Complete Care At Multi Medical Center Llc

The surveyor shared the concern that 2 out of 7 showers (28%) were not provided in March 2025, 3 out of 9 (33%) showers were not provided in April 2025 and May 2025; and 1 out of 3 (33%) showers were not provided in June 2025.

Furthermore, the surveyor shared the concern that the Kardex stated, Patient shower day is Tuesday and Friday 7-3.

Please ensure shower sheet is completed.

However, there were no corresponding shower sheets for the following dates: 3/7/25, 3/11/25, 3/14/25, 3/18/25, 3/21/25, 3/28/25, 4/1/25, 4/4/25, 4/8/25, 4/11/25, 4/15/25, 4/22/25, 4/25/25, 4/29/25, 5/2/25, 5/6/25, 5/9/25, 5/13/25, 5/16/25, 5/20/25, 5/23/25, or 5/27/25.

The DON acknowledged understanding of the concerns.

215096 03/02/2026

Complete Care at Multi Medical Center LLC 7700 York Road Towson, MD 21204

Review of the physician's orders showed Right carrot splint: Apply at 12 midnight and leave on 8 hours as tolerated; requires frequent adjustment. A carrot splint is a soft cone shaped device used to gently open, position, and treat severe hand contractures, preventing finger-to-palm skin breakdown, moisture build up and potential nail punctures.

Further review into the medical record showed a care plan identifying that Resident #17 has an alteration in musculoskeletal status related to contractures and to assist the resident with use of supportive devices (carrot splints) as recommended.An additional observation on 02/26/2026 at 7:10 AM revealed no splint on Resident #17's right upper extremity.

When the surveyor asked if he had a device in his/her right hand overnight, the resident shook his/her head, no.On 02/26/2026 at 8:14 AM, an interview with RN #13 while conducting observations in Resident #17's room, the surveyor asked if the resident usually wears a splint and RN #13 responded, I do not know, but I will request one.An interview 02/26/2026 at 8:22 AM with the Director of Rehabilitation (DOR) revealed that she brought up a new carrot splint for Resident #17.

The surveyor observed the DOR place it into the palm of Resident #17's right hand.The Director of Nursing (DON) was made aware of these findings on 02/26/2026 at 8:45 AM.

215096 03/02/2026

Complete Care at Multi Medical Center LLC 7700 York Road Towson, MD 21204

During the facility investigation, interviews were conducted with Employee #34, the supervisor on duty, Employee #36 and Employee #35.Following this incident the facility had more security cameras installed and had the wanderguard alarm separated from the regular door opening alarm.

The facility also educated the staff on elopement prevention and alarm response.

The resident's elopement assessment was updated to increase the risk of elopement level to high.

The resident had an elopement/wandering element on their care plan prior to this incident that included checking the wanderguard for placement and function, though the surveyor could not find any documentation that these checks were being performed.On February 26,2026 at 2:40 pm, the administrator was interviewed and verified that the information in the facility incident report was accurate.

215096 03/02/2026

Complete Care at Multi Medical Center LLC 7700 York Road Towson, MD 21204

minimal harm observation and interview, it was determined that the facility failed to post complete and accurate daily nurse staffing information on each resident care unit, including the required staffing ratios for

(Chesapeake, Evergreen, [NAME], and [NAME]) during the recertification survey.The findings include:On 2/24/26 at 7:47 AM, during initial tour of the Chesapeake unit, observation of the staffing dry erase board revealed no staffing ratio was posted.On 2/24/26 at 7:50 AM, observation of the staffing board on the Evergreen unit revealed no staffing ratio was posted.On 2/24/26 at 7:59 AM, observation of the staffing board on the [NAME] unit revealed no staffing ratio was posted.On 2/24/26 at 8:06 AM, observation of the staffing board on the [NAME] unit revealed the board had not been filled out and did not include any staffing information or ratios.On 2/26/26 at 10:43 AM, follow-up observation of the Chesapeake unit staffing board again revealed no staffing ratio was posted.At 10:44 AM, observation of the Evergreen unit staffing board revealed an incomplete staffing ratio listing, which included licensed nurses only and did not include Geriatric Nursing Assistants (GNAs).At 10:47 AM, observation of the [NAME] unit staffing board revealed no staffing ratio was posted.At 10:48 AM, observation of the [NAME] unit staffing board revealed no staffing ratio was posted. At that time, the Director of Nursing (DON) was made aware of the findings.

The DON immediately updated the [NAME] unit board and stated the remaining units with missing or incomplete staffing ratios would be corrected.On 3/2/26 at 1:06pm, the concerns were discussed with the Nursing home administrator during the exit conference.

During the interview when asked why Resident #70 did not receive his/her Jardiance, he stated, He/She got that this morning when we went in with the pills.

The surveyor asked CMA #11 to see the package for the Jardiance. He opened the medication cart and pulled out several blister packs of medications; however, he was unable to produce a package of Jardiance for Resident #70. As this point, the surveyor shared that he had told the surveyor each medication he was going to administer along with the dose and quantity and then handed the medication to the surveyor to observe and that Jardiance was not mentioned by CMA #11 nor Jardiance package observed nor Jardiance observed being dispensed or administered.

During the interview, when asked if he is supposed to reorder medication when it gets low, he stated, I think I did the other day, but stuff doesn't come here on time from the pharmacy. In a dual observation, both surveyor and CMA #11 observed on his laptop, the date the medication was last ordered was 1/20/26. CMA #11 verified and confirmed, No, there's no more of this medication.

When asked if the medication was signed off as administered, CMA #11 said, Yes, because sometimes we have to borrow from another resident's blister pack.

When asked if that was something he was supposed to do, CMA #11 stated no and shook his head.

When asked how Jardiance could have been administered when the Resident did not have any Jardiance, he offered no further comments.

When asked why Resident #70 did not receive Miralax, CMA #11 stated, She took it in her water.

The surveyor stated that he did not verbalize or show the surveyor Miralax during the medication administration, nor did the surveyor observe Miralax being prepared or administered. CMA #11 stated, That was in the water later.

About 10-15 minutes ago I did her knee pads and gave him/her the Miralax.

When asked why Resident #70 did not receive eye drops, CMA #11 stated, Sometimes I do them after.When asked why Resident #70 did not receive either fluoride treatment, CMA #11 stated, It's no particular reason.

The surveyor shared these were all concerns to CMA #11 who verbalized and acknowledged understanding of the concerns.

215096 03/02/2026

Complete Care at Multi Medical Center LLC 7700 York Road Towson, MD 21204

Based on interview with facility staff and observations, it was determined that the facility failed to

residents observed during the medication administration facility task for the recertification survey.

The findings include:During a medication administration observation that took place on 2/25/26 at 8:18 AM, the surveyor observed Licensed Practical Nurse (LPN #10) prepare and administer 2 medications to Resident #57.

Following the medication administration, a review of Resident #57's medical record on 2/25/26 at 9:58 AM revealed the resident was also ordered and not observed receiving: Menthol (Topical Analgesic) External Gel 4 %.

Apply to skin topically two times a day for Pain at 9:00 AM and Diclofenac Sodium External Gel 1 %.

Apply to left knee topically two times a day for pain at 9:00 AM. On 2/25/26 at 11:13 AM in an interview with LPN #10 when asked why the Menthol gel was not administered, LPN #10 stated, I didn't give it to him/her because I do ointments after the medications, so I don't mix them together.

The surveyor asked to see the medication. LPN #10 went to the treatment cart, and the Menthol gel was not inside.

She looked inside the medication cart, and it was not there. At that point LPN #10 said, We don't have it. I confused the name. I thought it was the Diclofenac.

The nurse went into Resident #57's room and asked if she could see his/her creams.

The Diclofenac was observed on the resident's bedside table, and the nurse picked it up.

The nurse opened the drawers in the resident's bedside nightstand and was unable to locate the Menthol gel.

After exiting the resident's room, the nurse said, I know he/she has 2 boxes and they're normally in his/her room.

When asked if the medications were supposed to be stored in the resident's room, she said, No, but if it's left in the cart, sometimes it's not there and we have to look for it.

The surveyor shared this was a concern. LPN #10 acknowledged understanding of the concern.On 2/25/26 at 2:06 PM in an interview with the Director of Nursing (DON) when asked if medications should be stored at the bedside, she stated no.

The surveyor shared the concern that during the medication administration observation there were medications found at the bedside.

The DON acknowledged the concerns and offered no further comments at that time.On 2/27/26 at 9:49 AM review of the facility's Medication Storage policy revealed, All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.

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Complete Care at Multi Medical Center LLC 7700 York Road Towson, MD 21204

During the interview he/she stated that every morning he/she drinks a cup of coffee, but he/she must ask for the coffee.

Furthermore, he/she stated they think he/she has a milk allergy, but that he/she was not allergic to milk, it is just that if he/she drinks a whole container, he/she will have loose bowels.

When asked if staff ask or asked him/her what they want to eat, he/she stated, They have a menu and they do it themselves. No, they never ask me what I want. I prefer orange juice.

Orange juice was on the menu. I got this reddish drink.

The surveyor observed a small amount of a clear, reddish beverage in the resident's cup on his/her tray.

Also observed was the resident's meal ticket which had listed: Cold cereal of choice, biscuit, jelly, margarine, coffee or hot tea, orange juice and a dairy allergen listed. A medical record review on 2/24/26 at 12:12 PM showed that Resident #6 was originally admitted to the facility in June 2025 and able to communicate needs verbally. On 2/26/26 at 9:16 AM in an interview with Resident #6 when asked what he/she had for breakfast this morning, he/she said a piece of meat that looked like a hamburger and dry cereal.

During the interview he/she stated that he/she had to ask for milk and coffee again because they do not bring it. Resident #6 stated, I have to remind them to give me coffee. I have to ask to get coffee even though I drink it every morning and have told them.

He/She also stated that he/she did not receive orange juice and got a brown liquid that was maybe tea. On 2/26/26 at 3:08 PM in an interview with the Kitchen Manager (KM #24), when asked what week menu the facility was on, she stated, We are in in Week 4. On 2/26/26 at 3:10 PM review of the Week 4 menu revealed on Tuesday, 2/24/26, breakfast was scrambled eggs with cheese, oatmeal cereal, cold cereal of choice, biscuit, margarine, jelly, milk, coffee or hot tea, and orange juice.

Further review revealed Thursday's breakfast menu was buttermilk pancakes, margarine, syrup, sausage patty, oatmeal cereal, cold cereal of choice, milk, coffee or hot tea, and orange juice. On 2/26/26 at 3:19 PM in an interview with KM #24 she stated, Everyone gets the regular meal unless they have a dislike or allergy and then they get the alternate.

When asked if the food delivered should match the menu, she stated, Yes.

During the interview, a dual observation of Resident #6's meal ticket from 2/24/26 and 2/26/26 and the Week 4 menu was conducted.

For Tuesday, 2/24/26, the breakfast menu included scrambled eggs with cheese and orange juice; however, the resident's tray ticket nor breakfast tray included these food items nor did he/she receive the alternate.

For Thursday, 2/26/26, the breakfast menu included buttermilk pancakes and orange juice; however, the resident's meal ticket nor breakfast tray included these food items nor did he/she receive the alternate.

The surveyor shared the concern that for 2 out of 2 breakfast observations, Resident #6 did not receive what was on the menu.

When asked why the meal delivered did not match what was on the menu, KM #24 stated, I can't say. KM #24 then stated it was probably because buttermilk pancakes have buttermilk and the resident has a milk allergy.

When asked why Resident #6 did not receive an alternate breakfast, she stated, There was no alternate typed in.

The system doesn't default to anything in place of the regular meal, but we can surely put something in there.

When asked if the facility had milk alternatives such as almond milk, soy milk, oat milk, et cetera, KM #24 replied yes.

When asked why Resident #6 did not receive an alternate milk, she said she did not know.

The surveyor shared these were concerns and KM #24 acknowledged understanding of the concerns.

215096 03/02/2026

Complete Care at Multi Medical Center LLC 7700 York Road Towson, MD 21204

During the initial tour of the kitchen on 2/24/2026 at 8:10 am with Employee #39 it was discovered that a box of sausage patties in the freezer was open and the plastic bag holding the sausage was pulled completely back exposing the sausage to the environment.

Employee #39 was made aware of the concern and disposed of the sausage.2. On 2/25/2026 at 2:54 pm during a temperature check of the nourishment refrigerators on the units, it was discovered that the refrigerator on the 2nd floor unit was registering a temperature of 52 degrees.

The Regional Food Service Manager was notified, and they had all of the food in the refrigerator disposed of and stated that they would monitor the refrigerator and either repair or replace it.

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Complete Care at Multi Medical Center LLC 7700 York Road Towson, MD 21204

in accordance with accepted professional standards.

interviews and record review, it was determined that the facility failed to keep complete and up to

during the annual survey.The findings include:A Kardex is primarily a nursing documentation system used for quick reference to patient care information.

Its purpose is to streamline shift handoffs and provide a snapshot of daily care tasks.

The facility used electronic Kardex (e-Kardex) modules integrated into the electronic health record (EHR).

During an interview on 2/25/2026 at 8:56 AM, Resident #80 in room [ROOM NUMBER]-B stated to surveyor that they had not been showered by staff since they were admitted to the facility on [DATE]. Resident #80 was admitted to rehabilitation services at the facility after receiving a left hemiarthroplasty at an acute care hospital.A medical record review on 2/25/2026 at 11:05 AM revealed one documented bed bath in Resident #80's Kardex on 2/21/2026. No other documentation about showers or bed baths was found in the EHR.

Additionally, there were no active medical orders in the EHR for Resident #80 to receive bathing/shower services or an order to not shower if contraindicated.On 2/25/2026 at 12:47 PM, the shower/bed bath log binder (hard chart) was reviewed on Resident #80's unit (Chesapeake). It contained a shower/bed bath schedule for the unit, which room [ROOM NUMBER]-B was to receive on Tuesdays and Fridays.

There was no documentation in the binder for Resident #80 that they had received a shower or bed bath on those days since admission.On 2/25/2026 at 12:59 PM, Registered Nurse (RN) #9 was interviewed and stated the resident showering/bathing schedules are based on resident room numbers and the shower log binder contains a form that is filled out when residents receive showers/bed baths that includes a skin assessment, if the resident received a shower or bed bath, or if the resident refused. RN #9 stated it is expected that these forms are filled out and placed in shower/bed bath binder, as well as documented in the EHR. RN #9 reviewed the shower binder and Resident #80's EHR and confirmed the only documentation for shower/bed bath was in the EHR for 2/21/2026.The Director of Nursing (DON) stated during an interview on 2/25/2026 at 2:14 PM that it is the facility's expectation that all shower/bed baths are forms are documented in the shower/bed bath binder and the Kardex.

The DON acknowledged surveyor concern of lack of documentation.On 2/25/2026 at 2:50 PM, the DON provided paper documentation of the shower/bad bath sheet which documented that Resident #80 refused a shower/bed bath on 2/25/2026.On 2/26/2026 at 3:00 PM, RN #9 showed surveyor an updated Kardex with stated Shower patient every Tuesdays and Fridays 7-3 shifts, ensure shower sheet is signed by nurse.

Record review showed that the Kardex had been updated with this intervention on 2/25/2026.On 2/25/2026 at 3:10 PM, the DON provided shower/bed bath paper sheets dated 2/10/2026 and 2/17/2026 that stated Resident # 80 had received bed baths on those dates and refused showers.

The DON could not answer why these forms were not in the shower/bed bath binder when surveyor reviewed previously.

The DON also provided an email dated 2/25/2026 between the facility and Resident 80's orthopedist office that stated the office preferred patients do not shower until their post-operative appointment.On 2/26/2026 at 9:45 AM, a review of Resident 80's EHR revealed an order placed on 2/25/2026 at 8:01 PM that stated, SHOWERING RESTRICTION: Patient may not take a shower per orthopedics at John Hopkins Hospital until post op appointment (post discharge).

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Complete Care at Multi Medical Center LLC 7700 York Road Towson, MD 21204

with infection control practices.

This deficient practice was evident for 2 (Residents #43 and #60) of

revealed Resident #43 was receiving oxygen therapy with a humidifier bottle attached; however, the bottle and the oxygen tubing were not dated to indicate when it had been placed in use.

Staff #6 was notified at 7:55 AM and accompanied the surveyor to the resident's room.

Staff #6 confirmed there was no date present on the humidifier bottle or the oxygen tubing. A new humidifier bottle and oxygen tubing were obtained and replaced at that time.2. On 2/24/26 at 8:04 AM, observation revealed Resident #60 was receiving oxygen therapy with oxygen tubing and a humidifier bottle attached that were also not dated.

Staff #7 was notified at 8:06 AM and confirmed the absence of a date on the bottle and tubing.

The issue was resolved at that time with replacement of the oxygen tubing and humidifier bottle.The Director of Nursing was informed of the findings on 2/24/26 at 12:47pm.

215096 03/02/2026

Complete Care at Multi Medical Center LLC 7700 York Road Towson, MD 21204

Based on surveyor observations, medical record review and facility staff interviews, it was determined that the facility failed to ensure residents had access to a call device system.

This was evident for 2 of 2 resident room observations and 1 of 1 shower room observations.

The findings include: 1. On 02/24/2026 at 10:34 AM, 02/26/2026 at 6:50 AM and at 8:14 AM Resident #17's call bell device was observed out of the resident's reach (entangled on the headboard).02/26/2026 8:14 AM Interview with RN#13 was conducted while in Resident #17's room. RN #17 nurse located the resident's call bell device entangled behind the resident's headboard. RN #13 untangled the call bell device from being wrapped around the headboard and placed it near the resident's left hand.A review of the resident's medical record revealed that Resident # 17 is totally dependent for all care and bed mobility with contractures to his/her right upper extremity and right sided paralysis. 2. On 02/27/26 at 7:15 AM an observation of a shower room on the [NAME] Unit revealed 1 of 3 shower bays without adequate length call device activation cord.

This observation was made with the unit manager, UM #37.On 2/27/2026 12:05 PM the Nursing Home Administrator (NHA) was made aware of these concerns.

The NHA confirmed the call device in the [NAME] shower room was replaced with a longer device cord.

215096 03/02/2026

Complete Care at Multi Medical Center LLC 7700 York Road Towson, MD 21204