14014 Marsh Pike, Hagerstown, MD 21742 · Washington County · (301) 733-8700
60 certified beds, about 86 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 2018
CMS Care Compare ratings, data as of September 1, 2026 · CCN 215365 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on July 14, 2026, inspectors cited 21 health deficiencies (the Maryland average is 17, the national average 9.2).
Of 102 health citations since July 2021, 3 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 2 fines totaling $43,352 in the last three years; the largest was $29,270, and the latest is dated January 29, 2026.
Nurses and nurse aides worked 3.92 hours per resident per day, against 3.87 across Maryland and 3.86 nationally. Registered nurses accounted for 0.99 of those hours.
56.0% of nursing staff left within the year CMS measured (Maryland average 40.2%).
CMS links it to Complete Care, an affiliated group of 85 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 102 health citations on file.
Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure advance directive documentation was maintained and readily accessible in the resident's medical record for1 (Resident #17) of 1 residents reviewed for advance directives.
Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to follow resident grievance requirements by failing to provide the resident with a written grievance decision that included the required investigation findings and outcome and failed to follow its own grievance policy and procedure. This was evident for 1 (Resident #19) out of 7 residents investigated for potential abuse related to Facility Reported Incident (FRI) #3017272.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to conduct thorough investigations of allegations of neglect prior to concluding the allegations were unsubstantiated for 2 (Resident #41 and Resident #70) of 2 residents reviewed with facility reported incidents.
Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment. This was found to be evident for one (Resident #5) out of five residents reviewed for unnecessary medications.
Inspectors wroteBased on medical record review and interview it was determined that the facility failed to develop a comprehensive care plan. This was found to be evident for one (Resident #5) out of one resident reviewed for communication.
Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure care plan meetings were conducted following the Minimum Data Set Assessment completion. This was found to be evident for one (Resident #12) out of five residents reviewed for unnecessary medications.
Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure staff accurately documented the provision of care. This was found to be evident for one (Resident #5) out of five residents reviewed for unnecessary medication.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to provide necessary Activities of Daily Living (ADL) care, including timely incontinence care, for a resident. This was evident for 1 (Resident #37) of 2 residents reviewed for ADL care and investigation of a facility-reported incident (FRI #3038101).
Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to ensure activities were provided as indicated in the resident's care plan. This was found to be evident for two (Resident #10 and #7) out of two residents reviewed for activities.
Inspectors wroteBased on medical record reviews and interviews, it was determined that the facility failed to ensure the rotation of insulin injection sites for residents receiving multiple daily insulin injections and failed to report a resident's change in medical condition to a supervisor. This was evident for 1 (Resident #7) of 5 residents reviewed for unnecessary medications, 1 (Resident #59) of 1 resident reviewed for insulin use, and 1 (Resident #19) of 7 residents reviewed for potential abuse related to Facility Reported Incident (FRI #3017272).
Inspectors wroteBased on medical record review and interview it was determined that the facility failed to address the resident's needs in regard to a hearing aid. This was found to be evident for one (Resident #5) out of one resident reviewed for communication needs.
Inspectors wroteBased on interviews, observations, and record reviews, it was determined that the facility failed to protect a dependent resident from injury while using Hoyer lift equipment. This was evident for 1 (Resident #59) of 7 residents investigated for potential abuse related to a facility reported incident (FRI #3003045) and an anonymous complaint (#3005562).
Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure residents receiving hemodialysis received care and services consistent with professional standards of practice for 2 (Residents #4 and #26) of 2 residents reviewed for hemodialysis services.
Inspectors wroteBased on medical record review and interview it was determined that the facility failed to have an effective system in place to ensure monthly pharmacy review recommendations were addressed by the providers in a timely manner. This was found to be evident for two (Resident #12 and #7) out of the five residents reviewed for unnecessary medications.
Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure resident's were free from unnecessary medications. This was found to be evident for 2 (Resident #5 and #7) of 5 residents reviewed for unnecessary medications.
Inspectors wroteBased on record review and interview it was determined that the facility failed to ensure abnormal laboratory results were uploaded into the resident's electronic medical record in a timely manner. This was evident for 1 resident (Resident # 48) of 1 resident reviewed for pressure ulcer care during the annual survey.
Inspectors wroteBased on interview and record review it was determined that the facility failed to follow up on a resident's need for oral surgery. This was evident for 1 resident (Resident #11) of 1 resident reviewed for dental care during the recertification survey.
Inspectors wroteBased on interview and review of facility documentation it was determined that the facility failed to have a qualified food service director. This was found to be evident for the one out of one food service director at the facility.
Inspectors wroteBased on observation, review of menus and medical records and interviews it was determined that the facility failed to ensure menus were followed. This was found to be evident for one out of one pureed test tray observed and has the potential to affect any resident who requires pureed texture foods.
Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety. This has the potential to affect all residents.
Inspectors wroteBased on record review and interviews it was determined the facility staff failed to ensure MOLST (Medical Orders for Life Sustaining Treatment) forms were voided and filed in the resident records and to ensure medical records were complete and accurately documented. This was evident for 1 (#94) of 4 residents reviewed for Advance Directives and for 1 (Resident #10) of 6 reviewed for accidents.
Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to maintain a homelike environment as evidenced by a stained ceiling tile in a resident's room and damaged drywall behind a residents' bed. This deficient practice was evidenced in 2 (#301, #302) of 2 rooms located on the unit [NAME] that were assessed during the complaint survey.
Inspectors wroteBased on record review and interview it was determined that the facility staff failed to clarify a verbal order for a resident to receive intravenous fluids. This deficient practice was evidenced in 1(Resident #2) of 5 medical records reviewed for medical staff adhering to physician orders during the complaint survey.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that their resident received care and treatment for wounds. This was evident for 1 (Resident #1) of 1 resident reviewed for wounds.
Inspectors wroteBased on record review and interview it was determined that the facility failed to identify a cognitively impaired resident as an elopement risk and implement interventions to prevent elopement. This was evident for 1 (#6) of 1 resident reviewed for elopement. As a result of these findings, a state of immediate jeopardy (IJ) was declared on 1/15/26 at 3:50 PM and an IJ summary tool was provided to the facility at that time. The facility submitted the first draft of their plan to remove the immediacy on 1/15/26 at 5:35 PM and it was not accepted. The facility submitted a second draft at 6:23 PM, and it was not accepted. The third draft was submitted at 6:38 PM and the facility's written plan to remove the immediacy was accepted on 1/15/26 at 7:00PM. After the immediacy was removed, the noncompliance was determined to continue with a scope and severity of D.
Inspectors wroteBased on record review and interview, it was determined that facility staff failed to develop a process to ensure that nurse aides had annual performance evaluation of their skills to allow them to determine weaknesses in the nurse aide's performance and provide training based on those weaknesses. This was evident for 3 (#37, #14, and #36) of 3 staff reviewed for performance evaluations.
Inspectors wroteBased on medical record review, interview with facility staff and review of facility policy, it was determined that the facility administration allowed consultations to be completed in the facility without established contracts with said company and without an order from the residents' attending physician. This was evident for at least 5 residents reviewed (R#16, #1, #7, #10, #19) during the survey.
Inspectors wroteBased on record review and interview, facility staff failed to develop and implement an effective training plan to ensure that staff, contracted staff, and volunteers receive the required trainings and other appropriate training topics and frequency of training based on their facility assessment. This was evident during the extended survey.
Inspectors wroteBased on record review and interview, it was determined that facility staff failed to develop and implement a nurses' aide training program to ensure that each nurses' aide received 12 hours of training annually and that the training was included on weaknesses that were identified during their annual performance evaluation. This was evident for 3 (#37, #14, and #36) of 3 staff reviewed for performance evaluations.
Inspectors wroteBased on review of facility documents, staff interview and review of facility policy it was determined the facility failed to report allegations of abuse or neglect immediately but not later than 2 hours after an allegation was made. This was evident for 5 (#8, #4, #10, #1, and #9) of 8 residents reviewed for abuse during a complaint survey.
Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility staff failed to enhance residents' dignity by failing to address a resident's activities of daily (ADL) needs in a timely fashion (Resident #7) and respect their preferences regarding the time frame they did not want to be disturbed while sleeping (Resident #4). This was evident during a random for 2 of 8 residents reviewed for abuse allegations.
Inspectors wroteBased on the review of facility reported incidents, interview and review of facility policy, it was determined that a facility staff member failed to treat a resident with respect and dignity by failing to provide care to a dependent resident (Resident #10) and free from intimidation (Resident #1) . This was evident during the review of 2 of 10 residents reviewed and the related facility reported incidents.
Inspectors wroteBased on record review, interview and review of facility policy, it was determined that the facility failed to ensure the safety of all residents by sending an employee home or away from patient care immediately when there was an allegation/concern of abuse. This was evidenced by the review of 1 of 10 facility reported incidents.
Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility staff failed to report a medication error when they became aware, putting the resident at risk of discomfort and even death. This was evident during the review of 1 of 3 residents (R#16) reviewed during a complaint survey.
Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the physicians failed to have their notes in the medical record timely after seeing residents and complete a total review of the residents' plan of care and appropriately implement said plans and treatment. This was evident for 2 of 2 (R#16, R#15) residents reviewed and 4 of 4 physicians reviewed during a complaint survey.
Inspectors wroteBased on the review of resident records, a facility reported incidents and a review of employee files and interviews, it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) were competent with their skill sets. This was found to be evident for 2 of 2 employee files reviewed for competencies and skill sets.
Inspectors wroteBased on medical record review, interview and review of facility policies and procedures it revealed that the facility failed to ensure that the facility staff administered medication without ensuring there was duplicate therapy being administered. This was evident for 1 of 3 residents reviewed during the complaint survey for medication errors.
Inspectors wroteBased on record review and interview, it was determined that facility staff failed to: 1) ensure appropriate conditions in place, including contracts and physician orders when having a consultant in their facility, 2) complete a facility assessment and use this information to develop and implement a training program for all staff 3) ensure that all staff, contracted staff and visitors had the required trainings on hire and ongoing, and 4) evaluate the skill performances of their nurses aides and ensure that they had 12 hours of training annually. This was evident throughout the complaint survey.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to establish and implement a process for the mode of communication, how often communication occurs, and what was to be communicated between the administrator and governing body. This was evident during the complaint and extended survey.
Inspectors wroteBased on record review and staff interview, it was determined that facility staff failed to complete a facility assessment as required. This was evident during the extended survey review.
Inspectors wroteBased on record review and interview, it was determined that facility staff failed to ensure that the Infection Preventionist was in attendance to the Quality Assurance and Performance Improvement (QAPI) committee meetings. This was evident for 5 of 10 meetings reviewed.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to thoroughly investigate allegations of abuse and neglect. This was evident for 1 (Resident #2) of 9 facility-reported incidents reviewed for abuse and for 1 (Resident #4) of 9 facility-reported incidents reviewed for neglect.
Inspectors wroteBased on record reviews and staff and resident interviews, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADL) received the necessary personal care. This deficient practice was evident in 3 of 9 facility-reported incidents reviewed during the complaint survey, affecting Residents #4, #5, and #8.
Inspectors wroteBased 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.
Inspectors wroteBased on observation and interviews, it was determined that the facility staff failed to wear beard restraint in the kitchen. This was evident in 2 of 4 observations of meal preparation in the kitchen during the recertification survey.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that the most recent facility survey was readily accessible to residents, family members, and legal representatives of residents. This was evident for 1 Survey binder out of 1 survey binder reviewed during a survey.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to provide information to a resident to formulate an advanced directive. This was evident for 1 (Resident #4) of 4 residents reviewed for advanced directives.
Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to notify attending physician, Residents' representative, and registered dietitian in a timely manner when there were documented changes in residents' condition. This was evident for one out of three complaints reviewed during the recertification survey and one (#56) out of three Residents reviewed for tube feeding.
Inspectors wroteBased on observations and resident and staff interviews, it was determined that the facility failed to exercise reasonable care for the protection of the Resident's property from loss or theft. This was evident for one (Resident #18) reviewed during the recertification survey.
Inspectors wroteBased on record reviews and resident and staff interviews, it was determined that the facility failed to identify a Grievance Official in the facility's grievance policy, ensure that the policy in place processed grievances, and make prompt efforts to resolve a Resident's grievance. This was evident in one grievance investigation reviewed during the recertification survey.
Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure residents were free from unnecessary psychotropic medication, as evidenced by the lack of documentation for non-pharmacological interventions (NPIs) and adequate indication for its use. This was evident for 1 (#35) of 5 residents reviewed for unnecessary medications.
Inspectors wroteBased on record review and interviews, it was determined that the facility failed to provide written transfer notice and written bed hold policy to a Resident's representative upon transfer to an acute care facility. This was evident for 1 (#274) of 5 residents reviewed for hospitalization.
Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the residents' medication usage. This was evident for one (Resident #31) out of one resident reviewed for Resident Assessment.
Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure a required Level II Preadmission Screening and Resident Review (PASARR) evaluation was completed for 1 (#68) of 3 Residents reviewed for PASARR compliance during the recertification survey.
Inspectors wroteBased on record review, interviews, and observations, it was determined that the facility failed to develop and implement comprehensive resident-centered care plans for residents. This was evident for 2 (#7, #276) of 32 residents reviewed during the recertification survey.
Inspectors wroteBased on record review and interviews, it was determined that the facility failed to provide a Resident with the amount of assistance needed during meals. This was evident for 1 out of 3 complaints reviewed during the recertification survey.
Inspectors wroteBased on medical record review, interviews, and observations, it was determined that the facility failed to provide an ongoing program of activities to meet the needs and preferences of residents. This was evident for 2 (#7, #276) out of 3 residents reviewed for activities.
Inspectors wroteBased on interviews, observations, and record review, it was determined that the facility failed to assist a resident in gaining access to hearing services to maintain hearing abilities. This was evident for one resident (#18) investigated during the recertification survey.
Inspectors wroteBased on medical record review, interview, and observation, it was determined that the facility failed to ensure wound care orders were entered correctly into the electronic health record and failed to ensure an air mattress was kept at the correct setting. This was evident for one (#7) out of three Residents reviewed for pressure ulcers.
Inspectors wroteBased on observation and staff interview it was determined that the facility failed to ensure toxic chemicals were stored safely and appropriately. This was evident when toilet bowl cleaner was found in 1 ([NAME] Hall Pantry) of 4 nourishment pantries inspected during the recertification survey.
Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to manage a resident's pain effectively. This was evident for 1 out of 3 complaints reviewed during the recertification survey.
Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that a resident with a history of trauma received the appropriate trauma-informed care. This was evident for 1 (#74) of 32 residents reviewed during the recertification survey.
Inspectors wroteBased on pertinent document review and interview, it was determined that the facility failed to ensure that Geriatric Nursing Assistants (GNAs) received annual performance reviews. This was evident for 2 GNAs (GNA #14 and GNA #6) of 3 GNAs reviewed during the Sufficient and Competent staffing task portion of the recertification survey.
Inspectors wroteBased on observation, staff interviews, and record review, it was determined that the facility failed to establish systems to accurately reconcile controlled medications using acceptable standards of practice. During observation of the facility's narcotic books, it was observed that 1 of 4 narcotic reconciliations was inaccurately documented during the recertification survey.
Inspectors wroteBased on records review and interviews, it was determined that the facility failed to 1a) ensure pharmacy recommendations were reported to the facility in a timely manner, 1b) specify all necessary timeframes for the steps in the Medication Regimen Review (MRR) policy and 2) ensure that an attending provider documented in residents medical record that pharmacist's recommendations were reviewed and stated what if any, actions were taken to address them. This was evident for 2 (#35, #18) of 5 residents reviewed for unnecessary medications.
Inspectors wroteBased on records review and interviews, it was determined that the facility failed to ensure residents were free from unnecessary medications. This was evident in 1 (Resident #35) of 5 residents reviewed for unnecessary medications.
Inspectors wroteBased on observation and interviews, it was determined that the facility failed to 1) maintain medical products within expiration dates and in a secure location and 2) have a system to secure access to controlled medications. This was evident during the recertification survey.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to provide routine dental services to a resident. This was evident in 1 (Resident #19) of 1 resident reviewed for dental care.
Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to ensure the orders for life sustaining treatment in the electronic health record matched the orders found on the Maryland Orders for Life sustaining Treatment (MOLST) form and failed to ensure the accuracy of physician orders. This was evident for one (#56) out of four residents reviewed for advance directives and one (Resident #71) of 3 system selected closed record reviews during the recertification survey.
Inspectors wroteBased on observations, record review and staff interviews, it was determined that the facility failed to ensure staff use appropriate infection control practices. This was evident for 3 (#18, #51, #425) out of 32 residents reviewed during the recertification survey.
Inspectors wroteBased on pertinent document review and interviews, it was determined that the facility failed to offer the current COVID-19 vaccination or document the refusal for the current COVID vaccine for their staff. This was evident for 5 out of 6 staff reviewed for Infection Control during a survey.
Inspectors wroteBased on record review, observations and facility interviews, it was determined that the facility failed to maintain safe operating condition of facility exits equipped with the WanderGuard System, potentially affecting six residents identified as elopement risk. This was evident for 1 of 2 exits alarmed with the WanderGuard System investigated during the recertification survey.
Inspectors wroteBased on record review, staff interviews, and review of facility policy Pressure Injury Prevention and Management, the facility failed to provide wound care to one resident (R#1) of 5 residents reviewed for pressure ulcers. This resulted in R#1's stage 3 pressure ulcer to worsen resulting in hospitalization.
Inspectors wroteBased on record review and staff interview it was determined that the facility failed to 1.) ensure that residents were free of accidents and 2) ensure that interventions were initiated after a fall to prevent recurrence. This was evident for 1 (#31) of 17 residents reviewed for abuse and 1 (#12) of 6 residents reviewed for falls. The deficient practice resulted in actual harm to resident # 31.
Inspectors wroteBased on record review and interview it was determined that facility staff failed to ensure that all allegations of abuse were reported to the state agency within the required 2-hour timeframe. This was evident for 2 (#31 and #29) of 17 residents reviewed for abuse.
Inspectors wroteBased on observation, record review, and interview it was determined that facility staff failed to treat their residents with dignity. This was evident for 1 (#31) of 17 residents reviewed for abuse.
Inspectors wroteBased on record review and staff interview it was determined that the facility failed to conduct a thorough investigation of an allegation of abuse and to ensure that an employee had access to vulnerable residents until it was determined they abused the resident or not. This was evident for 1 (#31) of 17 residents reviewed for abuse.
Inspectors wroteBased on record review, staff interview, and review of facility policy Care Plans, Comprehensive Person-Centered , the facility failed to implement a care plan for 1 resident (R#1) of 8 residents reviewed.
Inspectors wroteBased on observation, record review, and staff interview it was determined that facility staff failed to provide pain management in accordance with standards of professional practice. This was evident for 1 (#31) of 1 resident reviewed for pain management.
Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 2 (#32, #42) of 5 residents reviewed for hospitalization during the annual survey.
Inspectors wroteBased on medical record review and resident and staff interview, it was determined the facility failed to provide the resident or resident representative with a summary of their baseline care plan and a summary of their medications on admission. This was evident for 2 (#42, #1) of 5 residents reviewed for hospitalization, and 1 (#11) of 2 residents reviewed for Dementia Care.
Inspectors wroteBased on medical record review and staff interview, it was determined that facility staff failed to develop and initiate comprehensive, resident centered care plans with measurable goals. This was evident for 7 (#32, #63, #107, #64, #38, #1, #27) of 47 residents reviewed during the annual survey.
Inspectors wroteBased on medical record review, observation and interview, it was determined that the facility failed to ensure that nursing staff administered medications via g-tube according to accepted professional standards resulting in the administration of more than the resident's entire daily requirement of water during the administration of morning medications; and failed to ensure that staff did not document the administration of a medication that had not been given. This was found to be evident for two out of four residents (Resident #1 and #4) observed during medication administration observation.
Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to keep a resident's drug regimen free from unnecessary drugs by 1) failing to follow physician ordered blood pressure parameters for administering a blood pressure medication, 2) failing to have all medications included for a bowel regimen and have indications on when to administer, and, 3) failing to ensure a resident did not have duplicate orders for the same medication. This was evident for 2 (#32, #1 ) of 5 residents reviewed for unnecessary medications during an annual survey.
Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to ensure that a psychotropic medication was prescribed as needed for 14 days was transcribed and administered as ordered. This was evident for 1 (#42) of 5 residents reviewed for hospitalization.
Inspectors wroteBased on observation, interview and medical record review, it was determined that the facility failed to ensure a medication error rate of less than 5% as evidenced by 4 errors out of 28 opportunities for errors. This was found to be evident for 3 out of 4 residents (Resident #4, #2 and #1) observed during medication administration observation.
Inspectors wroteBased on interview and review of medical records and other pertinent documentation, it was determined that the facility 1) failed to ensure that the infection preventionist kept a line listing of residents and staff that were exhibiting signs and symptoms of infections to assist with the surveillance of infections in the facility, and 2) failed to ensure that facility staff failed to wear a face mask appropriately. This was found during review of the infection control program and surveyor observations and had the potential to affect all the residents.
Inspectors wroteBased on surveyor observation during an annual recertification of the facility, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident for 3 resident rooms and one resident hallway.
Inspectors wroteBased on review of facility documents and staff interview, it was determined the facility failed to report an allegation of an injury of unknown injury to the State Agency, the Office of Health Care Quality (OHCQ), immediately but not later than 2 hours after the abuse allegation are made. This was evident for 1 (#59) of 11 residents reviewed for abuse.
Inspectors wroteBased on review of facility reported incident investigations and interview, it was determined the facility failed to thoroughly investigate allegations of abuse, including an injury of unknown injury. This was evident for 2 (#58-1, #59) of 11 residents reviewed for abuse.
Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to document that information was provided to the acute care facility when a resident was transferred there emergently. This was evident for 1 (#32) of 5 residents reviewed for transfer to an acute care facility.
Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #32) of 5 residents reviewed for unnecessary medications and 1 (#63) of 2 residents reviewed for neglect.
Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff who evaluate care plans failed to revise the interdisciplinary care plans to reveal accurate interventions, and failed to evaluate the resident's response to care plan interventions and the effectiveness/ineffectiveness of the care plan. This was evident for 1 (#63) of 2 residents reviewed for neglect and 1 (#38) of 5 residents reviewed for accidents during the annual survey.
Inspectors wroteBased on review of a closed medical record and staff interview, it was determined that the facility staff failed to provide a resident with a completed discharge summary. This was evident for 1 (Resident #58) of 47 residents reviewed during an annual recertification survey.
Inspectors wroteBased on medical record review, it was determined that the facility failed to provide treatment and care in accordance with professional standards of practice. This was evident for 1 (#58) of 47 residents reviewed during the annual survey.
Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to provide a resident with necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer. This was evident for 1 (#53) out of 47 residents reviewed during the annual survey.
Inspectors wroteBased on record review and interview with the resident and staff, it was determined the facility staff failed to ensure that a physician, physician assistant, nurse practitioner or clinical nurse specialist provided orders for the immediate care and needs of a resident with an indwelling urinary catheter. This was evident for 1 (#28) of 1 resident reviewed for Urinary catheter.
Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility staff failed to ensure that opened medications were dated when opened and documented with an expiration date. This was found to be evident in 2 out of 3 medication carts, and 1 out of 2 treatment carts during observation of medication storage and labeling. This deficient practice had the potential to affect all residents.
Inspectors wroteBased on interview and medical record review, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 1 (#107) of 4 residents reviewed for dental services.
Inspectors wroteBased on review of the medical record and interview with residents and staff it was determined the facility staff failed to maintain medical records on each resident that were complete and accurately documented for 6 (#9, #39, #28, #42, #1, #58) of 47 residents reviewed during the annual survey 1) Maryland MOLST (Maryland Orders for Life Sustaining Treatment) is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a patient's wishes about medical treatments. Per the MOLST instructions: Voiding the Form: To void this medical order form, the physician, NP, or PA shall draw a diagonal line through the sheet, write VOID in large letters across the page, and sign and date below the line. A nurse may take a verbal order from a physician, NP, or PA to void the MOLST order form. [...]
Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to ensure that residents had a means of directly contacting staff. This was evident for Resident #30.
Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure that an adequate amount of available potable emergency water was maintained. This was evident during the facilities annual survey.
29 fire safety citations on file: 10 on July 14, 2026, 12 on May 14, 2025, 7 on July 2, 2021.
| Date | Penalty | Amount or length |
|---|---|---|
| January 29, 2026 | Fine | $14,082 |
| January 9, 2025 | Fine | $29,270 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Maryland | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.92 | 3.87 | 3.86 |
| Registered nurses | 0.99 | 0.84 | 0.69 |
| All nursing staff on weekends | 3.75 | 3.47 | 3.42 |
| Nurse aides | 1.83 | ||
| Licensed practical nurses | 1.09 | ||
| Nursing staff turnover (share who left in a year) | 56.0% | 40.2% | 45.8% |
| Registered nurse turnover | 58.8% | 38.7% | 42.9% |
| Administrators who left | 1 |
CMS expects 4.86 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.99 on weekdays and 3.75 on weekends, 6% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 8.5% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.43 in April to June 2025 to 3.92 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.92 | 0.99 | 3.99 | 3.75 | 8.5% | 0 of 90 | 86 |
| Oct to Dec 2025 | 4.17 | 0.92 | 4.32 | 3.80 | 0.0% | 0 of 92 | 87 |
| Jul to Sep 2025 | 4.22 | 0.95 | 4.39 | 3.80 | 0.0% | 0 of 92 | 85 |
| Apr to Jun 2025 | 4.43 | 0.89 | 4.60 | 4.01 | 0.0% | 0 of 91 | 79 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Maryland, Jan to Mar 2026 | 3.73 | 0.74 | 3.88 | 3.34 | 8.0% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Maryland, all employers | |||
| CNAs (nursing assistants) | $20.79 | $18.46 to $22.00 | 27,720 |
| LPNs and LVNs | $35.89 | $31.40 to $38.30 | 9,560 |
| Registered nurses | $47.98 | $40.26 to $51.61 | 52,910 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Maryland | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 13.6 | 20.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.9 | 0.5 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 2.6 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.5 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.6 | 1.1 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 16.9 | 22.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 8.8 | 5.9 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 7.5 | 13.8 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 20.8 | 21.0 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 11.6 | 9.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.8 | 1.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.1 | 1.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Complete Care at Hagerstown's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (56.6% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
56.6% this home
Better than the national rate
US median of homes 51.5% · Maryland: 90 better, 29 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 279 eligible stays.
10.4% this home
No different from the national rate
US median of homes 10.7% · Maryland: 0 better, 41 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 231 eligible stays.
8.4% this home
No different from the national rate
US median of homes 7.1% · Maryland: 5 better, 6 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 212 eligible stays.
88.9% this home
Median of homes: Maryland61.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 126 residents counted.
0.0% this home
Median of homes: Maryland0.4% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 211 residents counted.
0.0% this home
Median of homes: Maryland2.4% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 211 residents counted.
93.8% this home
Median of homes: Maryland98.1% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 48 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: COMPLETE CARE AT HAGERSTOWN LLC. CMS links this home to Complete Care, a group of 85 nursing homes averaging 3.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| PC Md5 Opco Holdco LLC | 5% or greater direct ownership interest | Organization | 100% | 02/01/2023 |
| PC Md5 Topco LLC | 5% or greater indirect ownership interest | Organization | 02/01/2023 | |
| Sms 2021 Trust | 5% or greater indirect ownership interest | Organization | 02/01/2023 | |
| Des Capital LLC | Indirect ownership interest | Organization | 02/01/2023 | |
| Jrk Investments LLC | Indirect ownership interest | Organization | 02/01/2023 | |
| Klugman, Jacob | Indirect ownership interest | Individual | 02/01/2023 | |
| Stein, Shalom | Indirect ownership interest | Individual | 02/01/2023 | |
| Sternbuch, Daniel | Indirect ownership interest | Individual | 02/01/2023 | |
| Stein, Shalom | Managing control - governing body | Individual | 02/01/2023 | |
| Stein, Shalom | Corporate officer | Individual | 02/01/2023 | |
| Cox, Vickie | Operational/managerial control | Individual | 02/01/2023 | |
| Mansfield, Melissa | Operational/managerial control | Individual | 02/01/2023 | |
| Silverberg, Nisanel | Operational/managerial control | Individual | 02/01/2023 | |
| Simmers, Robert | Operational/managerial control | Individual | 06/03/2024 | |
| Sweeney, Barbara | Operational/managerial control | Individual | 02/01/2023 | |
| Waseem, Muhammad | Operational/managerial control | Individual | 02/01/2023 | |
| Schonfeld, Akiva | Trustee of the SNF | Individual | 02/01/2023 | |
| Stein, Shalom | Trustee of the SNF | Individual | 02/01/2023 | |
| Adesse Holdings LLC | Adp of the SNF | Organization | 02/01/2023 | |
| Adesse Md Peace Md5 Propco Holdco LLC | Adp of the SNF | Organization | 02/01/2023 | |
| Adesse Md5 Propco Holdco LLC | Adp of the SNF | Organization | 02/01/2023 | |
| Hagerstown Md Propco Holdco LLC | Adp of the SNF | Organization | 02/01/2023 | |
| Hagerstown Md Propco LLC | Adp of the SNF | Organization | 02/01/2023 | |
| Hc Family Trust | Adp of the SNF | Organization | 02/01/2023 | |
| PC Md5 Topco LLC | Adp of the SNF | Organization | 02/01/2023 | |
| Peace Capital Holdings LLC | Adp of the SNF | Organization | 02/01/2023 | |
| Sms 2021 Trust | Adp of the SNF | Organization | 02/01/2023 | |
| Cox, Vickie | Adp of the SNF | Individual | 02/01/2023 | |
| Mansfield, Melissa | Adp of the SNF | Individual | 02/01/2023 | |
| Schonfeld, Akiva | Adp of the SNF | Individual | 02/01/2023 | |
| Silverberg, Nisanel | Adp of the SNF | Individual | 02/01/2023 | |
| Simmers, Robert | Adp of the SNF | Individual | 06/03/2024 | |
| Sweeney, Barbara | Adp of the SNF | Individual | 02/01/2023 | |
| Waseem, Muhammad | Adp of the SNF | Individual | 02/01/2023 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Maryland. NursingHomeClear cannot take or act on complaints.