Complete Care At Hagerstown

F 0610 Level of Harm - Minimal harm or potential for actual harm

felt safe or had concerns with GNA #2, and without asking staff whether they had observed concerning behaviors, the facility's investigation did not constitute a thorough investigation. 2). A review of a facility-reported incident #2609546 on 10/20/2025 at 9:02 AM, contained an allegation of neglect by Resident #4 involving a staff member.

Residents Affected - Few Further review of the facility's investigation into the allegation included statements from the alleged perpetrator and other staff who may have witnessed or been aware of the event.

The review also noted that the alleged perpetrator had been suspended pending an investigation into the allegation.

A continued review showed that five residents on the alleged perpetrator's assignment on 9/5/25 were interviewed regarding the care they received, and no concerns were identified.

However, the review failed to show that the facility had completed a thorough investigation, including a head-to-toe assessment of the other residents who had been cared for by the alleged perpetrator on 9/5/25 and could not speak for themselves when the perpetrator was assigned to take care of about 15 residents that shift.

In an interview on 10/20/2025 at 12:42 PM, the Director of Nursing (DON) reported that as part of the investigation into the allegation, she interviewed some residents on the alleged perpetrator's assignment who were alert and could speak for themselves, however she did not do a head-to-toe assessment for the other residents on the GNA's assignment who could not speak for themselves.

The DON verbalized understanding of the concern of not thoroughly investigating the allegation.

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

10/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Hagerstown

14014 Marsh Pike Hagerstown, MD 21742

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 0677

health record (EHR) and reported that Resident #5's showers were not scheduled.

Level of Harm - Minimal harm or potential for actual harm

During an interview on 10/21/2025 at 11:44 AM, the DON stated that the facility had identified an issue in which the paper shower schedules on the units did not match the shower schedules in the EHR. However,

after the surveyor's intervention, staff #3 made her aware that the problem still existed.

Residents Affected - Few

The DON added that there was no additional evidence that Resident #5 received his/her showers on the other days in July, August, September, and October. 3) A review of Resident #8's clinical record revealed that he/she had fallen at home, been hospitalized with serious medical concerns and was then transferred to the facility on 9/05/25 for rehabilitation and nursing care.

On 10/20/25 at 8:30 AM a review of complaint #2640271 revealed an allegation that the facility failed to provide personal care to Resident #8 on more than one occasion. On 10/20/25 at 11:19 AM, in a telephone

interview with the complainant, they reaffirmed the concerns.

On 10/20/21 at 2:26 PM a review of the Geriatric Nursing Assistant (GNA) care documentation for Resident #8 revealed multiple shifts with blanks where no care was documented. On 9/05/25 the spaces to document care was blank for two of three shifts for personal hygiene, eating, dressing and toileting hygiene.

On 10/21/25 at 8:05 AM an interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) to review the concern that a complainant alleged the facility failed to provide personal care to Resident #8, and that the clinical record lacked documentation that care was provided.

When the DON was asked what would be documented if a resident refused care, she said the record would have an entry that reflected that. When asked if no entry – a blank space- meant that the resident did not get care she said she did not know for sure. When asked how the DON ensured that residents received ADL care she said that she did rounds, and the night supervisor, and charge nurses also made rounds. She also said she reviewed documentation for completeness and followed up with employees when deficiencies were found. She said she was unaware of Resident #8's lack of documentation.

On 10/21/25 at 11:43 AM an interview was conducted with the NHA to review the finding that the facility failed to provide personal care to Resident #8. She acknowledged the finding and provided no further evidence prior to the end of the survey.

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

10/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Complete Care at Hagerstown

14014 Marsh Pike Hagerstown, MD 21742

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on record review and interview it was determined that the facility failed to ensure that resident records were accurate and complete. This was evident for 1 resident (Resident #8) of 2 residents reviewed for neglect.The findings include:On 10/20/25 at 8:30 AM a review of Resident #8's clinical record revealed that the resident was transferred to the hospital on 9/10/25 due to shortness of breath.On 10/21/25 at 10:04 AM an interview was conducted with the Director of Nursing (DON). When asked about treatment for the resident's shortness of breath, the DON explained that the resident experienced a change in condition on 9/09/25 and that Resident #8's on call provider gave new orders for oxygen and other treatments. The DON provided a copy of a document dated 9/09/25, titled Change in Condition, written by Licensed Practical Nurse (Staff #4). It noted that PRN [as needed] O2 [oxygen] 2L [at two liters/minute]. Further review of the

record failed to reveal any physician's order for the oxygen use.On 10/21/25 at 11:43 AM the DON was interviewed again and she confirmed that no order for oxygen was entered into Resident #8's medical record.

Event ID:

Facility ID:

If continuation sheet