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Health Inspection Summary

Complete Care at Springbrook

12325 New Hampshire Avenue

Silver Spring, MD 20904

(301) 622-4600

Deficiency Category	Inspection Date: 9/16/20 Complaint Reporting Period: 5/1/24 - 4/30/25	Inspection Date: 9/12/19 Complaint Reporting Period: 5/1/23 - 4/30/24	Inspection Date: 3/29/19 Complaint Reporting Period: 5/1/22 - 4/30/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	2	0	0
Quality of Life and Care Deficiencies	4	2	3
Infection Control Deficiencies	1	0	0
Resident Assessment and Care Planning Deficiencies	2	5	1
Nursing and Physician Services Deficiencies	0	0	0
Resident Rights Deficiencies	2	1	3
Nutrition and Dietary Deficiencies	0	0	0
Pharmacy Service Deficiencies	1	0	2
Environmental Deficiencies	0	0	0
Administration Deficiencies	0	0	1

Detailed result for inspection on 9/16/20

Date of last standard health inspection:	9/16/20Read the full report (PDF)
Date(s) of complaint inspection(s) between 5/1/24 - 4/30/25	12/18/24Read the full report (PDF)
Date(s) of infection control inspection(s) between 5/1/24 - 4/30/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	12
Average number of Health Deficiencies in Maryland:	19.3
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Respond appropriately to all alleged violations.	12/18/24	1/27/25	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	12/18/24	1/27/25	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	9/16/20	10/16/20	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	12/18/24	1/27/25	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	12/18/24	1/27/25	2 - Minimal harm or potential for actual harm	Few
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.	9/16/20	10/16/20	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	9/16/20	10/16/20	2 - Minimal harm or potential for actual harm	Some

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	12/18/24	1/27/25	2 - Minimal harm or potential for actual harm	Few
Ensure services provided by the nursing facility meet professional standards of quality.	9/16/20	10/16/20	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.	9/16/20	10/16/20	2 - Minimal harm or potential for actual harm	Few
Keep residents' personal and medical records private and confidential.	9/16/20	10/16/20	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
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.	9/16/20	10/16/20	2 - Minimal harm or potential for actual harm	Some

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 9/12/19

Date of last standard health inspection:	9/12/19Read the full report (PDF)
Date(s) of complaint inspection(s) between 5/1/23 - 4/30/24	No complaint inspections
Date(s) of infection control inspection(s) between 5/1/23 - 4/30/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	8
Average number of Health Deficiencies in Maryland:	14.5
Average number of Health Deficiencies in the United States:	9.5

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	9/12/19	10/28/19	2 - Minimal harm or potential for actual harm	Few
Provide safe and appropriate respiratory care for a resident when needed.	9/12/19	10/28/19	2 - Minimal harm or potential for actual harm	Some

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure services provided by the nursing facility meet professional standards of quality.	9/12/19	10/28/19	2 - Minimal harm or potential for actual harm	Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	9/12/19	10/28/19	2 - Minimal harm or potential for actual harm	Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	9/12/19	10/28/19	2 - Minimal harm or potential for actual harm	Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	9/12/19	10/28/19	2 - Minimal harm or potential for actual harm	Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	9/12/19	10/28/19	1 - Potential for minimal harm	Some

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	9/12/19	10/28/19	1 - Potential for minimal harm	Some

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 3/29/19

Date of last standard health inspection:	3/29/19Read the full report (PDF)
Date(s) of complaint inspection(s) between 5/1/22 - 4/30/23	No complaint inspections
Date(s) of infection control inspection(s) between 5/1/22 - 4/30/23	No infection control inspections
Total number of Health Deficiencies for this nursing home:	10
Average number of Health Deficiencies in Maryland:	12.1
Average number of Health Deficiencies in the United States:	8.8

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	3/29/19	1/24/19	4 - Immediate jeopardy to resident health or safety	Few
Provide care and assistance to perform activities of daily living for any resident who is unable.	3/29/19	5/17/19	2 - Minimal harm or potential for actual harm	Few
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.	3/29/19	5/17/19	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	3/29/19	5/17/19	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Give the resident's representative the ability to exercise the resident's rights.	3/29/19	5/17/19	2 - Minimal harm or potential for actual harm	Few
Give residents a notice of rights, rules, services and charges.	3/29/19	5/17/19	2 - Minimal harm or potential for actual harm	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	3/29/19	5/17/19	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
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.	3/29/19	5/17/19	2 - Minimal harm or potential for actual harm	Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	3/29/19	5/17/19	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.	3/29/19	5/17/19	2 - Minimal harm or potential for actual harm	Some

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Respond appropriately to all alleged violations.	12/18/24	1/27/25	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	12/18/24	1/27/25	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	12/18/24	1/27/25	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	12/18/24	1/27/25	2 - Minimal harm or potential for actual harm	Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	12/18/24	1/27/25	2 - Minimal harm or potential for actual harm	Few

Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.

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