Deficiency Records for Hagerstown Healthcare Center
Updated as of November 01, 2021
This is not the most recent data for Hagerstown Healthcare Center. For the most recent information, click here.
A list of the most recent deficiencies for Hagerstown Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-12-15 | 2021-01-02 | N |
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. | Health | 2020-12-03 | 2021-01-02 | N |
Provide and implement an infection prevention and control program. | Health | 2020-12-03 | 2021-01-02 | N |
Assess the resident when there is a significant change in condition | Health | 2020-11-02 | 2020-12-15 | Y |
Ensure each resident receives an accurate assessment. | Health | 2020-11-02 | 2020-12-15 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-11-02 | 2020-12-15 | Y |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-11-02 | 2020-12-15 | Y |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-11-02 | 2020-12-15 | Y |
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2020-11-02 | 2020-12-15 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-11-02 | 2020-12-15 | Y |
Provide and implement an infection prevention and control program. | Health | 2020-11-02 | 2020-12-15 | Y |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2020-11-02 | 2020-12-15 | Y |
Provide and implement an infection prevention and control program. | Health | 2020-07-28 | 2020-09-04 | N |
Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2019-04-08 | 2019-08-27 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-04-08 | 2019-08-27 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-08 | 2019-08-27 | Y |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-08 | 2019-08-27 | Y |
Ensure each resident receives an accurate assessment. | Health | 2019-04-08 | 2019-08-27 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-08 | 2019-08-27 | Y |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-04-08 | 2019-08-27 | Y |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-04-08 | 2019-08-27 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-08 | 2019-08-27 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-05 | 2019-08-27 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-05 | 2019-08-27 | Y |
Observe each nurse aide's job performance and give regular training. | Health | 2019-08-05 | 2019-08-27 | Y |
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-08-05 | 2019-08-27 | Y |
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. | Health | 2019-04-08 | 2019-06-24 | N |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-04-08 | 2019-06-24 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-08 | 2019-06-24 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-08 | 2019-06-24 | N |
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2019-04-08 | 2019-06-24 | N |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2019-04-08 | 2019-06-24 | N |
Ensure that residents are free from significant medication errors. | Health | 2019-04-08 | 2019-06-24 | N |
Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2019-04-08 | 2019-06-24 | Y |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-04-08 | 2019-06-24 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-08 | 2019-06-24 | Y |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-08 | 2019-06-24 | Y |
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. | Health | 2019-04-08 | 2019-06-24 | Y |
Respond appropriately to all alleged violations. | Health | 2019-04-08 | 2019-06-24 | Y |
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. | Health | 2019-04-08 | 2019-06-24 | Y |
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-04-08 | 2019-06-24 | Y |
Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2019-04-08 | 2019-06-24 | Y |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-08 | 2019-06-24 | Y |
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2019-04-08 | 2019-06-24 | Y |
Provide activities to meet all resident's needs. | Health | 2019-04-08 | 2019-06-24 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-08 | 2019-06-24 | Y |
Assist a resident in gaining access to vision and hearing services. | Health | 2019-04-08 | 2019-06-24 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-08 | 2019-06-24 | Y |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-04-08 | 2019-06-24 | Y |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-08 | 2019-06-24 | Y |
Post nurse staffing information every day. | Health | 2019-04-08 | 2019-06-24 | Y |
Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-08 | 2019-06-24 | Y |
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. | Health | 2019-04-08 | 2019-06-24 | Y |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-08 | 2019-06-24 | Y |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-04-08 | 2019-06-24 | Y |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-04-08 | 2019-06-24 | Y |
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-04-08 | 2019-06-24 | Y |
Provide and implement an infection prevention and control program. | Health | 2019-04-08 | 2019-06-24 | Y |
Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-04-08 | 2019-06-24 | Y |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-04-08 | 2019-06-24 | Y |
Meet other general requirements. | Fire Safety | 2019-04-10 | 2019-05-31 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-10 | 2019-05-31 | N |
Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-04-10 | 2019-05-31 | N |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-04-10 | 2019-05-31 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-04-10 | 2019-05-31 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-04-10 | 2019-05-31 | N |
Install properly constructed and protected linen or trash chutes. | Fire Safety | 2019-04-10 | 2019-05-31 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-10 | 2019-05-31 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-11 | 2019-01-18 | Y |
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. | Health | 2018-12-11 | 2019-01-18 | Y |
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. | Health | 2018-12-11 | 2019-01-18 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-12-11 | 2019-01-18 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-12-11 | 2019-01-18 | Y |
Provide appropriate foot care. | Health | 2018-12-11 | 2019-01-18 | Y |
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. | Health | 2018-12-11 | 2019-01-18 | Y |
Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2018-12-11 | 2019-01-18 | Y |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-10-30 | 2017-12-14 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-10-30 | 2017-12-14 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2017-10-30 | 2017-12-14 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-10-26 | 2017-12-04 | N |
Provide housekeeping and maintenance services. | Health | 2017-10-26 | 2017-12-04 | N |
Maintain comfortable and safe temperature levels. | Health | 2017-10-26 | 2017-12-04 | N |
Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-10-26 | 2017-12-04 | N |
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-10-26 | 2017-12-04 | N |
Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-10-26 | 2017-12-04 | N |
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-10-26 | 2017-12-04 | N |
Post nurse staffing information/data on a daily basis. | Health | 2017-10-26 | 2017-12-04 | N |
Store, cook, and serve food in a safe and clean way. | Health | 2017-10-26 | 2017-12-04 | N |
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-10-26 | 2017-12-04 | N |
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-10-26 | 2017-12-04 | N |
Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-10-26 | 2017-12-04 | N |
Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2017-10-26 | 2017-12-04 | N |
Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-10-26 | 2017-12-04 | N |
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-10-26 | 2017-12-04 | N |
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2016-09-20 | 2016-11-14 | N |
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-09-20 | 2016-11-14 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2016-09-20 | 2016-11-14 | N |
Provide housekeeping and maintenance services. | Health | 2016-09-20 | 2016-11-14 | N |
Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-09-20 | 2016-11-14 | N |
Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-09-20 | 2016-11-14 | N |
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-09-20 | 2016-11-14 | N |
Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-09-20 | 2016-11-14 | N |
Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-09-20 | 2016-11-14 | N |
Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-09-20 | 2016-11-14 | N |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-09-20 | 2016-11-14 | N |
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-09-20 | 2016-11-14 | N |
Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2016-09-20 | 2016-11-14 | N |
Provide a tasty and well-balanced diet that meets the nutritional needs of each resident. | Health | 2016-09-20 | 2016-11-14 | N |
Store, cook, and serve food in a safe and clean way. | Health | 2016-09-20 | 2016-11-14 | N |
Give or get specialized rehabilitative services per the patient's assessment or plan of care. | Health | 2016-09-20 | 2016-11-14 | N |
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-09-20 | 2016-11-14 | N |
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-09-20 | 2016-11-14 | N |
Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-09-20 | 2016-11-14 | N |
Keep all essential equipment working safely. | Health | 2016-09-20 | 2016-11-14 | N |
Have enough backup water supply for essential areas of the nursing home. | Health | 2016-09-20 | 2016-11-14 | N |
Put firmly secured handrails on each side of hallways. | Health | 2016-09-20 | 2016-11-14 | N |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2016-09-20 | 2016-11-14 | N |
1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. | Health | 2016-09-20 | 2016-11-14 | N |
Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-09-20 | 2016-11-14 | N |
Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-09-22 | 2016-10-24 | N |
Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-09-22 | 2016-10-24 | N |
An externally vented heating system. | Fire Safety | 2016-09-22 | 2016-10-24 | N |
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-05-22 | Not Fixed | Y |