Complete Care At Heritage Llc
Inspection Findings
F-Tag F0677
F 0677 Level of Harm - Minimal harm or potential for actual harm
Goal: Resident's ADL needs will be met: bathing, grooming/personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting.
On 9/15/25 at 7:34 AM the surveyor requested documentation of showers for Resident #42 from January 2025 to present.
Residents Affected - Few
On 9/15/25 at 11:28 AM in an interview with the Nursing Home Administrator (NHA), he provided the Documentation Survey Reports from January 2025 to present and had highlighted “GG-Shower/Bathe Self”. The surveyor shared the concern that this section just documented
the resident's ability to shower/bathe and not whether the resident actually received a shower. The NHA verified and confirmed there was no evidence the facility could provide that Resident #42 had been given a shower in 2025. The surveyor shared this was a concern and the NHA verified and confirmed understanding.
FORM CMS-2567 (02/99) Previous Versions Obsolete
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
09/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Heritage LLC
7232 German Hill Road Dundalk, MD 21222
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-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm
On 9/15/25 at 10:01 AM review of Resident #174's medical record revealed s/he was admitted on [DATE REDACTED].
Further review of the medical record revealed the following order: Wound: (L) plantar foot - cleanse wound with ns [normal saline], pack with silver alginate, cover with abd [abdominal gauze pad, used to absorb discharges from draining wounds] pad then wrap with kling [a stretchy gauze bandage that sticks to itself].
Every day shift for wound care AND as needed for wound care. This was ordered on 10/31/23.
Residents Affected - Few
On 9/15/25 at 11:39 AM in an interview with the Director of Nursing (DON) the concern was shared that the resident's wound treatment was not cleaned or dressed until two days after his/her admission. During the interview, a dual observation of the resident's October TAR [Treatment Administration Record] the wound treatment order Resident #174's left foot wound was observed with an order date of 10/31/23. The surveyor shared the concern that this treatment was not ordered until two days after the resident was admitted to the facility. The DON acknowledged the concern and stated she would see if there was any additional documentation/evidence of earlier wound treatment.
On 9/15/25 at 12:57 PM in an interview with the DON she stated she looked and there was no additional wound treatment order aside from the 10/31/23 order. The surveyor shared this was a concern and the DON confirmed understanding.
On 9/15/25 at 12:59 PM review of Resident #174's physician orders and his/her October 2023 MAR revealed the following orders for IV antibiotics: - Vancomycin Intravenous Solution, order date: 10/29/23 12:00 PM.
There were no doses documented as administered by nursing staff in the MAR [Medication Administration Record]. - Vancomycin Intravenous Solution, order date: 10/29/23 10:48 PM
The first dose documented as administered by nursing staff in the October MAR was on 10/30/23.
On 9/15/25 at 12:29 PM review of the Medication Administration Audit Report [MAAR] for Resident #174 revealed the IV vancomycin (antibiotic) was first scheduled for 10/30/2023 at 9:00 AM and first administered 10/30/2023 at 11:57 AM; however, the resident was admitted to the facility on [DATE REDACTED] at 11:02 AM.
On 9/15/25 at 2:27 PM in an interview with the NHA he stated there were no additional orders for the IV vancomycin aside from the one ordered a day after Resident #174's admission. The surveyor shared this a concern and the NHA acknowledged understanding.
FORM CMS-2567 (02/99) Previous Versions Obsolete
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
09/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Heritage LLC
7232 German Hill Road Dundalk, MD 21222
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-Tag F0697
F 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm or potential for actual harm
Based on investigating complaints, medical record review, and staff interview it was determined that the facility failed to provide pain management timely. This was found to be evident for one (Resident #178) out of 10 residents reviewed for pain management during the recertification/complaint survey.
Residents Affected - Few
The findings include:
A complaint review on 09/11/25 at 9:00 AM showed that a complainant reported that Resident #178 experienced severe pain from approximately 9:00 PM on 05/12/24 until 10:20 AM on 05/13/24. The resident was reported to have cried and screamed in pain, but no pain assessment or medication was provided.
On 9/11/25 at 9:57 AM, a review of Resident #178's medical records revealed that the resident was alert and oriented with a BIMS score of 15/15. A progress notes dated on 5/12/24 at 10:58 AM documented that
the resident complained of bilateral leg pain with a pain level of 10/10, indicating severe pain. Additional progress noted dated 5/12/24 at 15:10 (3:10 PM) documented that “…MD ordered routine typenol 1000mg q 12 hrs and Tylenol 650 mg q 6 PRN (as needed), Tylenol 1000mg administered, lidocaine patch administered, resident repositioned. Approximately 10 mins after medications was administered, family visited.” The transfer form for Resident #178 was documented that he/she was transferred to the hospital on 5/12/24 at 4:30 PM.
On 9/11/25 at 10:30 AM, review of the Medical Administration Record (MAR) showed no documentation to support that Tylenol was ever administered to the resident on 05/12/24 Additionally, there was no pain assessment documented in the medical record.
On 09/10/25 at 10:33 AM, Staff #28 (Registered Nurse) stated that every resident is evaluated for pain every shift. This statement contradicts the lack of a documented pain assessment for Resident #178.
The Director of Nursing (DON), interviewed on 09/11/25 at 11:50 AM, confirmed that if staff noted a resident's pain, it should be managed immediately and all medication administration must be documented
in the MAR. The DON also confirmed that the five-hour gap between the initial documentation of pain at 10:58 AM and the resident's transfer to the hospital at 4:30 PM was a failure to address the resident's pain
in a timely manner.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
COMPLETE CARE AT HERITAGE LLC in DUNDALK, MD inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DUNDALK, MD, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from COMPLETE CARE AT HERITAGE LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.