Complete Care At Hagerstown
COMPLETE CARE AT HAGERSTOWN in HAGERSTOWN, MD — inspection on October 21, 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
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.
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/21/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Hagerstown
14014 Marsh Pike Hagerstown, MD 21742
SUMMARY STATEMENT OF DEFICIENCIES
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.
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/21/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at Hagerstown
14014 Marsh Pike Hagerstown, MD 21742
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID: