A list of the most recent deficiencies for Complete Care at Hagerstown. 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? |
|---|---|---|---|---|
| Install proper backup exit lighting. | Fire Safety | 2021-06-29 | 2021-08-09 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-06-29 | 2021-08-09 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-06-29 | 2021-08-09 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2021-06-29 | 2021-08-09 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2021-06-29 | 2021-08-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-29 | 2021-08-09 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-06-29 | 2021-08-09 | N |
| 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 | 2021-07-02 | 2021-08-03 | N |
| 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 | 2021-07-02 | 2021-08-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-02 | 2021-08-03 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-07-02 | 2021-08-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-02 | 2021-08-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-02 | 2021-08-03 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-07-02 | 2021-08-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-07-02 | 2021-08-03 | N |
| 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. | Health | 2021-07-02 | 2021-08-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-02 | 2021-08-03 | 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 | 2021-07-02 | 2021-08-03 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-07-02 | 2021-08-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-02 | 2021-08-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-02 | 2021-08-03 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-07-02 | 2021-08-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-02 | 2021-08-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-02 | 2021-08-03 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-07-02 | 2021-08-03 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-02 | 2021-08-03 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-02 | 2021-08-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-02 | 2021-08-03 | 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 | 2021-07-02 | 2021-08-03 | Y |
| Have enough backup water supply for essential areas of the nursing home. | Health | 2021-07-02 | 2021-08-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-02 | 2021-08-03 | Y |
| Assess the resident when there is a significant change in condition | Health | 2021-07-02 | 2021-08-03 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-05-11 | 2021-06-09 | Y |
| Post nurse staffing information every day. | Health | 2021-05-11 | 2021-06-09 | Y |
| Meet other general requirements. | Fire Safety | 2021-03-05 | 2021-03-15 | Y |
| Construct fire resistant interior walls. | Fire Safety | 2021-03-05 | 2021-03-15 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-03-05 | 2021-03-15 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-05 | 2021-03-15 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-03-05 | 2021-03-15 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-05-24 | 2018-05-25 | 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 | 2018-05-24 | 2018-05-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-24 | 2018-05-25 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-05-24 | 2018-05-25 | N |
