Complete Care at Hagerstown: Staff Training Failures - MD
She told inspectors she had no copy of the previous administrator's assessment either. Nobody had made one.
That gap sits at the center of what federal inspectors found at Complete Care at Hagerstown during a complaint inspection that concluded January 29, 2026. The facility's required staff training program, the one that covers resident rights, elder abuse, infection control, behavioral health and more, had been running for years without anyone verifying that staff were actually completing it. When inspectors pulled training records, the results were stark.
A Licensed Practical Nurse, identified in the inspection report as LPN #43, had last completed any computerized training modules in 2022. That's three years without documented completion of annual requirements that include recognizing abuse and controlling infection.
A Geriatric Nursing Assistant identified as GNA #37 completed four computer-based modules in 2024. Of the required training topics, abuse was the only one listed among those four. Before that, she had completed no computerized training since 2021. That's a three-year gap, followed by a partial catch-up that still left most required topics untouched.
Two other nursing assistants, GNA #14 and GNA #36, had not completed their computerized training modules since 2024. A laundry aide identified as Laundry Aid #44 had not completed Resident Rights training since 2023 and had never completed an infection control module that included the facility's own policies and procedures.
The infection control gap runs deeper than individual employees missing modules. Inspectors reviewed the facility's computer-based training program and found that the infection control module itself failed to include the facility's specific policies and procedures for infection prevention and control. Staff who did complete it were not actually learning how the facility they worked in handled infection prevention.
The orientation materials had their own problem. A review of the facility's orientation PowerPoint presentation on January 22 found that behavioral health topics had been left out entirely, despite the fact that a proper facility assessment would have identified the behavioral health needs of the resident population and required that training to address them. Without the assessment, nobody had determined what those needs were. Without that determination, the training program had no way to address them.
The person responsible for the training program explained how it worked. The Corporate Clinical Resource Nurse, identified as Staff #3, had served as interim Director of Nursing until December 1, 2025, and was now covering as the Nurse Practice Educator. She told inspectors that the corporate office determined the training topics and periodically sent a list to the facility. The corporate office assigned each employee a list of modules to complete each year. The modules existed. The assignments went out.
But the facility, she said, had no way to ensure that staff actually completed them.
That sentence describes the entire problem. A training system that assigns work and then never checks whether the work gets done is not a training system. It is a list. The LPN who last trained in 2022 was presumably assigned modules in 2023, 2024, and 2025. The nursing assistant who hadn't completed required training since 2021 was presumably assigned modules in the years that followed. The assignments existed on paper. The completions did not.
The nursing home administrator was presented with these findings on January 27 at 4:28 in the afternoon. According to the inspection report, she offered no rationale for the deficient practice.
That response, or the absence of one, matters. An administrator who can explain a gap, who can point to a system failure and describe what went wrong, gives inspectors and the public something to evaluate. An administrator who offers nothing leaves the record exactly as it stands: staff working with residents for years without completing training the facility itself assigned them to do, and no one in a position of authority able to say why.
The facility assessment problem compounds everything else. The administrator told inspectors on January 16 that she had been back in her position since August 2025 and had not completed a facility assessment since returning. The assessment is the document that drives the training program. It identifies the specific characteristics of the resident population, including their medical needs, their behavioral health needs, and the level of care complexity staff will encounter. A training program built without one is built on assumptions, or on whatever the previous administrator thought was important, or on nothing in particular.
The orientation presentation missing behavioral health content is a direct result. Without an assessment identifying what behavioral health needs exist among residents, nobody flagged the omission. The presentation went out to new employees without it.
Behavioral health in a nursing home population covers a wide range: residents with dementia, residents with depression, residents managing anxiety or agitation, residents whose behavior can be difficult to interpret or respond to safely. Staff who haven't been trained on behavioral health topics specific to the people they care for are less equipped to recognize when a resident is in distress, less equipped to de-escalate a difficult moment, and less equipped to distinguish a behavioral symptom from a medical one.
The inspection report rates the level of harm as minimal harm or potential for actual harm, and notes that many residents were affected. That rating reflects where inspectors placed the violation on the federal scale, not a finding that no harm occurred. Training failures of this duration, across this many staff members, in topics including abuse recognition and infection control, represent years of accumulated risk in a setting where residents depend entirely on the people caring for them.
The laundry aide who hadn't completed Resident Rights training since 2023 works in a facility where residents have rights that every employee is expected to understand and uphold. The nurse who last trained in 2022 has spent three years without documented completion of the annual requirements her employer assigned. The nursing assistant who completed four modules in 2024, with abuse as the only required topic represented, had been working since 2021 without the rest.
Complete Care at Hagerstown is located at 14014 Marsh Pike. The inspection was a complaint survey. The administrator who returned to her position in August 2025 had not, by the time inspectors arrived in January 2026, produced a facility assessment or a training program grounded in one.
When inspectors laid out what they found, she had nothing to say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Hagerstown from 2026-01-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
COMPLETE CARE AT HAGERSTOWN in HAGERSTOWN, MD was cited for violations during a health inspection on January 29, 2026.
She told inspectors she had no copy of the previous administrator's assessment either.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.