Cycle 1
Health 2025-05-14 · Fire 2025-05-14
48 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Hagerstown, MD
Complete Care At Hagerstown
1-star overall rating with 1-star inspections with $50,935 in total fines with 48 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
14014 Marsh Pike, Hagerstown, MD
(301) 733-8700
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
2018-08-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.95
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
1.37
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.22
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
2.33
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.80
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.72
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
3.18
CMS adjusted total nurse staffing hours
Case-mix index
1.82
Higher values indicate more complex resident acuity
RN turnover
35%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,859
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.02
Baseline 20.89% · Performance 20.96% · Measure score 1.02 · Achievement 1.02 · Improvement 0
Healthcare-associated infections
1.92
Baseline 9.46% · Performance 8.38% · Measure score 1.92 · Achievement 0 · Improvement 1.92
Total nurse turnover
5.97
Baseline 44.29% · Performance 39.29% · Measure score 5.97 · Achievement 5.97 · Improvement 2.07
Adjusted total nurse staffing
0
Baseline 3.02 hours · Performance 2.89 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.4% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 231 · Observed rate 11.26% · Lower 95% interval 8.02% |
| Discharge to community | 56.6% |
50.57%
6 pts better
|
Better than the National Rate · Eligible stays 279 · Observed rate 46.59% · Lower 95% interval 51.1% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 196 · Denominator 196 |
| Falls with major injury | 0.51% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 196 |
| Discharge self-care score | 76.92% |
53.69%
23.2 pts better
|
Numerator 90 · Denominator 117 |
| Discharge mobility score | 76.92% |
50.94%
26 pts better
|
Numerator 90 · Denominator 117 |
| Pressure ulcers or injuries, new or worsened | 3.06% |
2.29%
0.8 pts worse
|
Numerator 6 · Denominator 196 · Adjusted rate 2.85% |
| Healthcare-associated infections requiring hospitalization | 8.38% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 212 · Observed rate 10.38% · Lower 95% interval 5.63% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 161 |
| Staff flu vaccination coverage | 67.46% |
42%
25.5 pts better
|
Numerator 85 · Denominator 126 |
| Discharge function score | 84.62% |
56.45%
28.2 pts better
|
Numerator 99 · Denominator 117 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 148 · Denominator 148 |
| Transfer of health information to patient | 84.62% |
96.28%
11.7 pts worse
|
Numerator 22 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 28.43% |
25.2%
3.2 pts better
|
Numerator 29 · Denominator 102 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
1.3
2 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 4.7 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.2
0.9 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.5 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
91.9%
7.7 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.2% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.6%
3.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
2.3%
0.2 pts worse
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 0.0% · Q3 1.8% · Q4 1.8% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 96.5% |
21.4%
75.1 pts worse
|
11.4%
85.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 100.0% · Q3 100.0% · Q4 89.6% · 4Q avg 96.5% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
5.7%
0.5 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 6.9% · Q3 5.5% · Q4 3.7% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 40.3% |
16.1%
24.2 pts worse
|
19.6%
20.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.1% · Q2 41.4% · Q3 38.2% · Q4 38.2% · 4Q avg 40.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.5% |
15.3%
11.8 pts better
|
16.7%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 0.0% · Q3 2.3% · Q4 4.4% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.8% |
26.6%
12.8 pts better
|
16.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.8% |
22.9%
6.1 pts better
|
14.9%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 23.5% · Q3 14.0% · Q4 13.0% · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
0.7%
1.2 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · Q3 2.7% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
1.5%
2.7 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 5.1% · Q3 8.8% · Q4 0.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.8% |
25.4%
6.4 pts worse
|
19.8%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.9% · Q2 35.1% · Q3 30.1% · Q4 27.4% · 4Q avg 31.8% |
| Percentage of long-stay residents with pressure ulcers | 11.3% |
6.3%
5 pts worse
|
5.1%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 10.1% · Q3 12.8% · Q4 9.3% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 74.8% |
78.4%
3.6 pts worse
|
81.7%
6.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 88.9% · Q2 74.3% · Q3 77.1% · Q4 62.6% · 4Q avg 74.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
9.9%
0.9 pts worse
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 12.3% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.3%
0.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.8% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.5% |
80.6%
7.1 pts worse
|
79.7%
6.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
21.2%
1.5 pts worse
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 26.2% · Expected 27.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-07-02 · Fire 2021-07-02
30 health deficiencies
Top issue: Resident Assessment and Care Planning (8 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2018-08-14 · Fire 2018-08-14
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-27
F · Potential for more than minimal harm
2025-05-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-27
F · Potential for more than minimal harm
2025-05-14
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-06-27
F · Potential for more than minimal harm
2025-05-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-27
E · Potential for more than minimal harm
2025-05-14
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-27
E · Potential for more than minimal harm
2021-07-02
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2021-08-09
D · Potential for more than minimal harm
2021-07-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-08-09
D · Potential for more than minimal harm
2021-07-02
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2021-08-09
D · Potential for more than minimal harm
2021-07-02
K907 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure medical gas and vacuum systems have documented maintenance programs.
Corrected 2021-08-09
D · Potential for more than minimal harm
2021-07-02
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2021-08-09
D · Potential for more than minimal harm
2021-07-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-08-09
C · Minimal harm
2021-07-02
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2021-08-09
C · Minimal harm
2018-08-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-05-25
C · Minimal harm
2018-08-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-05-25
B · Minimal harm
2018-08-14
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2018-05-25
B · Minimal harm
2018-08-14
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2018-05-25
Inspection history
Recent health citations
J · Immediate jeopardy
2026-01-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
F · Potential for more than minimal harm
2026-01-29
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Not marked corrected
F · Potential for more than minimal harm
2026-01-29
F840 · Administration Deficiencies
Health
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.
Not marked corrected
F · Potential for more than minimal harm
2026-01-29
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Not marked corrected
F · Potential for more than minimal harm
2026-01-29
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Not marked corrected
E · Potential for more than minimal harm
2026-01-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Not marked corrected
D · Potential for more than minimal harm
2026-01-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Not marked corrected
D · Potential for more than minimal harm
2026-01-29
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
D · Potential for more than minimal harm
2026-01-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Not marked corrected
D · Potential for more than minimal harm
2026-01-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Not marked corrected
D · Potential for more than minimal harm
2026-01-29
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Not marked corrected
D · Potential for more than minimal harm
2026-01-29
F726 · Nursing and Physician Services Deficiencies
Health
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Not marked corrected
D · Potential for more than minimal harm
2026-01-29
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Not marked corrected
D · Potential for more than minimal harm
2026-01-29
F837 · Administration Deficiencies
Health
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-29
F838 · Administration Deficiencies
Health
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-29
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Not marked corrected
D · Potential for more than minimal harm
2025-10-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-10-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-12-03
D · Potential for more than minimal harm
2025-10-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-03
F · Potential for more than minimal harm
2025-05-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-14
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-06-27
G · Actual harm
2025-01-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-25
G · Actual harm
2025-01-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-25
E · Potential for more than minimal harm
2025-01-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-25
D · Potential for more than minimal harm
2025-01-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-02-25
E · Potential for more than minimal harm
2021-07-02
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2021-08-03
E · Potential for more than minimal harm
2021-07-02
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-08-03
E · Potential for more than minimal harm
2021-07-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-08-03
E · Potential for more than minimal harm
2021-07-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-08-03
E · Potential for more than minimal harm
2021-07-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-08-03
E · Potential for more than minimal harm
2021-07-02
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-08-03
E · Potential for more than minimal harm
2021-07-02
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-08-03
E · Potential for more than minimal harm
2021-07-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-02
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-02
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-02
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-02
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-02
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-02
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-02
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-02
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-02
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-02
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-08-03
D · Potential for more than minimal harm
2021-07-02
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2021-08-03
C · Minimal harm
2021-07-02
F922 · Environmental Deficiencies
Health
Have enough backup water supply for essential areas of the nursing home.
Corrected 2021-08-03
Penalties and ownership
What sits behind the stars
$21,665
2026-01-29
Fine
Fine · fine $21,665
Fine
$29,270
2025-01-09
Fine
Fine · fine $29,270
Fine
Ownership
Pc Md5 Opco Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Cox, Vickie
Operational/Managerial Control · Individual
Mansfield, Melissa
Operational/Managerial Control · Individual
Pc Md5 Topco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Silverberg, Nisanel
Operational/Managerial Control · Individual
Simmers, Robert
Operational/Managerial Control · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Sweeney, Barbara
Operational/Managerial Control · Individual
Waseem, Muhammad
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Western Md Hospital Center
Hagerstown, MD
2-star overall rating with 1-star inspections with $24,060 in total fines with 26 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Coffman Nursing Home
Hagerstown, MD
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Hagerstown Healthcare Center
Hagerstown, MD
1-star overall rating with 1-star inspections with $8,190 in total fines with 31 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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