Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 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.
Incomplete Investigation of Narcan-Related Incident: The facility failed to thoroughly investigate a self-reported incident involving a resident with opioid dependence, HF, and a history of stroke who became minimally responsive and received Narcan after a provider was contacted. The investigation file lacked witness statements and the provider’s clinical note, and it did not document any review for possible non-prescribed drugs or substances, including no room search or visitor log review despite the resident’s prior substance-related history.
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.
Unlabeled food, poor kitchen sanitation, and unsafe cold storage conditions were observed during survey. Surveyors found multiple food items in the walk-in and reach-in refrigerators without proper labels or dates, saw dirty floors and heavily soiled equipment and surfaces throughout the kitchen, and noted that cleaning logs had not been completed. Surveyors also observed a walk-in refrigerator door that was not sealing properly, with temperatures above 41 F and a missed temp log entry.
Failure to perform hand hygiene during medication administration was observed for multiple residents. An CMA and an RN were seen administering meds without hand hygiene before or during the med pass, including a PRN oxycodone dose for one resident. Facility policy required hand hygiene before beginning med administration and before and after each resident’s meds, and staff stated that observations were made but not tracked or documented.
Failure to notify a resident’s representative of a change in condition. A resident developed bilateral lower leg wounds with dry flakes, open areas, purulent drainage, and odor; the attending provider was informed, but the family/health care agent notification section was left blank and the record did not show the representative was told. The representative later stated she was unaware of the onset or type of the wounds, and the DON confirmed the representative was not notified.
Late Significant Change in Status MDS Assessments: The facility failed to complete Significant Change in Status MDS assessments within the required timeframe for two residents. One resident admitted to hospice had the assessment completed 6 days late, and another resident readmitted from the hospital with a change in transfer ability had the assessment completed 8 days late. An MDS Coordinator confirmed both assessments were late.
A resident’s MDS was inaccurate because Section P did not document bedrails even though the care plan included bilateral 1/4 siderails to promote independence and the bedrails were observed in place. The MDS nurse acknowledged the omission after confirming that the resident’s record and care plan included the bedrails, and the resident stated the rails were needed to move in bed.
Failure to provide medically related social services occurred when a resident triggered for PASARR screening was not given the required second PASARR after the provisional period expired. The resident had a recent post-fall admission with dx including HTN, hemorrhagic brain bleed, Alzheimer, anxiety, and depression, with a BIMS of 9 and a certification stating lack of capacity. The DSS acknowledged missing the required PASARR.
Care Plan Did Not Reflect Discharge Plan A resident with Cerebral Palsy and Fragile X had a care plan that stated there were no discharge plans to LTC, even though care plan notes documented the resident/family’s desire to discharge to a DDA group home and a referral to county DDA. The DSS confirmed the discharge plan was in process and acknowledged the care plan should have reflected the updated plan.
Missing IDT Care Plan Meetings After MDS Assessments: The facility failed to document interdisciplinary care plan meetings after MDS assessments for 3 residents. One resident had quarterly and annual MDSs with no documented care conference after two assessments, one resident admitted to hospice had no documented IDT meeting after a Significant Change in Status MDS, and another resident had no documented care conference after a Significant Change in Status MDS related to a transfer decline. Staff confirmed the missing documentation.
Activities Program Did Not Reflect Resident Preferences: A resident with altered mental status and dementia was observed in bed and not engaged in activities. The resident’s MDS showed a preference for keeping up with the news and going outside for fresh air when the weather was good, but the activity care plan was not person-centered and activity logs only showed 1:1 visits, sleep, talk, TV, and refusals, without evidence of those preferences being offered or supported.
A resident who was identified in the smoker log and smoking assessment as needing an apron and staff supervision was observed smoking without an apron during scheduled smoke breaks. Staff present during the observations were unaware that the resident required an apron, and the resident stated that no one had offered one. The DON said the Activity Dept was responsible for supervision and aprons, but there was no supporting documentation of the resident's alleged refusal at the time of the observations.
A GNA received a verbal warning and was later written up again for insubordination, including yelling at a clinical manager and not following direction. The performance evaluation did not include details about the warning, and the NHA stated there was no evidence that education or follow-up training was provided after the issues were identified.
The facility failed to complete the resident Matrix accurately during a recertification survey. The DON presented a Matrix that incorrectly showed three residents as receiving parental feedings and one resident as receiving hospice care, even though supporting resident lists did not match those entries. The DON confirmed the hospice status had changed before survey entry and that the other listed therapies were not being received.
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.
Incomplete Investigation of Narcan-Related Incident
Penalty
Summary
The facility failed to thoroughly investigate a self-reported incident involving Resident #3, who was admitted with diagnoses including opioid dependence, pain, heart failure, and a history of stroke. The resident became minimally responsive and was given Narcan after a provider was contacted. During survey review of the facility’s investigation file, there were no witness statements and no clinical note from the provider who evaluated the resident and ordered Narcan to be administered. Further review of the investigation file also failed to show any investigation into the possible presence of non-prescribed drugs or substances. An ADON later described the resident as frail, with Type 1 diabetes, brittle blood sugars, and a history of substance abuse, and stated the resident became very lethargic, had blood sugar checked, received Narcan, and was later sent to the hospital when not back to baseline. The ADON also stated the resident had a prior incident involving an illegal substance at the facility, but for the recent event she did not think witness statements, a room search, or review of the visitor log had been done because the episode was believed to be related only to the resident’s medical condition.
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.
Unlabeled Food, Unsanitary Kitchen Conditions, and Improper Refrigerator Temperatures
Penalty
Summary
Food storage and kitchen sanitation practices were not maintained as required during the annual survey. In the walk-in refrigerator, surveyors observed multiple food items that were not labeled and/or dated, including ground meat in a container marked only with a freeze-by date, shredded cabbage in a clear container with no date or label, and chocolate pudding in a covered metal container with no name label. In the reach-in refrigerator, a container of pureed orange-colored food was initially unidentified by dietary staff and was then labeled with the current date, although the staff member stated she was unsure when it had actually been placed in the refrigerator and later said it was probably from the previous day. Facility dietary leadership acknowledged that the items should have been labeled and dated when placed in storage. The kitchen environment and equipment were also observed to be unclean. Surveyors saw dirty plates, cups, and utensils stored next to clean items, soiled floors with food debris and spills, grease and grime on the stove, backsplash, griddle, warmer, and steamers, dirt particles in a cart used for clean cups, streaks and dried food-like substances on the reach-in refrigerator exterior, and buildup on the iced tea cart. The dietary manager stated he was assisting during survey and was unsure where cleaning logs were kept. Later, the dietary manager provided a blank daily cleaning assignment sheet and stated that no November cleaning log had been completed by staff. The registered dietitian stated that sanitation audits identified a need for deep cleaning, and facility leadership acknowledged that the kitchen should not have reached that level of uncleanliness if cleaning checklists had been completed regularly. The walk-in refrigerator was also found to be operating with temperature control concerns. Surveyors observed that the door latch was not closing properly and the door was not sealing, and a dietary aide reported that the problem had been present for a while. The exterior thermometer read 44 F and the interior thermometer read 42 F, with a second thermometer confirming the reading. The temperature log showed a missed PM entry on one day and a morning entry of 41 F the next day. Facility staff and leadership acknowledged the concern and stated that the latch had been repaired, but at the time of the observation the refrigerator had not been sealed properly and the recorded temperatures and missed log entry did not establish that safe storage temperatures had been maintained.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to prevent the spread of infection when licensed nursing staff did not perform hand hygiene during medication administration for 3 of 4 residents observed. On 11/19/2025 at 8:15 AM, a surveyor observed CMA #2 dispensing medications for Resident #10 without performing hand hygiene when beginning to pull blister packages from the medication cart and again before administering the medications. At 8:30 AM, Nurse #1 administered a PRN oxycodone 5 mg medication for Resident #11 without performing hand hygiene. At 8:35 AM, CMA #2 began administering medications to Resident #85 without performing hand hygiene. The facility’s Infection Prevention and Infection Control Program policy, reviewed on 11/21/2025, stated that prevention of spread of infections is accomplished by education and implementation of hand hygiene, standard precautions, and transmission-based precautions as appropriate. The Medication Administration policy also required appropriate hand hygiene before beginning medication administration and before and after each resident’s medication is administered. During an interview on 11/21/2025, Staff #11 stated that monthly in-service education is provided on standard infection control practices and that she makes observations of medication passes, but she does not track or document the observations or audits. She acknowledged the deficiency after being informed of the observations involving Nurse #1 and CMA #2. On 11/26/2025, the Nursing Home Administrator and DON were made aware of the observations and findings.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident’s representative of a documented change in condition for one resident with bilateral lower leg wounds. A change in condition evaluation form completed on 6/26/24 documented that the resident’s bilateral legs and feet had dry flakes and open areas with purulent discharge and an odor, and that the change began that same day and was reported to the attending provider. A skin/wound note from the same date stated that the resident had open wounds on both lower legs, the areas were cleansed with normal saline, xeroform was applied, and the wounds were covered with rolled gauze, with the MD/NP made aware. The section of the change in condition form for the family/health care agent notified was left blank, and the record did not show that the resident’s representative was informed. In interview, the representative stated she was unaware of the onset or type of the wounds, and the DON confirmed that the representative was not notified of the change in condition.
Late Significant Change in Status MDS Assessments
Penalty
Summary
The facility failed to complete Significant Change in Status MDS assessments within 14 days after determining that two residents had significant changes in condition. For Resident #5, the record showed hospice admission effective 7/31/25, and the Significant Change in Status MDS assessment was completed and signed on 8/20/25, 21 days after hospice admission and 6 days late. An MDS Coordinator confirmed that the assessment was completed late. For Resident #10, the record showed readmission from the hospital to the facility and a Significant Change in Status MDS assessment dated 10/7/25. The assessment was completed and signed on 10/27/25, 22 days after readmission and 8 days late. During interview, the MDS Coordinator stated the resident had a change in ability to transfer that warranted a Significant Change in Status MDS assessment and confirmed that the assessment was completed late.
Inaccurate MDS Documentation of Bedrails
Penalty
Summary
The facility failed to accurately document a resident’s status on the MDS assessment for Resident #81. The resident was observed in bed, talkative and pleasant, with personal items, fresh water, and the call bell within reach, and 1/4 bilateral bedrails attached to the bed. The resident’s last recorded weight was 347.2 lbs. The care plan, initiated on 2/24/24, included an intervention for bilateral 1/4 siderails to the bed to promote independence. Review of the MDS with an ARD of 9/29/25 showed that Section P did not reflect that the resident had bedrails. During interview, the MDS nurse stated that information used to complete the MDS was gathered from the medical record, including nurses notes, census, medication records, appointments, physician orders, and the care plan, and acknowledged that bedrails were part of the care plan but were not documented in Section P. The surveyor later confirmed the bedrails on the resident’s bed, and the resident stated, “I need those to move in bed.”
PASARR Screening Not Completed When Required
Penalty
Summary
Failure to provide medically related social services occurred for a resident triggered for required PASARR screening. The resident had a recent admission after a fall and diagnoses including high blood pressure, hemorrhagic brain bleed, Alzheimer, anxiety, and depression. The resident’s BIMS score was 9, indicating moderate cognitive impairment, and a signed certification dated 10/23/25 stated that the resident lacked capacity. The resident’s PASARR I outcome completed on 10/10/2025 identified a 30-day Provisional Hospital Exempt PASARR and stated that if the nursing facility stay extended past 30 days, a new PASARR would be required. The resident remained in the facility beyond that timeframe, but the Director of Social Service stated, “I missed it,” and acknowledged that a second PASARR was required. The PASARR was completed only after surveyor intervention.
Care Plan Did Not Reflect Resident’s Discharge Plan
Penalty
Summary
The facility failed to accurately reflect Resident #32’s discharge plan on the individualized care plan. Resident #32 had diagnoses of Cerebral Palsy and Fragile X Chromosome. During a family interview, the resident’s family member stated that the facility had discussed arranging a transfer to a more appropriate setting because the facility did not have the capability to meet the resident’s specific needs, and that the facility was supposed to follow up but no additional information had been received. Record review showed that the care plan revised on 11/13/25 stated, "I have no plans for discharge secondary to LTC," and the surveyor could not find documentation supporting a plan to discharge the resident to another facility. However, care plan meeting notes documented that the resident/family desired discharge to a DDA group home and that a letter had been sent to the county DDA to add the resident to the wait list, with social work to follow up. The Director of Social Services confirmed that the resident’s discharge planning was in process and acknowledged that the care plan should have been updated to reflect the new discharge plan.
Missing IDT Care Plan Meetings After MDS Assessments
Penalty
Summary
The facility failed to ensure interdisciplinary care plan meetings were conducted after completion of MDS assessments for 3 residents reviewed during the recertification survey. For Resident #11, who had resided in the facility since September 2022, the record showed quarterly and annual MDS assessments completed in 2025, but there was no documentation that an IDT care plan meeting occurred after the MDS assessments dated 1/13/25 and 9/20/25. Although care conference notes documented IDT reviews and meetings on 4/8/25, 6/17/25, and 9/16/25, staff #4, the Social Services Director, confirmed there was no documentation showing care conference meetings after those two MDS assessments. For Resident #5, the record showed admission to hospice care effective 7/31/25 and a Significant Change in Status MDS completed and signed on 8/20/25, but there was no documentation of an IDT care plan meeting after that assessment. For Resident #10, a Significant Change in Status MDS was completed on 10/27/25 due to a change in ability to transfer, but care conference notes did not document an IDT care plan meeting after completion of the assessment. Staff #18, the MDS Coordinator, reviewed both records and confirmed that no care conference meeting occurred following the hospice admission assessment for Resident #5 or the Significant Change in Status assessment for Resident #10.
Activities Program Did Not Reflect Resident Preferences
Penalty
Summary
The facility failed to provide an ongoing activities program that met the needs and preferences of Resident #10. During an initial tour of the first-floor unit, the resident was observed lying in bed and not involved in any activity. Record review showed the resident had diagnoses including altered mental status with underlying dementia, and the MDS documented that it was very important for the resident to keep up with the news and go outside for fresh air when the weather was good. The activity care plan, initiated on 9/10/24 and revised on 8/27/25, stated the resident had little or no activity involvement and wished to participate in more activities when feeling better, with goals to participate in activities of choice and show engagement in activities of interest. The interventions included entertainment programs, group activities, volunteer demonstrations, religious activities, 1:1 in-room visits, and providing a schedule of activities, but the care plan was not person-centered and did not reflect the resident’s documented preferences from the MDS. Activity logs from 8/1/25 through 11/25/25 showed only 1:1 visits, sleep, talk, TV, and four refusals, and did not show participation in activities such as going outside for fresh air when the weather was good.
Failure to Provide Required Apron During Smoking Breaks
Penalty
Summary
The facility failed to provide an assistive device during smoking breaks for a resident who was identified in the smoker log and smoking assessment as needing an apron and staff supervision while smoking. During a scheduled smoke break, the resident was observed outside at the designated smoking area with staff present, smoking without an apron. When asked about the apron, the resident stated that no one had ever offered one, and the staff member present said she was unaware that the resident had to wear an apron for smoking. During a later scheduled smoke break, the resident was again observed smoking without wearing an apron, and the staff member present stated he was unaware that the resident needed to wear one during smoking breaks. He reported that he relied on the facility's smoker log report, then checked it and confirmed the resident was listed, but still did not know the resident required an apron. The DON stated that the Activity Department was responsible for supervising residents during smoking breaks and providing aprons, and said the resident refused to wear one, but there was no supporting documentation of that refusal at the time of the surveyor's observation.
Failure to Provide Required Education After Staff Performance Issues
Penalty
Summary
The facility failed to ensure that a Geriatric Nursing Assistant (GNA) received education based on issues identified during an annual performance evaluation. Staff #8 received a verbal warning, and the evaluation record did not include details about the reason for the warning. During interview, the Nursing Home Administrator stated she was unsure why the corrective action had been issued because she was new to the facility. When asked to provide the reason for the corrective action and evidence of any in-service or education provided in response to the deficiency, the NHA later produced an Employee Corrective Action Form showing that Staff #8 had received a verbal warning and was later written up again for insubordination, including yelling at a clinical manager and not following direction. The NHA stated there was no evidence that education or follow-up training had been provided after the performance issues were identified.
Inaccurate Resident Matrix
Penalty
Summary
The facility failed to complete the resident Matrix accurately during the recertification survey. After the survey team entered the facility, the DON presented a Matrix dated 11/19/25 at 10:01 AM that identified care categories for all residents. Review of the Matrix showed that Residents #35, #57, and #76 were listed as receiving parental feedings, and Resident #94 was listed as receiving hospice care. Further review of the DON-provided lists of residents receiving hospice care and parental feedings did not support those entries on the Matrix. The DON stated that Resident #94 had been discontinued from hospice care before the surveyors’ initial entry, but the Matrix had not been updated. The DON also confirmed that Residents #35, #57, and #76 did not receive parental feedings. In a later interview, the DON reported that the Matrix was corrected after the surveyor’s intervention.
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 | ★★★★★ | 47 | 0 |
| Creekside Center For Rehabilitation And Nursing | 1.4 mi | ★★★★★ | 34 | 1 |
| Coffman Nursing Home | 1.9 mi | ★★★★★ | 16 | 0 |
| Western Md Hospital Center | 2.2 mi | ★★★★★ | 20 | 0 |
| Complete Care At Hagerstown | 4.6 mi | ★★★★★ | 23 | 1 |
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