Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hagerstown Healthcare Center during CMS and state inspections, most recent first.
A resident who was cognitively intact, wheelchair-dependent, and normally required stretcher transport due to limited leg mobility was taken off campus in a wheelchair without leg rests. The GNA, reportedly in a hurry, asked the resident to hold their legs up and began pushing the wheelchair; shortly afterward, the resident’s foot became caught under the wheelchair frame, causing immediate pain. Another staff member later attached leg rests, but no thorough assessment was done at that time, and the resident’s pain increased over the day. Subsequent imaging confirmed a nondisplaced femoral condyle fracture, and orders were written for a knee immobilizer. The DON reported that wheelchair transports must include leg rests unless refused and that the resident’s usual stretcher transport requirement should have been known from the Kardex.
A resident who was alert, oriented, and assessed as having decision-making capacity disclosed to administration that they had been in an on-and-off sexual relationship with a GNA for about a year, with encounters occurring in the resident’s room and off-site. The resident reported the relationship as consensual and denied coercion or harm, but also stated they had given the GNA approximately $400 after the GNA requested to borrow money, a transaction corroborated by text messages that also contained explicit sexual content and plans for visits. At least two staff members had suspicions about the relationship but did not report them. The DON and ED stated that staff are expected to maintain professional boundaries and not engage in sexual relationships with or accept money from residents, demonstrating that the GNA’s actions and the failure of staff to report suspicions resulted in a deficiency related to protection from exploitation.
Two residents were involved in separate incidents that were not timely reported to the State Survey Agency. One resident reported leg pain and was found on X-ray to have chronic tibia and fibula fractures and a possible acute distal fibula fracture; facility leadership knew of these findings but did not submit the required report for several days while questioning whether the injury was pre-existing. Another resident disclosed an on-and-off sexual relationship with a GNA over about a year and reported giving the staff member money upon request; staff had prior knowledge or rumors of this inappropriate relationship but did not promptly report their concerns, and leadership believed the relationship was mutual due to the resident’s intact cognition while still expecting professional boundaries and no exchange of money.
A resident who required total assistance with transfers was injured when a staff member attempted to use a Hoyer lift alone, contrary to facility policy requiring two staff for such transfers. The improper fastening of the sling led to the resident falling onto the lift's iron bars, resulting in fractures to the leg and collarbone. The incident was confirmed through interviews and record review, with staff and management acknowledging that established safety procedures were not followed.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Failure to Follow Assessed Transport Needs and Use Wheelchair Leg Rests
Penalty
Summary
The deficiency involved the facility’s failure to ensure safe transport practices and adherence to a resident’s assessed transportation needs. A cognitively intact resident who used a wheelchair for mobility and was dependent for toileting and dressing was normally assessed to require stretcher transport due to limited leg mobility. On the day of the incident, the resident was transported off campus in a wheelchair without leg rests, despite the resident’s usual need for stretcher transport and inability to lift or maintain leg position. Shortly after transport began, the resident’s left foot became caught under the wheelchair frame, and the resident reported immediate pain. The resident stated that the GNA appeared to be in a hurry, did not use leg rests, and did not initially assess for injury when the resident yelled to stop. The GNA later acknowledged that leg rests should have been used because the resident could not self-propel and reported asking the resident to hold their legs up while pushing the wheelchair a short distance before the resident yelled out. Another staff member subsequently attached the leg rests, and the resident was transported to the appointment without further assessment at that time. The resident reported increasing pain throughout the day. Diagnostic imaging on subsequent dates showed chronic fractures with a possible acute femur fracture and later confirmed a nondisplaced femoral condyle fracture, and medical orders were initiated for a left knee immobilizer every shift. The DON stated that residents transported in wheelchairs must have leg rests unless they refuse, that this resident was normally transported via stretcher, and that the GNA should have known this by reviewing the Kardex.
Failure to Prevent Staff Sexual and Financial Exploitation of a Resident
Penalty
Summary
The facility failed to protect a resident from exploitation when a GNA engaged in a prolonged sexual and financial relationship with the resident. The incident came to light when the resident reported to the Administrator that the resident and GNA #13 had been in an on-and-off relationship for about a year, during which they had sexual intercourse many times, including in the resident’s room within the facility and at a motel. The resident, who had a BIMS score of 15/15, was alert, oriented, and assessed as having decision-making capacity. The resident consistently stated the relationship was consensual, never felt forced or pressured, and denied being raped, coerced, threatened, or physically harmed. The resident also stated they did not regret the relationship and would not change what occurred, and did not want law enforcement involved. Despite the resident’s statements of consent, the relationship involved a staff member borrowing approximately $400.00 from the resident, which the resident reported giving voluntarily around August 2025. Text messages between the resident and GNA #13, using the phone number the GNA had provided to the facility upon hire, documented the GNA’s request to borrow $400.00 and the resident’s agreement, as well as explicit language confirming an ongoing sexual relationship and plans for the GNA to visit the resident. Staff witness statements showed that at least two staff members had suspicions about the relationship but did not report their concerns. The DON and Executive Director both stated that staff are expected to remain professional, not engage in sexual relationships with residents, and not give or accept money from residents, indicating that the GNA’s conduct and the unreported suspicions by other staff were contrary to facility expectations and contributed to the failure to ensure the resident was free from exploitation.
Failure to Timely Report Injury of Unknown Origin and Staff–Resident Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to timely report an injury of unknown origin for one resident. One resident reported left leg pain on January 14, 2026, was evaluated by the facility provider, and had an X-ray completed on January 15, 2026. The X-ray showed chronic fractures of the proximal tibia and fibula and a possible acute fracture of the distal fibula, with a recommendation for follow-up imaging or MRI. Facility administrative staff confirmed they were aware of the radiology findings on January 15, 2026, but review of the incident reporting log showed the report to the State Survey Agency was not submitted until January 19, 2026, four days after the facility became aware of the fractures. The DON acknowledged in interview that the reportable incident was reported late and that the facility delayed reporting while attempting to clarify whether the injury was pre-existing. The deficiency also involves the facility’s failure to timely report an incident of resident exploitation and an inappropriate staff–resident relationship. A resident reported to the Administrator that they had been in an on-and-off sexual relationship with a GNA for about a year, with sexual intercourse occurring on occasions, and that the GNA had requested approximately $400, which the resident stated was given willingly. The resident had a BIMS score of 15 and was deemed capable. Witness statements documented that one staff member was aware of an inappropriate personal relationship between the GNA and the resident as of December 22, 2025, and another LPN heard a rumor of the relationship about a week before January 1, 2026, but did not report it at that time. In interviews, the LPN stated she did not initially report the rumor because she believed the alert and oriented resident was in a consensual relationship, and the DON stated she believed the relationship was mutual and not coerced, while also acknowledging that staff are expected to maintain professional boundaries and not exchange money with residents.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to provide sufficient supervision and follow appropriate safety procedures during the use of a Hoyer lift for a resident who required total assistance with activities of daily living. The facility's policy mandated that two staff members be present when using a mechanical lift, and the resident's care plan specifically directed the use of a Hoyer lift with two staff during transfers. Despite these requirements, a single staff member attempted to transfer the resident alone, resulting in the resident falling from the lift. The incident involved a resident with end-stage renal disease, dependence on dialysis, chronic pain, and impaired mobility, who was cognitively intact and required total assistance. During the transfer, the staff member did not properly fasten the sling, and the resident fell onto the iron bars of the lift, sustaining a left femoral condylar fracture and a left clavicle fracture. The resident was in significant pain and distress following the fall and was subsequently sent to the emergency department for evaluation. Interviews and record reviews confirmed that the staff member did not request or wait for assistance from another staff member, as required by facility policy. Other staff and management acknowledged that the policy was not followed, and the equipment was found to be in proper working order. The deficiency was attributed to the staff member's failure to adhere to established safety protocols during the transfer process.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hagerstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Julia Manor Nursing And Rehabilitation Center | 0.6 mi | — | 41 | 0 |
| Creekside Center For Rehabilitation And Nursing | 1.4 mi | — | 34 | 1 |
| Coffman Nursing Home | 1.9 mi | — | 0 | 0 |
| Western Md Hospital Center | 2.2 mi | — | 20 | 0 |
| Complete Care At Hagerstown | 4.6 mi | — | 23 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.