NMS HEALTHCARE OF HAGERSTOWN, LLC MD DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/14/2010	fire-resistant room wall surfaces.	Widespread	Potential for minimal harm
01/14/2010	corridor and hallway doors that block smoke.	Widespread	Potential for minimal harm
01/14/2010	a fire alarm system that can be heard throughout the facility.	Pattern	Potential for minimal harm
01/14/2010	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Potential for minimal harm
01/14/2010	an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Potential for minimal harm
01/14/2010	portable fire extinguishers.	Pattern	Potential for minimal harm
01/14/2010	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Minimal harm or potential for actual harm
01/14/2010	proper power supply for life support equipment.	Isolated	Minimal harm or potential for actual harm
01/14/2010	fire safety features required by current fire safety codes.	Pattern	Potential for minimal harm
01/14/2010	no-smoking signs where oxygen is used.	Widespread	Potential for minimal harm
01/14/2010	weekly inspections and monthly testing of generators.	Isolated	Minimal harm or potential for actual harm
01/14/2010	properly installed electrical wiring and equipment.	Pattern	Potential for minimal harm
12/10/2009	Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Minimal harm or potential for actual harm
12/10/2009	1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
12/10/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
12/10/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
12/10/2009	Get services outside the nursing home that meet professional standards.	Isolated	Minimal harm or potential for actual harm
12/10/2009	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
05/28/2009	Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Minimal harm or potential for actual harm
05/28/2009	Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm
05/28/2009	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Pattern	Potential for minimal harm
05/28/2009	Quickly give a resident's personal money to the heads of his or her estate after the resident's death.	Pattern	Potential for minimal harm
05/28/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
05/28/2009	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
05/28/2009	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
05/28/2009	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
05/28/2009	Make sure that residents are safe from serious medication errors.	Pattern	Minimal harm or potential for actual harm
05/28/2009	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
05/28/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Potential for minimal harm
05/28/2009	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
05/05/2009	fire-resistant room wall surfaces.	Pattern	Potential for minimal harm
05/05/2009	exit stairways and towers that are smoke proof.	Pattern	Potential for minimal harm
05/05/2009	properly maintained smoke detectors.	Pattern	Potential for minimal harm
05/05/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
05/05/2009	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Widespread	Potential for minimal harm
05/05/2009	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
05/05/2009	properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm
04/23/2008	Tell the resident completely about his or her health status.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Pattern	Minimal harm or potential for actual harm
04/23/2008	Quickly give a resident's personal money to the heads of his or her estate after the resident's death.	Pattern	Minimal harm or potential for actual harm
04/23/2008	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Protect each resident from all abuse, physical punishment, and being separated from others.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
04/23/2008	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Screen residents when they are first admitted to send them to an area with special care for people with developmental disabilities or mental illness, if needed.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
04/23/2008	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
04/23/2008	Provide special eating equipment and utensils for each resident who needs them.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
04/23/2008	Get rid of garbage properly.	Pattern	Potential for minimal harm
04/23/2008	Make sure that a doctor approves a resident's admission in writing and that each resident has a doctor.	Pattern	Minimal harm or potential for actual harm
04/23/2008	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Keep all essential equipment working safely.	Widespread	Minimal harm or potential for actual harm
04/23/2008	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Pattern	Minimal harm or potential for actual harm
04/23/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
04/23/2008	Have enough outside airflow.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Give lab tests only when the attending doctor ordered them.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm
04/23/2008	Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
01/09/2008	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Potential for minimal harm
01/09/2008	properly working alarms on sprinkler valves.	Widespread	Potential for minimal harm
01/09/2008	fire-resistant room wall surfaces.	Widespread	Potential for minimal harm
01/09/2008	proper stairway enclosures and vertical shafts.	Isolated	Minimal harm or potential for actual harm
01/09/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Potential for minimal harm
01/09/2008	exit stairways and towers that are smoke proof.	Pattern	Potential for minimal harm
01/09/2008	exits that are accessible at all times.	Pattern	Potential for minimal harm
01/09/2008	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Potential for minimal harm
01/09/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
01/09/2008	portable fire extinguishers.	Pattern	Potential for minimal harm
01/09/2008	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
01/09/2008	properly installed electrical wiring and equipment.	Pattern	Potential for minimal harm

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Where does this data come from?

The data on this website describes nursing home characteristics, quality measures, inspection results, and nursing staff information.

The data come from 2 sources:

1. Centers for Medicare & Medicaid Services (CMS) have an Online Survey, Certification, and Reporting (OSCAR) database - Includes the nursing home characteristics and health deficiencies issued during the three most recent state inspections and recent complaint investigations.

   The survey inspection results are collected by the state survey agencies, who perform onsite visits to nursing homes . The inspections occur at least once during a 15-month period, or any time in between as a result of a complaint received by the state. The inspections ensure that the nursing home residents receive quality care and services in a safe and comfortable environment in accordance with rules established by CMS. Complaints may be reported and inspected during the year (outside of the 9-15 month survey cycle). Inspections about a complaint that result in the citation of a health deficiency are reported to CMS and included in this website. Sometimes the inspection finds a problem that the nursing home identified and corrected before the inspection occurred. The fact and the nature of these prior problems (deficiencies) may be included in this website.

   The information on the nursing homes' characteristics derived from OSCAR are prepared by each nursing home at the beginning of the regular State inspection. This information is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure data accuracy. In addition, this information changes frequently as residents are discharged and admitted, or resident conditions change.

2. National database known as the Minimum Data Set (MDS) Repository

   The data for the quality measures come from the MDS Repository. The MDS is collected on regular intervals for every resident in a Medicare or Medicaid certified nursing home. Information is collected on the resident's health, physical functioning, mental status, and general well-being. These data are used by the nursing home to access the needs and develop a plan of care unique to each resident.

   Regulations require that a MDS assessment be performed at admission, quarterly, annually, and whenever the resident experiences a significant change in status. For residents in a Medicare Part A stay, the MDS is also used to determine the Medicare reimbursement rate. These assessments are performed on the 5th, 14th, 30th, 60th and 90th day of admission.

   All of this data is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure that it is accurate. Every attempt is made to assure the accuracy and timeliness of this information. However, this information changes frequently as residents are discharged and admitted, or resident conditions change. We advise interpreting this information cautiously and supplementing it with information from the Ombudsman's office, the State Survey Agency, or other sources.

   Some MDS items used to calculate the quality measures consider the resident's condition during previous days prior to the assessment date. The following table provides these "observation" or "look back" time frames.

Signs of Nursing Home Abuse:

• Unexplained injuries or bruises
• Over or under medication
• Visible cuts, bruises, or welts
• Rapid weight loss or weight gain
• Dehydration, malnutrition, and bedsores
• Unsanitary living conditions
• Infections
• Broken bones
• Sudden death