Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Severna Park Llc during CMS and state inspections, most recent first.
Surveyors found that several residents did not have access to their call bells, with devices placed out of reach in drawers, on the floor, or on the opposite side of the bed. Staff acknowledged responsibility for ensuring call bell accessibility but did not follow a consistent process, resulting in residents being unable to summon assistance when needed.
Multiple residents were found to have nonfunctioning call bell systems, including cases where the alert signal could not be turned off or the call bell failed to signal staff. Some residents reported making repeated requests for repairs that were not addressed, and maintenance staff confirmed that no prior work orders had been submitted for certain rooms. The deficiency resulted in residents lacking reliable access to staff assistance.
Two residents experienced abuse by staff, including verbal aggression and physical force. In one case, a GNA used inappropriate language and yelled at a resident during care, as confirmed by a witness. In another case, a GNA forcibly removed tea bags from a resident's hands, causing pain and weakness, with the incident corroborated by both the resident and a witness. Both incidents were substantiated by the facility's investigation.
Surveyors found that the facility did not report suspected abuse and an injury of unknown origin to OHCQ within the required timeframe for two residents. In one case, a resident's hip fracture was reported late, and in another, staff delayed notifying the Administrator and OHCQ after a resident alleged inappropriate contact by a visitor. The facility's staff misunderstood or failed to follow required reporting timelines.
A resident with intact cognition reported that a GNA forcibly took tea bags from their hands, causing significant pain and weakness. While other residents assigned to the same staff member were interviewed and denied abuse, the facility did not perform required body checks on four non-verbal, cognitively impaired residents, resulting in an incomplete abuse investigation.
A resident who required supervision during meals, as indicated by their care plan and SLP recommendations, was incorrectly documented as independent for eating on multiple occasions. Staff interviews confirmed the resident needed supervision, and the discrepancy was attributed to staff misunderstanding documentation requirements.
The facility did not update care plans after significant events, such as a resident's abuse allegation or medication changes, and failed to ensure care plan meetings included all required interdisciplinary team members. Additionally, there was no documentation that residents were consistently invited to participate in their own care plan meetings, with only family members being invited in some cases.
Two residents experienced abuse by staff, including a GNA yelling and refusing to leave a resident's room, and another GNA providing rough incontinent care and holding a feces-soiled washcloth close to a resident's face. Both incidents were witnessed or reported, and staff failed to ensure residents were treated with respect and free from abuse.
Facility staff did not conduct a thorough investigation after a resident alleged being pushed and choked by a nursing staff member. The investigation lacked interviews with other residents to assess for possible widespread abuse, a gap confirmed by the Administrator during the survey.
Facility staff did not document the delivery of daily wound care for two residents with pressure ulcers, as required by physician orders. Review of treatment administration records revealed multiple dates where wound care was not recorded for wounds on the heel and sacrum. The DON confirmed the lack of documentation for these treatments.
Two residents experienced accidents due to inadequate supervision and failure to eliminate hazards, including a fall from a bed that flipped and a fall during a Hoyer lift transfer. In one case, required incident documentation and investigation were not completed as per facility policy.
A resident recovering from multiple fractures only had a physician order for Oxycodone to be administered for severe pain (pain score 7-10), but staff administered the medication 19 times for lower pain scores (0-6) without an appropriate order. This lack of specific orders for different pain levels resulted in medication being given outside the prescribed parameters.
A resident with a documented history of family trauma did not have trauma-informed interventions included in their care plan. Although the trauma was noted at admission, the care plan lacked specific measures to address these needs, as confirmed by the DON and Administrator.
A facility failed to complete competency evaluations for a newly hired GNA, resulting in an incident of verbal abuse toward a resident. The DON confirmed that competency assessments were not performed at hire, and the GNA's file lacked required documentation. The GNA was terminated and reported following the substantiated abuse event.
Two residents were affected by the facility's failure to monitor behaviors for those on antipsychotic medications and to ensure psychotropic medications were prescribed and documented appropriately. One resident with multiple psychiatric diagnoses received antipsychotic drugs without documented behavioral monitoring, while another was prescribed Seroquel for reasons not supported by diagnosis, with the DON confirming the documentation was inappropriate.
Surveyors found that medications, including a liquid dose and a blister pack of antibiotics, were left unattended and unsecured on two separate units. In both cases, residents with severe cognitive deficits and wandering behaviors were present in the area, and staff were not immediately available to supervise or secure the medications.
Two residents were affected by inaccurate medical record documentation, including incorrect dates for neuro checks after a fall and conflicting information about Seroquel administration in psychiatric notes and the MAR. The DON confirmed these documentation errors during the survey.
Failure to Ensure Resident Call Bells Were Accessible
Penalty
Summary
Surveyors identified that the facility failed to ensure residents had access to their call bells, as required for communication with staff. During observations, four residents were found without accessible call bells: one resident's call bell was inside a bedside table drawer, another's was on the opposite side of the bed, a third had the call bell wrapped around a bed rail out of reach, and a fourth resident's call bell was found on the floor under a roommate's bed. These observations were made while residents were either in bed or seated in wheelchairs, and in all cases, the call bells were not within reach for the residents to summon assistance. Interviews with staff, including a registered nurse and a GNA, confirmed that it was their responsibility to ensure call bells were accessible, but there was no consistent process or schedule for checking call bell accessibility. The staff acknowledged the issue when it was pointed out and repositioned the call bells to make them accessible. The deficiency was further confirmed during dual observations with staff, who admitted the oversight and took immediate action to correct the placement of the call bells.
Failure to Maintain Functioning Call Bell System for Residents
Penalty
Summary
The facility failed to ensure that a functioning call bell system was available for residents, as evidenced by observations and interviews during a complaint survey. Out of seven residents reviewed for call bell function, multiple instances were found where the call bell system did not operate as intended. In one case, a resident's call bell triggered the alert signal but the signal could not be turned off using the wall button, requiring maintenance intervention. The resident reported having previously requested repairs for this issue, but no action had been taken prior to the survey. In another instance, a resident's call bell did not function at all and failed to signal staff when pressed. Staff confirmed that maintenance had not received any prior work orders for this issue. Further review and interviews revealed that additional residents had nonfunctioning call bells, with the Maintenance Director identifying and confirming several rooms where the call bell systems were not operational. Documentation showed that these deficiencies had not been previously addressed, and residents had experienced periods without reliable access to staff assistance through the call bell system. The lack of timely response to repair requests and the absence of maintenance work orders contributed to the ongoing deficiency in ensuring resident safety and communication.
Failure to Prevent Resident Abuse by Staff
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two substantiated incidents involving staff members. In the first incident, a geriatric nursing assistant (GNA) engaged in verbally abusive behavior toward a resident, including yelling and using inappropriate language while providing care. This was corroborated by the resident's roommate's family member, who overheard the GNA's remarks and described escalating verbal aggression when the resident asked the GNA to stop. The facility's investigation confirmed the verbal abuse based on statements from those involved. In the second incident, another GNA was observed forcibly taking tea bags from a resident's hands, resulting in a tugging motion that the resident described as forceful enough to potentially pull them from their chair. The resident, who was cognitively intact with a BIMS score of 15, reported increased pain and weakness in their hands and arms following the incident, with a pain score of 9 out of 10 documented later that day. The incident was substantiated based on the resident's and a witness GNA's statements.
Failure to Timely Report Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report suspected abuse, neglect, or theft to the Office of Health Care Quality (OHCQ) within the required timeframe for two residents. In the first case, a resident sustained a left hip fracture of unknown origin, and the initial report to OHCQ was submitted nearly 24 hours after the incident, exceeding the required 2-hour reporting window. The final investigation report was also delayed, being submitted beyond the five working days requirement. The Director of Nursing (DON) incorrectly stated that the facility was required to report within 24 hours, indicating a misunderstanding of the regulatory timeframe. In the second case, a resident alleged inappropriate physical contact by a male visitor, reporting the incident to the Psych Social Worker, Unit Manager (UM), and Social Services Director (SSD). Despite the resident expressing that they did not feel abused and did not want the incident reported, staff failed to immediately notify the Administrator as required by facility policy. The Administrator only became aware of the allegation after the resident's representative contacted the facility the following day. The initial report to OHCQ was submitted more than 24 hours after staff first became aware of the allegation, exceeding the required timeframe. Documentation confirming timely reporting to the Administrator and OHCQ was not provided.
Failure to Conduct Comprehensive Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with intact cognition who reported that a Geriatric Nurse Assistant (GNA) forcibly took tea bags from their hands, resulting in increased pain and weakness in the resident's wrists and arms. The incident was witnessed by another GNA, who described a tugging motion between the staff member and the resident. The resident later reported a pain level of 9 out of 10 and ongoing weakness and tingling in the affected areas. Medical records confirmed the resident was cognitively intact at the time of the incident. During the investigation, the facility interviewed other residents assigned to the alleged staff member, with seven residents denying any abusive encounters. However, the facility did not conduct skin assessments or body checks for four cognitively impaired, non-verbal residents who were also under the care of the alleged perpetrator. Both the DON and the Nursing Home Administrator confirmed that body checks for non-verbal or vulnerable residents were expected as part of the abuse investigation process, but these assessments were not performed.
Inaccurate Documentation of Required Supervision During Meals
Penalty
Summary
The facility failed to maintain accurate documentation regarding the level of assistance required for a resident during meals. The resident's care plan and a speech-language pathologist's recommendation both specified that the resident required supervision while eating. However, a review of the Activities of Daily Living (ADL) documentation for May and June showed that the resident was repeatedly marked as 'Independent' for eating on several dates, which contradicted the care plan and professional recommendations. Interviews with the unit manager confirmed that the resident should not have been considered independent, as supervision was necessary during meals. The unit manager was unable to explain why the resident was documented as independent on those occasions. The administrator acknowledged that the discrepancy was likely due to staff not understanding the difference between 'Independent' and 'Supervision' when documenting the resident's level of assistance.
Failure to Revise Care Plans and Hold Proper Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plans were revised and care plan meetings were held as required for several residents. In one case, a resident who reported an allegation of abuse did not have their behavioral care plan updated following the incident, despite the care plan being last revised prior to the event. Another resident continued to have an active care plan for anticoagulant therapy even after the medication was discontinued, with no update to reflect the change in treatment until it was brought to staff attention during the survey. Additionally, care plan meetings did not consistently include all required interdisciplinary team members. Documentation showed that meetings for one resident were attended by social services, nursing, and the dietician, but not always by the full interdisciplinary team as required. In some instances, the family was notified but did not attend, and there was inconsistency in the presence of therapy staff and other disciplines based on the resident's needs. There was also a lack of documentation confirming that residents were invited to attend their care plan meetings. For one resident, records indicated that only the family had been invited to multiple care plan meetings, with the resident attending just one meeting since admission. There was no evidence in the documentation that the resident had been invited or had declined to attend the other meetings, and the facility could not provide documentation to confirm that invitations were extended to the resident as per their stated process.
Failure to Protect Residents from Verbal and Physical Abuse
Penalty
Summary
A staff member failed to treat a resident with respect and free from verbal and physical abuse, as evidenced by a witnessed verbal altercation between a resident and a Geriatric Nursing Assistant (GNA). The GNA was overheard yelling and cursing at the resident, refusing to leave the resident's room until a supervisor intervened and separated them. The resident reported that the GNA was yelling because the resident did not want to see pictures on the phone about previous staff and wanted the GNA to leave. The incident was witnessed and documented in the facility's investigation packet. In a separate incident, another resident reported that a male GNA was rough during incontinent care, causing pain, and held a feces-soiled washcloth close to the resident's face, asking if the resident wanted to stay like that. The resident reported the incident to the Unit Manager, who confirmed being told about rough care but not about the washcloth. The GNA admitted to being told he was hurting the resident but denied causing pain and continued care. The DON was unaware of the incident until informed by surveyors and later confirmed the GNA's behavior as inappropriate.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
Facility staff failed to thoroughly investigate an allegation of abuse made by a resident, who reported being pushed and choked by a nursing staff member. The facility's investigation into the incident did not include interviews with other residents to determine whether there was evidence of widespread abuse by staff. This omission was confirmed during an interview with the Administrator, who acknowledged that the investigation lacked resident interviews to disprove broader abuse concerns. The deficiency was identified during a complaint/annual survey, and the findings were based on medical record review and staff interviews. The report specifically notes that the investigation was incomplete due to the absence of additional resident interviews related to the abuse allegation.
Failure to Document Daily Wound Care for Pressure Ulcers
Penalty
Summary
Facility staff failed to document the delivery of daily wound care for residents with pressure ulcers, as evidenced by a review of medical records and treatment administration records (TARs) for two residents. One resident, observed with specialized heel protectors, had a physician order for daily wound care to the left heel, but the TAR showed no documentation of treatment on several specified dates. The Director of Nursing (DON) confirmed the absence of documentation for these dates and acknowledged that wound care should be signed or initialed when performed. A second resident, who had physician orders for daily wound care to the right heel and sacrum, also had missing documentation in the TAR for multiple dates across two months. The DON reviewed the records and confirmed that there was no documentation for the required wound care on the specified dates for both the right heel and sacral wounds. No additional documentation was provided by the facility at the time of the survey exit.
Failure to Prevent Accidents and Complete Required Incident Documentation
Penalty
Summary
The facility failed to ensure residents were free from accident hazards and did not provide adequate supervision to prevent accidents, as evidenced by two separate incidents involving two residents. In the first case, a resident was found on the floor in their room after their bed had flipped onto its side, though not onto the resident. Despite facility policy requiring completion of an incident report and documentation of all assessments and actions following a fall, no incident report or investigation was completed for this event. The Director of Nursing confirmed that the required documentation was not done, and no additional documentation was provided to the surveyor. In the second case, another resident reported falling to the floor when a Hoyer lift tilted during a transfer from wheelchair to bed. The resident subsequently experienced back pain and was transferred to the emergency department. The incident was documented in the medical record, and interviews revealed that the transfer was being performed in the hallway due to limited space in the resident's room. The Hoyer lift involved was removed from service and inspected, but no mechanical issues were found. The facility had been in the process of replacing older Hoyer lifts, and the one involved in the incident was replaced following the event.
Failure to Obtain Orders for Pain Management at Lower Pain Levels
Penalty
Summary
A deficiency was identified when a resident admitted after a fall with multiple fractures, requiring healing and physical therapy, did not have a physician order to address and medicate pain levels below a score of 7. The medical record review showed that the only pain medication order was for Oxycodone 5 mg, 2 tablets every 4 hours as needed for severe pain, defined as a pain score of 7-10. Despite this, the medication administration record indicated that Oxycodone was administered 64 times, including 19 instances for pain scores between 0-6, for which there was no corresponding physician order. This issue was confirmed through review of the resident's records and discussion with the facility's Director of Nursing.
Failure to Provide Trauma-Informed Care Planning
Penalty
Summary
The facility failed to provide trauma-informed care for a resident who disclosed a history of family trauma that led to running away from home at a young age. Upon review of the resident's medical record, it was found that although the trauma was documented at admission, there was no evidence that the care plan included interventions addressing the resident's past trauma. The DON confirmed that trauma-informed assessments are required at admission and after changes in condition, but acknowledged that no care plan interventions were created for this resident's trauma history. Both the DON and the Administrator verified the absence of trauma-related interventions in the resident's care plan.
Failure to Assess GNA Competency at Hire Leads to Abuse Incident
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) were competent in their skill sets, as evidenced by the lack of completed competency skills evaluations or check-off sheets for a newly hired GNA involved in a substantiated incident of verbal abuse toward a resident. Upon review of the employee file, it was found that no competency assessment had been conducted at the time of hire, and the Director of Nursing confirmed that staff competencies were only assessed if an incident occurred, rather than as part of the initial orientation process. Although 60-day and 90-day evaluations were present in other new employee files, the GNA in question did not reach the 30-day mark before being terminated and reported for the abuse incident.
Failure to Monitor Antipsychotic Use and Ensure Appropriate Psychotropic Medication Documentation
Penalty
Summary
The facility failed to adequately monitor the behaviors of a resident receiving antipsychotic medications and did not ensure that residents were free from unnecessary medications. One resident with diagnoses including Bipolar Disorder, Psychosis, Major Depressive Disorder, and Schizoaffective Disorder was prescribed Fluphenazine and Olanzapine. Although a care plan was initiated for hallucinations, anxiousness, and agitation, there was no evidence in the medical record that the resident's behaviors were being monitored as required. Staff interviews confirmed the lack of documented behavioral monitoring for this resident. Additionally, another resident was prescribed Seroquel, a psychotropic medication, with the reason for use documented incorrectly in the Medication Administration Record. The medication was listed as being prescribed for sundowning and as a supplement, which was acknowledged by the DON as inappropriate and not supported by the resident's medical diagnosis. These findings demonstrate failures in both monitoring and documentation related to the use of psychotropic medications.
Unsecured Medications Observed on Units with Cognitively Impaired Residents
Penalty
Summary
Surveyors observed that the facility failed to properly secure medications on two separate nursing units. On one occasion, a medicine cup containing a clear liquid was left unattended on top of a medication cart in a secure dementia unit. Two residents with documented severe cognitive deficits and wandering behaviors were present in the immediate area, and no staff were observed nearby at the time. The medication cart was later identified as belonging to an RN, who confirmed the medication was for another resident. In a separate incident, a blister pack containing 28 tablets of an antibiotic was found unattended at a nursing station desk. The medication was intended for a resident and had been separated for different halls, but was not secured in the appropriate medication cart. The medication remained unattended until a staff RN was questioned and subsequently secured the medication. Both incidents involved residents with significant cognitive impairments and occurred in areas where staff were not present to supervise the medications.
Failure to Maintain Accurate Medical Records and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as evidenced by errors in documentation related to neurological checks and psychiatric medication records. For one resident who experienced a fall, neurological checks were documented with incorrect dates, with entries reflecting dates that did not correspond to the actual event. Despite a correction to one entry, subsequent documentation continued to show inconsistent and inaccurate dates. The DON confirmed the expectation for accurate documentation and acknowledged the issue when it was brought to her attention. For another resident, psychiatric notes inaccurately stated that Seroquel had been discontinued months prior, and therefore a gradual dose reduction (GDR) was not attempted. However, a review of the Medication Administration Record (MAR) did not show an order for Seroquel at the time indicated in the psychiatric notes, and the first order for Seroquel appeared months later. The DON and surveyor confirmed the discrepancies between the psychiatric notes and the MAR, indicating inaccurate documentation regarding the resident's medication history.
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What surveyors actually found near you
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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 Severna Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fairfield Nursing & Rehabilitation Center | 4.1 mi | ★★★★★ | 48 | 0 |
| Future Care Chesapeake | 4.2 mi | ★★★★★ | 4 | 0 |
| Autumn Lake Healthcare At Baltimore Washington | 5 mi | ★★★★★ | 28 | 0 |
| Marley Neck Rehabilitation And Wellness Center | 5 mi | ★★★★★ | 9 | 0 |
| Autumn Lake Healthcare At Glen Burnie | 6.2 mi | ★★★★★ | 4 | 0 |
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