not always receive them: one resident said he or she did not receive a quarterly statement, another said he or she had an account but had never received statements and requested them, a third said he or she had never received a statement of account, and a fourth said he or she did not always receive quarterly fund statements. The Business Office Manager stated that statements were given monthly to residents who requested them and quarterly to all other residents, and that a binder was maintained to document distribution. She later stated that residents or responsible parties were to sign a copy of the receipt as acknowledgment of receiving the statement. Review of the statements for the residents who reported not receiving them did not show acknowledgments that the statements had been received, and the Business Office Manager confirmed there was no evidence that those residents had received the quarterly statements. The Nursing Home Administrator stated that statements were provided in person to capable residents and mailed or emailed to residents with responsible parties quarterly or per request, with acknowledged copies kept, and acknowledged the concern when informed of the issue.
Failure to Utilize Video Remote Interpreting for Deaf Resident
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to utilize Video Remote Interpreting (VRI) services for a deaf resident with communication-sensory impairment. A sign outside the resident’s room indicated the resident was deaf, and a VRI tablet was present in the room. Multiple staff members, including two geriatric nurse assistants and an LPN, reported that they communicated with the resident primarily through written communication, facial expressions, and gestures. The resident stated that written communication was not their preferred method of communication and reported that staff rarely used the VRI tablet. Further observations and interviews showed that staff were not effectively using the VRI system despite the facility’s expectation that it be used throughout the day during care for this resident. When the surveyor asked a geriatric nurse assistant and an LPN to obtain an interpreter through the VRI system, both were unable to do so because they did not know how to use it. The DON confirmed that the expectation was for staff to use the VRI system for this resident, and the Assistant DON acknowledged understanding of the concern when it was presented. These findings demonstrate that the resident’s preferred communication method via VRI was not being implemented in practice.
Failure to Timely Revise and Implement Fall Care Plans
Penalty
Summary
The facility failed to revise residents’ care plans in a timely manner and failed to implement care plan interventions for 2 residents reviewed for falls. Resident #93 had an actual fall on 1/13/2025 and was identified in the care plan as high risk for falls related to deconditioning and a history of multiple falls. The care plan included neuro-checks, but when the facility was asked for evidence that the checks were completed, the DON stated there was no evidence they were done. During interviews and observations, Resident #93’s bed was noted to be in a high position, and the DON stated the care plan revisions should have included keeping the bed in the lowest position with the wheels locked. Resident #8 reported falling off the bed in January 2026, fracturing a hip, and being sent to the hospital. The medical record showed an unwitnessed fall on 1/6/2026, and the resident was taking Plavix. The care plan was revised 3 days after the fall and stated to continue at-risk plans and perform neuro-checks per facility policy, but the facility could not provide evidence that the neuro-checks were completed. The DON stated that after a resident fall, a post-fall assessment, updated care plan, vital signs, and neurological assessment should be completed per facility protocol, and acknowledged that the care plan revisions for Resident #8 were not revised in a timely manner.
Failure to Provide Oral Hygiene and Showers to Dependent Residents
Penalty
Summary
The facility failed to provide oral hygiene care and showers to dependent residents. Resident #93 reported that no one at the facility cleaned their teeth and that a family member came in once a week to assist with oral hygiene. The resident’s MDS Section GG indicated partial/moderate assistance was required for oral hygiene, and the care plan identified an ADL self-care deficit related to fatigue and tremors to the upper extremities, with extensive assistance needed to maximize independence. The resident also stated during follow-up that they had not received oral care in the morning. Review of the electronic record showed several oral hygiene task entries marked not applicable, and the DON stated she was not aware what that meant. The DON later stated the facility protocol was to provide oral hygiene twice daily, but the resident’s documentation showed 7 of 30 days without oral care per protocol. Resident #86 reported not having had a shower for the last 5 weeks and said they would like showers more often if given the opportunity. The resident’s care plan identified a self-care performance deficit related to limited mobility and stated the resident was totally dependent on staff to provide showers on preferred days. The shower schedule showed showers were to be provided on Mondays and Thursdays, and the MDS Section GG coded the resident as requiring partial/moderate assistance for showers. Facility shower records from the prior 30 days showed the resident showered only once. A staff member confirmed that GNAs were responsible for offering and providing showers and stated she had not given the resident a shower or assisted with one during the last 30 days.
Oxygen Tubing Not Dated or Labeled
Penalty
Summary
The facility failed to ensure that oxygen administration equipment was dated and labeled after being changed in accordance with physician orders and facility expectations. During the initial tour, Resident #109 was observed eating breakfast in bed while receiving oxygen at 2 LPM via nasal cannula, and the tubing had no date or label. Resident #20 was also observed in bed preparing to eat breakfast while receiving oxygen at approximately 1.8 LPM via nasal cannula, and that tubing also had no date or label. Review of physician orders showed that Resident #20 had an order for oxygen at 2 L/min via nasal cannula as needed for shortness of breath, with the humidifier bottle and tubing to be changed weekly and as needed if visibly soiled, and each component labeled with the date and staff initials, scheduled every Sunday on the night shift. Resident #109 had an order for oxygen at 2 L/min via nasal cannula continuously for COPD, with the humidifier bottle and tubing to be changed weekly and each component labeled with the date and staff initials, scheduled every Sunday on the night shift. Follow-up observations showed Resident #109's tubing still without a date or label, and Resident #20's tubing also remained without a date or label. An LPN and an RN stated that oxygen tubing should be changed weekly and dated, and the DON stated that tubing should be changed weekly on Sundays and dated after each change.
Late Administration of Time-Sensitive Seizure Medications
Penalty
Summary
The facility failed to administer time-sensitive seizure medications on time for Resident #108. During an interview on 3/03/2026, the resident stated that staff had been giving seizure medications late. A review of the Medication Administration Audit on 3/10/2026 showed that Levetiracetam 1000 mg, ordered for 9:00 PM on 3/1/2026, was administered at 9:24 AM on 3/2/2026 by Staff #26. The audit also showed that Lamotrigine 150 mg, ordered for 5:00 PM on 3/6/2026, was administered at 8:25 PM the same day by Staff #27. The audit further showed that Levetiracetam 1000 mg, ordered for 9:00 PM on 3/7/2026, was administered at 10:15 PM by Staff #18. The report states that Lamotrigine is a time-sensitive medication requiring strict adherence to a specific dosing and titration schedule to maintain safety and efficacy, and that timely administration of Levetiracetam is medically critical because of its relatively short half-life and the high risk of breakthrough seizures associated with inconsistent blood levels. The DON was informed of the resident’s concern and the audit findings and confirmed them, stating that nursing staff are expected to give medications within a 1-hour window before to 1-hour after the due time.
Failure to Follow Resident Meal Preferences
Penalty
Summary
The facility failed to provide food in accordance with resident preferences for 2 of 4 residents reviewed during the dining observation. Resident #8 was observed at lunch receiving regular portions even though the meal ticket indicated large portions. During a brief interview, the resident stated that the meal ticket did not match what was served and said this happened "so many times." The Food Director reviewed the meal portions and confirmed that the portions served were regular and not large as indicated on the ticket. Resident #39 was observed at lunch receiving peas and carrots even though the meal ticket stated to serve green beans and not to serve peas. The resident reported not eating the peas and carrots. Staff confirmed that Resident #39 was not served green beans and also confirmed that the meal ticket indicated the resident should not be served peas. The Food Director stated that updating resident meal preferences was the dietician's responsibility and that if a resident had a pattern of refusing certain meals or portions, the facility expected the meal preferences to be honored and the meal tickets updated as soon as possible.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store food products in accordance with professional standards for food safety during an initial kitchen tour. In the kitchen storage areas, a Turkey Gravy Mix was observed without an expiration date, although the received date of 2/23/2026 was printed on it. Other non-perishable items without expiration dates included a bottle of maple syrup, and perishable items without expiration dates included a bag of frozen corn dogs, a bag of frozen meatballs, and a container of garlic. Expired items were also found, including 4 bags of bread rolls with an expiration date of 2/26/2026, a bottle of Teriyaki sauce with an expiration date of November 2025, and a container of peeled boiled eggs with an expiration date of 2/26/2026. During the fridge tour, 6 containers of cooked foods were observed without labels identifying the items and without dates to discard them. The Food Service Director stated that cooked foods should be labeled with the name of the item and the expiration or use-by date.
Failure to Timely Report Elopement and Abuse Allegations
Penalty
Summary
The facility staff failed to report an alleged elopement violation within the required two-hour timeframe to the Office of Health Care Quality (OHCQ). On the morning of May 2, 2024, a Geriatric Nursing Assistant (GNA) discovered that a resident with severe cognitive impairment was missing from their room. The resident was last seen at approximately 6:30 AM, and the local police were notified at 7:20 AM. The resident returned to the facility at 8:30 AM. However, the initial incident report was not submitted to OHCQ until 5:23 PM, which did not meet the two-hour reporting requirement. The resident had been care planned for being at risk of elopement due to impaired safety awareness. Additionally, the facility failed to report an allegation of abuse within the required timeframe. An allegation was made by a resident on August 24, 2022, at 5:10 AM, but the Self Report Form was not submitted to the State Agency until 3:00 PM the same day. The Director of Nursing (DON) confirmed that the allegation should have been reported within two hours. The staff involved in the reporting of this incident no longer work at the facility.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility staff failed to provide adequate supervision to prevent the elopement of two residents with severe cognitive impairment. Resident #98 was last seen in their room early in the morning and was later found missing. The resident, who was alert and oriented only to self, was discovered to have left the facility without staff observation. The investigation revealed that the resident likely climbed out of a window, as all door alarms and the resident's wander guard bracelet were functioning properly. The resident returned to the facility on their own after being gone for nearly one and a half hours. In a separate incident, Resident #29 was found outside the facility in a wheelchair by rehab staff. The resident, who also had severe cognitive impairment, indicated they exited through a side door. Upon investigation, it was found that the door was slightly ajar, and the alarm did not activate when the resident exited, despite the resident wearing a functioning wander guard. The Nursing Home Administrator confirmed the door malfunctioned, allowing the resident to leave the building without triggering an alarm. Both incidents highlight the facility's failure to adequately supervise residents at risk of elopement. Despite having systems in place, such as wander guards and door alarms, the facility did not prevent these residents from leaving the premises unsupervised. The lack of staff awareness and the malfunctioning of security measures contributed to these deficiencies, putting the residents at risk.
Failure to Follow Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to follow up on pharmacy recommendations after monthly drug regimen reviews, as evidenced by the cases of two residents. For one resident, the pharmacist recommended an Abnormal Involuntary Movement Scale (AIMS) evaluation due to the use of Quetiapine, an antipsychotic medication. This recommendation was made in September and November, but the physician was not informed, and the evaluation was not conducted. The facility's policy requires that all recommendations be addressed within 30 days, but this was not adhered to in this case. For another resident, the pharmacist recommended a fasting lipid panel due to the use of Atorvastatin, a cholesterol-lowering medication. This recommendation was made in October but was not carried out until December, after the pharmacist reiterated the recommendation. The facility's process involves the pharmacist entering notes into the electronic record, which are then accessed by the DON and ADON. The ADON is responsible for ensuring that unit managers discuss recommendations with physicians and obtain their feedback. However, this process was not effectively followed, leading to delays in addressing the pharmacist's recommendations.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility staff failed to provide written notification to a resident and their representative regarding the reason for a transfer to the hospital. This deficiency was identified during a recertification/complaint survey for a resident who was hospitalized. The resident was sent to the emergency room due to altered mental status, but there was no documentation or evidence that the resident or their representative was notified in writing about the transfer and its reason. Interviews with facility staff, including two LPNs and the Director of Nursing, revealed that the reason for the transfer was communicated verbally to the resident and their representative, but not in writing. The Director of Nursing confirmed that although the reason for transfer was documented in the transfer form sent with the resident to the hospital, there was no documentation to show that this information was mailed to the resident's representative. The facility did not mail the transfer form because the resident returned to the facility within 24 hours.
Failure to Provide Written Bed-Hold Policy Notification
Penalty
Summary
The facility failed to notify a resident and their representative in writing of the bed-hold policy upon the resident's transfer to an acute care facility. This deficiency was identified during a recertification/complaint survey for a resident who was hospitalized. The resident was sent to the emergency room due to altered mental status, and although the resident's daughter was present at the time of transfer, there was no documentation indicating that the facility provided written notification of the bed-hold policy. Interviews with two Licensed Practical Nurses (LPNs) revealed that while the bed-hold policy was included in the transfer packet sent to the hospital, it was not given to the resident or their representative. Both LPNs confirmed that they had never provided written notification of the bed-hold policy to residents or their representatives. The Director of Nursing (DON) stated that the bed-hold policy was typically sent with the transfer packet to the hospital and a copy mailed to the resident's representative by the Nursing Home Administrator. However, the DON could not find any documentation to show that the resident or their representative received written notification of the bed-hold policy. A review of the change in condition and transfer form confirmed that the bed-hold policy was not included in the packet sent with the resident. The DON acknowledged that the facility missed providing the transfer notice and bed-hold policy to this particular resident.
Failure to Provide and Document Resident Activities
Penalty
Summary
The facility staff failed to provide an activities program that met the needs and preferences of a resident, as evidenced by the lack of performance and documentation of activities per the resident's care plan. The care plan for the resident, who had physical limitations, included a goal for participation in in-room activities of choice, such as music therapy, once a day and three times a week. However, the surveyor found no documentation of these activities in the resident's electronic record, and interviews with staff revealed inconsistencies in the execution and documentation of the activities. During interviews, the resident's mother expressed concerns that the activity staff had not engaged with the resident as outlined in the care plan. The unit manager was unaware of the specific activities conducted with the resident, and the Activities Director admitted to inconsistencies in providing and documenting the activities. The Activities Director also acknowledged that the participation log sheets, which were supposed to be transferred to the electronic record, were not maintained, resulting in a lack of documentation for the activities performed with the resident.
Failure to Instruct Resident to Rinse Mouth After Inhaler Use
Penalty
Summary
The facility failed to ensure that a resident received appropriate care according to physician orders during a medication administration observation. Specifically, a Licensed Practical Nurse (LPN) administered Trelegy inhalation to a resident with chronic obstructive pulmonary disease (COPD) but did not instruct the resident to rinse their mouth afterward, as required by the physician's order. This oversight was identified during a recertification/complaint survey, where it was noted that the physician's order, dated five days prior, explicitly stated the need for the resident to rinse their mouth after using the inhaler. The Director of Nursing confirmed the findings during an interview, acknowledging the nurse's error in not following the complete order instructions.
Failure to Implement Physician's Order for Tracheostomy Care
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident with a tracheostomy by not implementing the physician's order for a speaking valve replacement. The resident, who had been at the facility for about a year, reported to the surveyor that their Passy-Muir valve had not been changed since their arrival, despite having prescriptions from an ENT physician for a speaking valve since April 2024 and another prescription for the same valve and a tracheostomy collar in November 2024. The resident provided a copy of the prescription to the surveyor, indicating that the facility had not acted on these orders. During interviews, the unit manager acknowledged awareness of the prescriptions but mistakenly believed the respiratory therapist would supply the necessary equipment. The Director of Nursing was unaware of the issue, and the Administrator only became aware of the prescriptions on the day of the survey through the resident's responsible party. The facility had not yet received the supplies, as they were waiting for delivery through the Administrator.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Annapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Spa Creek | 0.7 mi | ★★★★★ | 11 | 0 |
| Baywoods Of Annapolis | 0.9 mi | — | 0 | 0 |
| Ginger Cove | 3.7 mi | ★★★★★ | 12 | 0 |
| South River Rehabilitation And Wellness Center | 4.1 mi | ★★★★★ | 22 | 0 |
| Future Care Annapolis | 5.3 mi | — | 0 | 0 |
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