Complete Care at Hagerstown

In the surveyor’s words

From the most serious findings on record at Complete Care at Hagerstown, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 29, 2026

  Based 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. […]

• Actual harm, isolatedF686Jan 9, 2025

  Based 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 . Findings include: Review of facility policy titled Pressure Injury Prevention and Management last reviewed 5/26/2023 revealed, This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. […]

• Actual harm, isolatedF689Jan 9, 2025

  Based 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. The findings include: Care plan - is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) A medical record review on 1/6/25, at 9:45 AM for Resident #31 revealed that on 12/7/20, facility staff initiated a care plan for self-care deficit related to the resident ' s impaired mobility and disease process. […]

• No harm, potential for more than minimal, widespreadF730Jan 29, 2026

  Based 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.The finding include:On 1/22/26 at 11:43 AM a review of Geriatric Nursing Assistant (GNA) #37's employee file revealed she was hired on 11/2018, and there was no evidence of a performance evaluation in the last 12 months. […]

• No harm, potential for more than minimal, widespreadF840Jan 29, 2026

  Based 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. The findings include:1. The medical record for Resident #16 was reviewed on 1/21/26 at 10:00 AM. This noted a nephology consult completed on 1/13/26 that was not uploaded until 1/15/26. Within this consultation report the nurse practitioner (NP) #13 documented finding a medication error on the resident's medication administration record. […]