Complete Care at Hyattsville

Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to ensure that allegations of abuse were reported to the State Agency no later than 2 hours after the allegation was made. This was evident in one (Complaint #3026441) of 2 Complaints investigated during the complaint survey.

Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to ensure that thorough investigations were completed for allegations of abuse. This was evident in one (Complaint #3026441) of 2 Complaints investigated during the complaint survey.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure a resident received care and services in accordance with physician orders and the resident's care plan to prevent pressure injuries. Specifically, the facility failed to reposition a resident every two hours as ordered and care planned. This failure occurred during multiple observations and placed one (1) of one (1) resident at risk for increased pressure injury development who were reviewed for turning and positioning. During an observation on 1/7/26 at 10:04 am, the surveyor observed Resident #8 lying in bed on the right side at an angle facing the wall. During another observation on 1/7/26 at 4:54 pm, the surveyor observed the resident lying supine (lying on back facing upward) with a wedge at their feet. [...]

Inspectors wroteBased on observation, staff interview, and review of infection prevention practices, the facility failed to implement proper infection control measures to prevent contamination of tracheostomy equipment. Specifically, the facility failed to ensure tracheostomy tubing remained off the floor for three (3) of four (4) residents observed for tracheostomy equipment. This failure occurred on two separate days and placed residents at risk for infection.1.) During an observation on 1/6/2026 at 10:15 am resident #14 who had a tracheostomy, with tracheostomy tubing extending from the tracheostomy site and resting on the floor. No staff were observed intervening to reposition or replace the tubing at that time. Record review of Resident #14 revealed, an admission date of 1/6/2026, an admission date of 5/10/2022, an original admission date of 7/10/2020. [...]

Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure Residents were provided a dignified existence. This was found to be evident for 6 (Resident #126, #18, #162, #114, #229, & #183) out of 7 Residents observed for dignity during the recertification survey.

Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to 1. have quarterly Care Plan Meetings with the Interdisciplinary Team, 2. ensure care plan meetings were held in a timely manner and 3. review and revise the care plan to meet resident's needs. This was found to be evident for 5 (Resident #140, #120, #201, #232 and #285) out of 11 residents reviewed for care planning during the annual survey.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to store food in a manner that maintains professional standards of food service safety. This was evident during the initial tour of the kitchen during the annual survey.

Inspectors wroteBased on observations, interviews and record reviews, it was determined that the facility failed to 1) ensure appropriate personal protective equipment (PPE) was readily accessible and used by staff prior to entering the room of a resident on transmission based precautions, 2) ensure staff practiced infection control, 3) ensure that the environment was maintained in a manner that minimized the potential spread of infection and 4) ensure appropriate infection prevention and control practices were followed. This was evident for 1) 1 out of 2 residents (Resident #288) reviewed for transmission-based precautions, 2) 2 out of 7 residents (Resident #126, #150) observed for infection control, 3) 1 random observation of the laundry room, and 4) 1 out of 46 residents (Resident #14) reviewed during the annual survey.

Inspectors wroteBased on observations and interviews it was determined the facility failed to ensure a call bell was answered in a timely manner. This was found to be evident for 1 (Resident #126) out of 1 Resident observed for call bell response time during the recertification survey.

Inspectors wroteBased on interviews and record reviews it was determined that the facility failed to ensure showers were provided for a Resident. This was found to be evident for 1 (Resident #126) out of 1 Resident reviewed for self-determination during the recertification survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure that Advance Directives were discussed with residents and/or responsible representatives. This was for 1 (Resident #2) of 8 residents reviewed for Advance Directives.

Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to ensure the Ombudsman was notified of transfers and discharges. This was found to be evident for 2 (Resident #88 & #232) out of 2 Residents reviewed for hospitalization during the recertification survey.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS) Assessments were accurately coded for residents. This was evident for 2 (Resident #123 and #168) out of 46 sampled residents reviewed during the annual survey.

Inspectors wroteBased on clinical record review and interviews, it was determined the facility failed to provide residents and/or responsible representatives with summaries of their Baseline Care Plans. This was evident for 2 (Resident #3 and #14) of 46 residents reviewed during the annual /recertification survey.

Inspectors wroteBased on interviews and record reviews it was determined the facility failed to ensure Resident Care Plans were developed. This was found to be evident for 1 (Resident #6) out of 1 Resident reviewed for Care Plans during the recertification survey.

Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to ensure staff provided services that met professional standards of practice. This was found to be evident for 1 (Resident #88) out of 1 Resident reviewed for services meet professional standards of practice during the recertification survey.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide Activities of Daily Living (ADL) care to a dependent resident. This was found evident for 1 (Resident #20) out of 1 resident reviewed for ADL care.

Inspectors wroteBased on interviews and record reviews it was determined that the facility failed to ensure a Resident received treatment as ordered for a pressure ulcer. This was found to be evident for 1 (Resident #126) out of 1 Resident reviewed for pressure ulcer during the recertification survey.

Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to 1. date and label respiratory therapy equipment according to professional standards of practice and 2. ensure oxygen storage procedures were followed. This was evident for 2 (Resident #14 and #140) out of 5 residents reviewed for Respiratory Care during the annual survey.

Inspectors wroteBased on review of employees' files and interviews, it was determined that the facility failed to conduct Performance Reviews at least every 12 months for Geriatric Nursing Assistants (GNAs). This was evident for 1 (GNA #5) of 5 GNAs selected for reviews.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure medications were stored properly. This was found to be evident for 1 (Resident #229) out of 4 Residents observed for medication administration during the recertification survey.

Inspectors wroteBased on clinical record review, interviews and review of a complaint, it was determined the facility staff failed to maintain accurate medical records in accordance with accepted professional standards This was evident for 2 (#3, #285) out of 46 sampled residents reviewed during the annual survey.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure residents had access to call bells. This was evident for 2 (#140 & #120) of 46 Residents observed for call bell access during the annual survey.

Inspectors wroteBased on observations, interviews and record reviews, it was determined that the facility failed to maintain a safe, functional and sanitary environment for residents, staff and visitors. This was evident for 1 of 1 administrative hallways observed during the annual survey.

Inspectors wroteBased on review of employees' files and interviews, it was determined that the facility failed to provide continuing education training of no less than 12 hours per year for Geriatric Nursing Assistants (GNAs). This was evident for 2 (GNA #5 and GNA #22) of 5 GNAs selected for reviews.

Inspectors wroteBased on observations, staff interviews and review of medical record documentation, the facility failed to 1. maintain a safe and effective system for securing medication, treatment supplies, and hazardous medical equipment in their designated carts on nursing units with confused and wandering residents. Surveyors repeatedly observed these incidents on 2 of 5 floors. This has the potential to impact all residents, 2. ensure only authorized staff maintain a safe and effective system for securing medications in designated carts. This was found to be evident for 1 out of 2 medication carts located on the second-floor nursing unit observed during a tour of the facility. 3. label medication bottles when opened, discard expired medications and maintain proper temperatures for medications requiring refrigeration. [...]

Inspectors wroteBased on tours of the facility and staff interview it was determined that the facility staff failed to ensure the facility environment was maintained in a homelike manner. This was evident for 5 out of 5 floors.

Inspectors wroteBased on medical record review and interview, the facility staff failed to offer and/or obtain advance directives for residents (Resident #1, #8, #19, #22, #63, #87, #115, #176, #553). This was evident for 9 of 16 residents reviewed during an annual survey.

Inspectors wroteBased on interviews and review of the Facility Reported Incident (FRI) investigation documentation it was determined the facility failed to thoroughly investigate an allegation for: 1) abuse (Resident #316) and 2) misappropriation of funds (Resident #540). This was evident for 2 out of 2 residents (Resident# 316 and # 540) reviewed for conducting a throrough investigation.

Inspectors wroteBased on medical record review and staff interviewed it was determined that the facility failed to ensure the resident, and/or their responsible party, received written notification of a transfer to the hospital, including appeal rights and Ombudsman contact information (Residents #3, #22, #63, #94, #87, #107). This was found to be evident for 6 out of 13 residents reviewed for hospitalization during an annual survey.

Inspectors wroteBased on medical record review and interviews with resident and facility staff, it was determined that facility staff failed to 1.) appropriately code a resident's weight loss; and 2.) accurately code a resident's oral/dental status on the Minimum Data Set (MDS). This was evident for one out of one resident (#26) that was reviewed for both weight loss and oral/dental status.

Inspectors wroteBased on medical record review and interview with facility staff it was determined that the facility failed to revise Resident #26's plan of care accordingly after dental consults occurred. This was evident in 1 of 1 resident reviewed for dental problems. In addition, the facility staff failed to ensure care meetings were held for residents (#173 and #542). This was evident for 2 out of 53 residents reviewed during the annual survey.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to administer medications (Resident #204 and #161), failed to provide treatments and services (Residents #541, #555, #8, #201) as ordered by the physician and This was evident for 6 out of 103 residents reviewed during an annual survey.

Inspectors wroteBased on observation, interview and medical record review, it was determined the facility staff failed to follow up on urology concerns for residents (Resident #140, #534, #537, #108). This was evident for 4 of 103 residents reviewed during an annual survey. In addition the facility failed to keep resident's # 534 and # 537 clean and dry, This was evident for 2 out of 2 residents.

Inspectors wroteBased on clinical record review and staff interview it was determined that facility staff failed to ensure that a resident received medication according to the physician's orders. This was evident for 1 out of 53 residents in the survey sample.

Inspectors wroteBased on medical record review, observation and interview with resident and facility staff, it was determined that the facility failed to address and implement interventions for a resident with verbalized history of trauma. This was evident for 1 of 11 residents reviewed for trauma informed care (#242).

Inspectors wroteBased on medical record review and interview with facility staff it was determined that the facility staff failed to document an accurate overview of the resident during a physician visit. This was evident during 2 of 65 resident record reviews. (#242, #247)

Inspectors wroteBased on medical record review, observation and interview with resident and facility staff, it was determined that the facility failed to provide appropriate interventions for a resident with identified history of trauma. This was evident for 3 of 11 residents reviewed for behavioral and emotional concerns. (Resident # 242, #1 and # 109)

Inspectors wroteBased on clinical record review and staff interview it was determined that facility staff failed to ensure a resident received medication according to physician's orders. This was evident for 3 out of 53 residents in the survey sample. Resident (# 22, 242, 201).

Inspectors wroteBased on observation and clinical record review it was determined that the facility staff failed to ensure that residents received needed dental care (#22, #8, #210). This was evident for 3 out of the 53 residents in the survey sample.

Inspectors wroteBased on multiple random observations and interviews with facility staff, it was determined that the facility staff failed to maintain proper infection control practices while providing care to residents.

Inspectors wroteBased on tour of the facility and staff interview it was determined that the facility staff failed to ensure that handrails were secured to the walls.

Inspectors wroteBased on interviews and medical record review it was determined that the facility failed to notify a resident's Responsible Party of 1) an injury and 2) change in treatment. This was found evident of 9 (Residents #19, #22, #63, #87, #115, #176, #551, #553 and #556) of 10 residents reviewed for notifications during the facility's annual and complaint survey.

Inspectors wroteBased on record reviews and interviews it was determined the facility failed to provide a bed hold for a resident transferred to the hospital. This was found to be evident for 1 (resident #94) out of 1 residents reviewed for transfer and discharge.

Inspectors wroteBased on medical record review, interview with resident, and facility staff and observations, it was determined that the facility staff failed to appropriately code a residents mobility ability on admission Minimum Data Set (MDS). This was evident during the review of 1 of 9 (Resident #242) residents reviewed for positioning/mobility.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to develop and/or implement a resident's interdisciplinary care plan (Residents #1, #22 and #201). This was evident for 3 of 4 residents reviewed for care planning during an annual survey.

Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure nursing staff followed professional standards of practice. This was evident during 1 out of 2 medication administrations that were observed as part of the survey.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to provide grooming and personal hygiene services for a resident (Resident #3). This was evident for 1 out of 8 residents reviewed for activities of daily living (ADL) during an annual survey.

Inspectors wroteBased on interviews with staff and resident, and review of facility records, it was determined that the facility failed to have an activities program designed to meet the interests and needs of residents from both facility sponsored and individual activities based on the resident's comprehensive assessment and care plan. This was found evident of 1 of 2 residents reviewed for activities (Resident #114) during an annual survey.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to follow up and ensure ophthalmology services were obtained for Resident #140. This is evident for 1 of 4 residents reviewed for vision and hearing during an annual survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #1 and #554, 551). This is evident for 3 of 15 residents reviewed for pressure ulcers during an annual survey.

Inspectors wroteBased on interviews, record review, and observation it was determined that the facility failed to ensure Resident #201 was receiving proper foot care treatment. This was evident for one of one resident (#201) reviewed for foot care.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to follow up and implement interventions for a residents #231 and #57 with an identified impaired nutritional status. This was for 2 out of 53 residents reviewed within the survey sample.

Inspectors wroteBased on observations, interviews, and record review it was determined that the facility failed to provide post dialysis care consistent with professional standards of practice. This was evident of 1 of 4 Residents reviewed for dialysis during the annual survey (Resident #616).

Inspectors wroteBased on observation, resident interview, and staff interview it was determined that the facility failed to ensure properly working bedrails (#3). This was evident for 1 out of 53 residents in the survey sample.

Inspectors wroteBased on medical record review and observation and interview with resident and facility staff, it was determined that the facility failed to implement interventions to prevent potential trauma triggers as identified in the trauma screen in order to limit or prevent the exacerbation of a residents anxiety. This was evident during the review of 2 of 11 residents (#242, #1) reviewed for behavioral health services.

Inspectors wroteBased on medical record review and interview with resident and facility staff, it was determined that the facility failed to have non-pharmacologic interventions in place to address a resident's psychosocial well-being. This was evident for 2 of 11 residents reviewed for behavioral health. (residents # 1 and # 242).

Inspectors wroteBased on interviews, observation, and review of the facility's documentation, it was determined that the facility failed to accurately provide a meal based on the facility's established menu. This was evident of 1 of 2 residents (Resident #149) reviewed for accuracy of meals during an annual survey.

Inspectors wroteBased on observation and interview with facility staff it was determined that the facility failed to serve food at appetizing temperatures. This was evident on 2 of 2 meal tray delivery observations reviewed during an annual survey.

Inspectors wroteBased on observations and interviews with facility staff it was determined that the facility failed to store food in accordance with professional standards. This was evident of 2 of 5 kitchen observations done during the annual survey.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the provision of rehabilitation services for a resident who had surgery and was recommended to begin physical therapy by their surgeon. This was evident in one of one resident (#201) reviewed for rehabilitation services.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to ensure that a resident was scheduled for a necessary outside specialist provider appointment. This was evident for one out of one resident (#201) reviewed for wound care.

Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure that clinical records were maintained in a complete manner (#553, #262, #551, #56, #201). This was evident for 5 out of the 53 residents in the survey sample.

Inspectors wroteBased tour of the facility, observation, and staff interview it was determined that the facility staff failed to maintain patient care equipment. This was evident for 1 out of 5 floors toured.

Inspectors wroteBased on observation while touring the facility it was determined that the facility failed to ensure the facility was maintained in a safe manner.