D+
51/100COMPLETE CARE AT HAGERSTOWN Inspection Report, Violations & Safety Grade (HAGERSTOWN, Maryland)
14014 MARSH PIKE, HAGERSTOWN, Maryland 21742
Phone: 3017338700
CMS Overall:2/5
Overview & Bed Count
Certified Beds
60
Avg Residents/Day
82.5
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Washington
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall2/5
Health1/5
Staffing3/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | Maryland Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 1.25 | 0.88 | +0.37 |
| Total Nurse Hours per Resident per Day | 4.30 | 3.93 | +0.37 |
| CMS Staffing Rating | 3/5 | 3.2/5 | - |
| Nursing Staff Turnover | 62.6% | 40.2% | - |
Health Citation History
102 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-07-14 | Resident Rights Deficiencies | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | D – Moderate Harm Potential |
| 2026-07-14 | Resident Rights Deficiencies | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D – Moderate Harm Potential |
| 2026-07-14 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2026-07-14 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2026-07-14 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2026-07-14 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2026-07-14 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2026-07-14 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2026-07-14 | Quality of Life and Care Deficiencies | Provide activities to meet all resident's needs. | D – Moderate Harm Potential |
| 2026-07-14 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2026-07-14 | Quality of Life and Care Deficiencies | Assist a resident in gaining access to vision and hearing services. | D – Moderate Harm Potential |
| 2026-07-14 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2026-07-14 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
| 2026-07-14 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2026-07-14 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2026-07-14 | Administration Deficiencies | Keep complete, dated laboratory records in the resident's record. | D – Moderate Harm Potential |
| 2026-07-14 | Quality of Life and Care Deficiencies | Provide or obtain dental services for each resident. | D – Moderate Harm Potential |
| 2026-07-14 | Nutrition and Dietary Deficiencies | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | D – Moderate Harm Potential |
| 2026-07-14 | Nutrition and Dietary Deficiencies | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | D – Moderate Harm Potential |
| 2026-07-14 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D – Moderate Harm Potential |
| 2026-07-14 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2026-04-02 | Resident Rights Deficiencies | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | D – Moderate Harm Potential |
| 2026-04-02 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2026-04-02 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2026-01-29 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2026-01-29 | Nursing and Physician Services Deficiencies | Observe each nurse aide's job performance and give regular training. | F – Moderate Harm Potential |
| 2026-01-29 | Administration Deficiencies | Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | F – Moderate Harm Potential |
| 2026-01-29 | Administration Deficiencies | Develop, implement, and/or maintain an effective training program for all new and existing staff members. | F – Moderate Harm Potential |
| 2026-01-29 | Nursing and Physician Services Deficiencies | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | F – Moderate Harm Potential |
| 2026-01-29 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | E – Moderate Harm Potential |
| 2026-01-29 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2026-01-29 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2026-01-29 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2026-01-29 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2026-01-29 | Nursing and Physician Services Deficiencies | Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | D – Moderate Harm Potential |
| 2026-01-29 | Nursing and Physician Services Deficiencies | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | D – Moderate Harm Potential |
| 2026-01-29 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2026-01-29 | Administration Deficiencies | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | D – Moderate Harm Potential |
| 2026-01-29 | Administration Deficiencies | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | D – Moderate Harm Potential |
| 2026-01-29 | Administration Deficiencies | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | D – Moderate Harm Potential |
| 2026-01-29 | Administration Deficiencies | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | D – Moderate Harm Potential |
| 2025-10-21 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2025-10-21 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2025-10-21 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2025-05-14 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2025-05-14 | Resident Rights Deficiencies | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | D – Moderate Harm Potential |
| 2025-05-14 | Resident Rights Deficiencies | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | D – Moderate Harm Potential |
| 2025-05-14 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2025-05-14 | Resident Rights Deficiencies | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | D – Moderate Harm Potential |
| 2025-05-14 | Resident Rights Deficiencies | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D – Moderate Harm Potential |
Showing 50 of 102 citations.
Fire Safety Citation History
29 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-07-14 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2026-07-14 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2026-07-14 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2026-07-14 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2026-07-14 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | E – Moderate Harm Potential |
| 2026-07-14 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | E – Moderate Harm Potential |
| 2026-07-14 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2026-07-14 | Smoke Deficiencies | Construct fire resistant interior walls. | E – Moderate Harm Potential |
| 2026-07-14 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | E – Moderate Harm Potential |
| 2026-07-14 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | E – Moderate Harm Potential |
| 2025-05-14 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2025-05-14 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2025-05-14 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | F – Moderate Harm Potential |
| 2025-05-14 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2025-05-14 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | E – Moderate Harm Potential |
| 2025-05-14 | Egress Deficiencies | Install proper backup exit lighting. | D – Moderate Harm Potential |
| 2025-05-14 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2025-05-14 | Smoke Deficiencies | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | D – Moderate Harm Potential |
| 2025-05-14 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2025-05-14 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | D – Moderate Harm Potential |
| 2025-05-14 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
| 2025-05-14 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
| 2021-07-02 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure that testing and maintenance of electrical equipment is performed. | E – Moderate Harm Potential |
| 2021-07-02 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | D – Moderate Harm Potential |
| 2021-07-02 | Smoke Deficiencies | Have an enclosure around a vertical opening shaft. | D – Moderate Harm Potential |
| 2021-07-02 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure medical gas and vacuum systems have documented maintenance programs. | D – Moderate Harm Potential |
| 2021-07-02 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | D – Moderate Harm Potential |
| 2021-07-02 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
| 2021-07-02 | Egress Deficiencies | Install proper backup exit lighting. | C – Minimal Harm Potential |
Total Penalties & Fines
$43,352
Total Fine Amount (CMS)
2
Number of Fines
2
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2026-01-29 | Fine | $14,082 | - |
| 2025-01-09 | Fine | $29,270 | - |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the HAGERSTOWN area at no cost.
Find Safe, Vetted Facilities Near HAGERSTOWN
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.