Complete Care At Heritage Llc
COMPLETE CARE AT HERITAGE LLC in DUNDALK, MD — inspection on September 16, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/16/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Heritage LLC
7232 German Hill Road Dundalk, MD 21222
SUMMARY STATEMENT OF DEFICIENCIES
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] 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/16/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Heritage LLC
7232 German Hill Road Dundalk, MD 21222
SUMMARY STATEMENT OF DEFICIENCIES
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.
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.
Facility ID: