Complete Care At Springbrook

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

it. During interview on 12/18/25 at 8:11 pm, Staff Nurse #11 revealed that she returned to Resident #28 at about 12 noon on 12/17/25. Staff Nurse #11 confirmed that she administered to Resident #28 the medication that was placed in the medication cup, labelled with a room number. Staff Nurse #11 could not recall if the blood pressure had increased or not. Staff Nurse #11 confirmed that she did not notify physician or obtain a new physician order to administer the medication at 12 noon on 12/17/25 . Review of Medication administration record documentation for 12/17/25 indicated that Resident #28 did not receive Amlodipine 2.5 mg tablet. 4. Resident #29 was admitted to the facility on [DATE REDACTED] with a diagnosis of polyneuropathy, diabetes mellitus, osteoarthritis, pain in the right knee, pain in the left knee, vitamin D deficiency, and anemia. A review of the physician's orders dated 3/8/21 revealed Resident #29 was prescribed vitron -C tablet 65-125 mg(iron vitamin C), 1 tablet by mouth one time a day for anemia. A medication administration

observation was conducted on 12/17/25 at 10:02 am with Staff Nurse #11. Staff Nurse #11 was observed to not have administered vitron-c tablet 65-125 mg (iron vitamin C) to Resident #29 per physician orders.

During interview with Staff Nurse #11 on 12/18/25 at 8:11 pm, it was revealed that vitron-c tablet 65-125mg was not available . Staff Nurse #11 indicated she did not notify physician that Resident #29 did not receive medication. 5. Resident #30 was admitted to the facility on [DATE REDACTED] with diagnosis of diabetes, right ankle and foot osteomyletis, and peripheral vascular disease. A review of the physician's orders dated 11/5/25 revealed Resident #30 was prescribed Jardiance oral tablet (hypoglycemia medication) 25 mg , 1 tablet by mouth one time a day for diabetes. A medication administration observation was conducted on 12/17/25 at 10:27 am with Staff Nurse #11. Staff Nurse #11 was observed to not have administered Jardiance oral tablet to Resident #30 per physician orders. During interview with Staff Nurse #11 on 12/18/25 at 8:11 pm,

it was revealed that Jardiance oral tablet 25mg was not available. Staff Nurse #11 confirmed that Resident #30 did not receive the medications. Staff Nurse #11 indicated that she did not notify physician that Resident #30 did not receive the medication. During an interview with the Director of Nursing (DON) on 12/18/25 at 12:05 pm, she revealed that Resident #27, Resident #23, Resident #28, Resident #29 and Resident #30 should have received medications as per physician orders. DON further stated, that documentation should accurate on the medication administration record. DON stated that she was not aware that nursing staff were using insulin syringes to extract insulin from insulin pens/kwikpens.

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Springbrook

12325 New Hampshire Avenue Silver Spring, MD 20904

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review, resident, facility and pharmacy staff interviews, the facility failed to administer medication as ordered by the physician to meet the resident's need of 3 of 8 sampled residents reviewed for pharmacy services. (Resident #23, Resident #29 and Resident #30). a. Resident #23 was admitted to the facility on [DATE REDACTED] with a diagnosis of seizures adjustment disorder, hypertension, diabetes and dysarthria. The admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #23 was cognitively intact. A review of the physician's orders dated 11/3/25 revealed Resident #23 was prescribed Biofreeze cool the pain external gel 4% (menthol topical analgesic) apply to right shoulder topically two times a day for pain. A medication administration observation was conducted on 12/16/25 at 9:22 am with Staff Nurse #5. Staff Nurse #5 was observed to not have administered the medication biofreeze cool the pain external gel 4%(menthol topical analgesic) to Resident #23 as per physician orders. During interview on 12/18/25 at 10:33 am, Staff Nurse #5 stated that she thought she administered the medication to Resident #23. b.

Resident #29 was admitted to the facility on [DATE REDACTED] with a diagnosis of polyneuropathy, diabetes mellitus, osteoarthritis, pain in the right knee, pain in the left knee, vitamin D deficiency, and anemia. The quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #29 was cognitively intact. A review of the physician's orders dated 3/8/21 revealed Resident #29 was prescribed salonpas pain relieving patch 4 % (Lidocaine) apply to knees topically one time a day for pain. A medication administration observation was conducted on 12/17/25 at 10:02 am with Staff Nurse #11. Staff Nurse #11 was observed to not have administered salonpas pain relieving patch 4% (lidocaine) to Resident #29 per physician orders. A review of

the physician's orders dated 3/8/21 revealed Resident #29 was prescribed vitron -C tablet 65-125 mg(iron vitamin C), 1 tablet by mouth one time a day for anemia. A medication administration observation was conducted on 12/17/25 at 10:02 am with Staff Nurse #11. Staff Nurse #11 was observed to not have administered vitron-c tablet 65-125 mg (iron vitamin C) to Resident #29 per physician orders. During

interview with Staff Nurse #11 on 12/18/25 at 8:11 pm, it was revealed that vitron-c tablet 65-125mg was not available . Staff Nurse #11 indicated that she misunderstood the order for salonpas pain relieving patch 4% and administered lidocaine and prilocaine cream 2.5% instead. Staff Nurse #11 confirmed that Resident #29 did not receive Salonpas pain relieving patch 4% to both knees and vitron-c 65-125mg tablet per physician orders.c. Resident #30 was admitted to the facility on [DATE REDACTED] with diagnosis of diabetes, right ankle and foot osteomyletis, and peripheral vascular disease. The admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #30 was cognitively intact. A review of the physician's orders dated 11/5/25 revealed Resident #30 was prescribed Jardiance oral tablet (hypoglycemia medication) 25 mg , 1 tablet by mouth one time a day for diabetes. A medication administration observation was conducted

on 12/17/25 at 10:27 am with Staff Nurse #11. Staff Nurse #11 was observed to not have administered Jardiance oral tablet to Resident #30 per physician orders. During interview with Staff Nurse #11 on 12/18/25 at 8:11 pm, it was revealed that Jardiance oral tablet 25mg was not available. Staff Nurse #11 confirmed that Resident #30 did not receive the medications. During interview on 12/17/25 at 12:37pm, Pharmacist indicated that Resident #23, Resident #29 and Resident #30 should have received their medications as per physician orders. During an interview with the Director of Nursing (DON) on 12/18/25 at 12:05 pm, she revealed that Resident #23, Resident #29 and Resident #30 should have received medications as per physician orders. She further stated that all nurses will be retrained on reordering medication timely.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Springbrook

12325 New Hampshire Avenue Silver Spring, MD 20904

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident #30 was prescribed Jardiance oral tablet (hypoglycemia medication) 25 mg , 1 tablet by mouth one time a day for diabetes. A medication administration observation was conducted on 12/17/25 at 10:27 am with Staff Nurse #11. Staff Nurse #11 was observed to not have administered Jardiance oral tablet to Resident #30 per physician orders. During interview with Staff Nurse #11 on 12/18/25 at 8:11 pm, it was revealed that Jardiance oral tablet 25mg was not available. Staff Nurse #11 confirmed that Resident #30 did not receive the medications. During interview on 12/17/25 at 12:37pm, Pharmacist indicated that all residents should receive their medications as per physician orders. During an interview with the Director of Nursing (DON) on 12/18/25 at 12:05 pm, she revealed that all residents should receive medications as per physician orders.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Springbrook

12325 New Hampshire Avenue Silver Spring, MD 20904

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Based on observations, and staff and pharmacist interviews, the facility failed to label opened insulin pens with the patient name, physician name, date used for 1 insulin pens for 1 of 3 medication carts reviewed for medication storage (West Wing Medication Cart). The [NAME] Wing Medication Cart was observed on 12/16/25 at 11:49 am in the presence of Staff Nurse #6. The observation revealed 1 opened and used insulin pen of Humalog (insulin lispro) that was stored with no label indicating patient name, physician name and order. The facility insulin pens policy copyright 2025, provided by the Director of nursing , indicated that Insulin pens must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date.During interview on 12/17/25 at 12:33pm, Staff Nurse #6 indicated that he used an unlabeled insulin lispro kwikpen , to administer insulin.

Staff Nurse #6 stated that the kwikpen, had a room number, manually handwritten on the kwikpen, with a black marker. Staff Nurse #6 indicated that he did not require a label, because the room number manually written on the kwikpen, was enough to identify the resident. During an interview with the Director of Nursing (DON) on 12/18/25 at 12:05 pm, indicated that nursing staff should discard any unlabeled insulin pens and notify pharmacy to reorder new insulin pens that have labels. During interview on 12/17/25 at 12:37pm, Pharmacist indicated that all insulin pens must be labelled with the patient's name, physician name and date opened. Pharmacy consultant further stated that once insulin pen is opened, it should be labelled with

the date opened. Pharmacy consultant also indicated that any opened, unlabeled insulin pens should not be used, but facility should notify pharmacy and order a new insulin pen.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Springbrook

12325 New Hampshire Avenue Silver Spring, MD 20904

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0919 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

(MDS) dated [DATE REDACTED], documented his/her BIMS score was 15, indicating Resident R37 was cognitively intact. In section GG of the MDS, documented Resident R37 was dependent on staff with activities of daily living. Record

review of R37s Face sheet revealed Resident R37 was admitted on [DATE REDACTED]. R37s diagnoses included, End Stage Renal Disease, Adjustment Disorder, and Pressure Ulcer. During observation and interview on [DATE REDACTED] at 11:50 AM, GNA15 walked into room [ROOM NUMBER] and stated she was not aware the call was broken and was detached from the socket. GNA15 pressed both call lights in room [ROOM NUMBER]-A and 133-B and stated both call lights were not working. GNA15 proceeded to room [ROOM NUMBER]-A and stated that the call light in room [ROOM NUMBER] A was not working. GNA 15 concluded that she would notify

the administrator and the maintenance manager. During an interview on [DATE REDACTED] at 1:37 PM the Maintenance Director (MD) 17 stated he was aware that some of the facility call lights needed to be replaced. According to MD17, the facility attempted to order the required parts and was unable to find the correct parts. MD17 stated the administrator was aware. MD17 concluded the entire call light socket in room [ROOM NUMBER] needed to be replaced. During an interview on [DATE REDACTED] at 2:34 PM with Director of Nursing (DON) and the Administrator, the DON revealed, staff will distribute manual call bells in rooms where call lights were not working. The Administrator concluded the maintenance director did not mention

he had problems with getting specific repairs done, and he concluded staff will continuously monitor broken call lights throughout the facility. The administrator stated staff completed a call light audit and will continuously perform call light audits.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Springbrook

12325 New Hampshire Avenue Silver Spring, MD 20904

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

plumber documented that the toilet bowl was repaired and recommended the facility to replace the toilet bolts and replace the toilet pipes. Based on interviews, observations, and recorded reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for three (Resident R13, Resident R33, and Resident R34) of

the 3 sampled residents. When the facility failed to replace a damaged, leaking commode toilet in Resident R33 and Resident R34 bathrooms for several months, and failed to provide a sanitary environment in Resident R13's room. During an

interview on 12/17/2025 at 11:30 AM, the Housekeeping Director (HKD) 18 stated that the entire floor in Resident R33 and the bathroom in Resident R34 needed to be replaced. According to HKD 18, the smell of urine emanated from the floor tiles, and he explained that he had been treating the same bathroom several times a day but was unable to get rid of the odor. HKD 18 concluded that the administrator was aware. During an interview

on 12/17/2025 at 1:37 PM, the Maintenance Director (MD) 17 stated that the administrator was aware that Resident R33 and R34s needed their toilets replaced. According to MD17, plumbing concerns had been ongoing since he started working at the facility date on 10/20/2025. MD17 concluded there was major sewer blockage and pipe damage. During an interview on 12/17/2025 at 2:34 PM, the Administrator stated he was not aware that Resident R33 and Resident R34 had a plumbing issue with their toilets and said he would notify a professional plumber as soon as possible. A record review of a facility work order dated 12/17/2025 showed that a private plumber documented that the toilet bowl was repaired and recommended that the facility replace the toilet bolts and the toilet pipes.

Event ID:

Facility ID:

If continuation sheet