Hagerstown Healthcare Center

In the surveyor’s words

From the most serious findings on record at Hagerstown Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 6, 2026

  Based on interviews and record review, the facility failed to ensure safe transport practices for 1 (Resident #8) of 6 residents reviewed during the complaint survey. This failure resulted in actual harm to Resident #8.The findings include:During record review it was revealed that on 1/13/26, Resident #8 (R#8) was transported off campus for an appointment in a wheelchair without leg rests, although the resident normally required stretcher transport due to limited ability 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.During an interview on 3/3/26 at 10:14 AM, R#8 stated that Geriatric Nursing Assistant (GNA) #12 appeared to be in a hurry and did not use leg rests. […]

• Actual harm, isolatedF689Jul 25, 2025

  Based on interviews and record review it was determined that the facility failed to provide sufficient supervision to prevent an avoidable accident from occurring by not following appropriate safety procedures while using a Hoyer lift (a mechanical device used to transfer and to lift Residents). As a result, Resident (R#7) suffered a fall with harm (fractures to collarbone and femur). This was evident for 1 (R#7) of 34 residents reviewed during a complaint survey. Findings Include: Record review of the facility undated policy titled “Mechanical Lifts and Transfer” documented, it was the facility policy to “provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the Residents. […]

• Actual harm, isolatedF689Aug 21, 2023

  Based on medical record review and staff interview, facility staff failed to implement interventions to prevent a vulnerable, cognitively impaired resident (resident #2) from experiencing a fall that resulted in harm. This was evident for 1 of 4 residents reviewed during a complaint survey. The findings include: Review of resident #2's medical record on 8/18/23 at 1:30 PM revealed the resident was admitted to the facility on [DATE] for long term care after receiving a diagnosis of Alzheimer's Disease and Dementia. The diagnosis of Dementia describes a group of symptoms affecting memory, thinking and social abilities severe enough to interfere with the daily life of a resident. […]

• Actual harm, isolatedF600Jan 13, 2023

  Based on record review, and interviews of staff and residents, it was determined that the facility failed to ensure that residents were free from abuse. This was found to be evident for 1 (Resident #88) out of 11 residents reviewed for resident to resident abuse and 4 (Resident #20, #38, #16, #8) of 40 residents reviewed for facility reported abuse allegations. As a result, actual harm was identified for the facility's failure to ensure that resident # 88 was free from physical abuse and injury due to another resident's aggressive behavior. The findings include: An FRI (facility reported incident) is a self- report with investigations conducted by nursing home facilities. 1) On 01/05/23 at 08:47 AM, the surveyor interviewed the residents #72 and #74. […]

• No harm, potential for more than minimal, widespreadF812Nov 26, 2025

  Based on observations, interviews, and record reviews, it was determined that the facility failed to label and date foods stored in facility refrigerators, ensure cleanliness of the kitchen environment and equipment, and maintain safe food storage temperatures in the walk-in refrigerator. This was evident during kitchen tours conducted throughout the facility's annual survey.The findings include:A. On 11/19/25 at 8:24 AM, the Surveyor conducted a brief initial tour of the facility kitchen. Upon stepping inside the walk-in refrigerator, the Surveyor observed multiple food items that were not labeled and/or not dated, including:Ground meat in a container labeled only freeze by 10/21/25, with no description of the food item or date when it was moved to the refrigerator. […]