Hagerstown Healthcare Center

Inspectors wroteBased on complaints, a facility reported incident (FRI), reviews of a clinical record, reviews of facility investigation documents, and staff interview, it was determined that the facility staff failed to provide adequate supervision to Resident #5 to prevent Resident #5 from entering other resident rooms. On 07/01/26, Resident #5 was left unsupervised which allowed him to enter Resident #4's room and expose his groin area to Resident #4 and his family member. This was evident for 1 (Resident #5) of 8 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint, observation, record review, and interviews, it was determined that the facility failed to ensure that a resident was served a meal according to a predetermined menu that incorporated the resident's preferences. This was evident for 1 (Resident #3) of 8 residents reviewed during a complaint survey.

Inspectors wroteBased on interview and record review, the facility failed to ensure a grievance received was documented, entered into the facility grievance log, tracked, investigated, and followed up according to the facility's grievance process for 1 (Resident #1) of 1 residents reviewed for grievances.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to thoroughly investigate a self-reported incident. This was evident for 1 facility reported incident (FRI #2969278) of 2 FRIs reviewed.

Inspectors wroteBased 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.

Inspectors wroteBased on the review of a facility reported incident 2699068, medical record review, and interviews with facility staff, it was determined that the facility failed to ensure that residents were free from exploitation. This was evident for 1 (Resident #7) of 1 allegation of exploitation reviewed during the complaint survey.

Inspectors wroteBased on record review and interview, the facility failed to timely report an injury of unknown origin and an incident of resident exploitation to the State Survey Agency. This was true for two (Resident #7 and #8) of six residents sampled for reporting during the complaint survey.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, policy review, and interviews, the facility failed to prevent the spread of infection, as evidenced by the failure of licensed nursing staff to perform hand hygiene during medication administration for 3 (Residents #10, #11, and #85) of 4 residents observed. On 11/19/2025 at 8:15 AM, the surveyor arrived on the first floor and observed medication administration by CMA #2, who dispensed medication for Resident #10. Hand hygiene was not performed as the CMA began pulling blister packages from the medication cart for this resident. Hand hygiene was also not performed before administering medications to Resident #10. On 11/19/2025 at 8:30 AM, Hand hygiene was not performed when Nurse #1 approached the medication cart and administered a PRN medication (oxycodone 5) for Resident #11. [...]

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to notify a Resident's representative of a documented change in the Resident's condition. This was evident for one (Resident #22) out of one Resident reviewed for Notification of change.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to complete Significant Change in Status Minimum Data Set (MDS) assessments within 14 days following a significant decline in the Residents' condition. This was evident for 1 (Resident #5) of 1 Resident reviewed for Hospice, and 1 (Resident #10) out of 5 Residents reviewed for Unnecessary medication regimen review

Inspectors wroteBased on observation, record review and staff and resident interview, it was determined that the facility failed to accurately document a resident's status on the Minimum Data Set (MDS) assessment for 1 resident (Resident #81) of four residents reviewed for accidents during the survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to provide medically related social services to a resident triggered for required PASARR screening. This finding was evident for one (Resident #54) of three residents reviewed for PASARR screening during the survey.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to accurately reflect a resident's discharge plan on their individualized care plan. This was evident for one (Resident #32) of three residents reviewed for discharge planning.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to ensure interdisciplinary care plan meetings were conducted following the completion of Minimum Data Set (MDS) assessments. This was evident for 3 ( Resident #11, #5, and #10) out of 41 Residents reviewed during the recertification survey.

Inspectors wroteBased on observation, record reviews, and interviews, it was determined that the facility failed to provide an ongoing program of activities that met residents' needs and preferences. This was evident for 1 (#10) out of 2 residents reviewed for activities.

Inspectors wroteBased on record review, observations, and interviews, it was determined that the facility failed to provide an assistive device to residents during smoking breaks to prevent accidents. This was evident for one Resident (Resident #40), who was reviewed for accidents.

Inspectors wroteBased on staff record review and interviews, it was determined that the facility failed to ensure that a Geriatric Nursing Assistant (GNA) was provided education based on issues identified during the employee's annual performance evaluation. This was evident for one staff member (Staff #8) out of six employees reviewed for sufficient and competent staffing.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to complete the residents' Matrix accurately. This was evident during the recertification survey.

Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to 1) follow physician orders and 2) implement resident's non-pharmacological interventions prior to administration of pain medication and identify individualized non-pharmacological interventions for behaviors. This was evident for 2 (#1 and #3) of 3 residents reviewed during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to keep complete and accurate medical records by failing to ensure a resident had only one unvoided MOLST in the medical record. This was evident for 1 (#3) of 4 residents reviewed during a complaint survey.

Inspectors wroteBased 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. Safety is a primary concern of our residents, staff and visitors. [...]

Inspectors wroteBased on record review, interviews, and observations, the facility failed to maintain an environment free from Resident-to-Resident sexual abuse. Specifically, Resident #34 (R#34) made unwanted sexual contact with Resident #13 (R#13) one time. The facility census was 111 and the sample size was 34.

Inspectors wroteBased on medical records review and staff interview, it was determined that the facility staff failed to reveal evidence that the resident or resident representative was informed of their right to formulate an advanced directive. This was evident for 4 (Resident #86, #50, #83, #26) of 4 residents reviewed for advanced directives.

Inspectors wroteBased on observations, records review, and interviews, it was determined that the facility failed to have a process in place for staff to install and maintain bed rails in a safe manner for their residents. This was evident for 3 (Resident #69, #42, and #58) of 5 residents reviewed for use of bed rails.

Inspectors wroteBased on interviews of the facility staff and observations, it was determined that the facility failed to provide frequently scheduled consultations between a qualified dietitian and the facilities food service director for oversight of food preparation and daily kitchen operation. This has the potential to affect all residents.

Inspectors wroteBased on observations, record review, and staff interviews, it was determined that facility staff failed to ensure that residents were able to make choices about their daily schedules. This was evident for 1 (Resident #19) of 4 residents reviewed for choices.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to have an effective system in place to ensure that maintenance concerns were reported and addressed. This was found to be evident for rooms on 2 out of the 2 units in the facility.

Inspectors wroteBased on review of medical records and other pertinent documentation and interviews, it was determined that the facility failed to ensure grievances regarding allegations of abuse were immediately reported to the administrator; and failed to ensure documentation of summary of investigation or follow up with the complainant. This was found to be evident for 2 (Resident #87 and #61) out of 37 residents reviewed for abuse during the survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to protect a resident from abuse. This was evident for 1 (Resident #11) of 37 residents reviewed for abuse.

Inspectors wroteBased on review of medical records and other pertinent documentation and interviews, it was determined that the facility failed to ensure allegations of abuse were reported in a timely manner. This was found to be evident for 3 (Resident #31, #61, #86) of 37 residents reviewed for abuse during the survey.

Inspectors wroteBased on records review and interviews, it was determined that the facility failed to conduct a thorough investigation regarding a misappropriation of property allegation. This was evident in 1 (Resident #31) of 37 residents reviewed for abuse.

Inspectors wroteBased on medical records review, observations, and interviews, it was determined that the facility staff failed to document the residents Minimum Data Set (MDS) assessments accurately. this was evident for 3 (Resident #69, #81, #86) of 64 residents investigated during this survey process.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that a discharge summary was completed for all discharged residents within a reasonable time frame. This was evident for 2 residents (Resident #110, Resident #111) out of 3 residents reviewed for closed record review during a survey.

Inspectors wroteBased on record review and interview, it was determined that staff failed to ensure that residents were given assistance with activities of daily living (ADL which include but are not limited to showering, bathing, personal hygiene, dressing, and toileting) as needed. This was evident for 1 (#99) of 3 residents reviewed for ADL care.

Inspectors wroteBased on observation, record review, and staff interviews, it was determined that the facility failed to develop and implement an activities program to meet the needs of their residents. This was evident for 1 (Resident #42) of 6 residents reviewed for activity programs.

Inspectors wroteBased on record review, observation and interviews it was determined that facility staff failed to follow an order for enhanced barrier precautions. This was evident for 1 (Resident #18) out of 1 resident reviewed for urinary catheter and urinary tract infection during the survey.

Inspectors wroteBased on record review, observations, and interviews, it was determined that the facility failed to implement the physical therapist's therapeutic recommendations to prevent the worsening of contractures. This was evident for 1 (Resident #103) out of 3 residents reviewed for position and mobility during a survey.

Inspectors wroteBased on records review and interviews, it was determined that the facility failed to ensure that pain management was provided to the resident that is consistent with professional standards of practice. This was evident for 1 (Resident #31) of 2 residents reviewed for pain management.

Inspectors wroteBased on records review, interviews, and observations, it was determined that the facility failed to provide a resident with dementia purposeful and meaningful activities to maintain his/her highest practicable physical, mental, and psychosocial well-being. This was evident in 1 (Resident #7) of 2 residents reviewed for dementia care.

Inspectors wroteBased on medical records review and staff interviews, it was determined the pharmacist failed to identify a medication order discrepancy during a monthly pharmacy medication review. This was evident for 1 (#86) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on pertinent document review and interviews, it was determined that the facility failed to administer medication according to a physician's orders. This was evident for 1 (Resident #37) out of 4 residents reviewed for unnecessary medications during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to ensure that a resident's medication regimen was free from an unnecessary psychotropic medication and failed to ensure that a psychotropic medication prescribed as needed was limited to 14 days. This was evident for 1 (#86) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review, and interview, it was determined that facility staff failed to have a medication administration error of less than 5%. This was evident for 1 of 3 staff observed for medication administration.

Inspectors wroteBased on family interview, observation, record review, and staff interview, it was determined that facility staff were disposing of medications in an open trash can on the medication cart. This was evident for 1 of 1 medication disposed of during an observation of medication administration.

Inspectors wroteBased on interviews, pertinent documentation, and observation it was determined that the facility failed to develop menus that take into consideration the resident's food preferences. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on observations, interviews, and pertinent documentation reviews, it was determined that the facility failed to practice proper hygiene, properly store food, monitor food and refrigerator temperatures, and maintain clean sanitary equipment to prevent foodborne illness. This was evident for 1 kitchen during the survey. This deficient practice has the potential to affect all the residents in the facility. 1) On 12/3/23 at 9:23 AM, an observation of the kitchen was made. The observation revealed a Dietary Aide (Staff #59) walking in the kitchen without a hairnet. On 12/3/23 at 9:28 AM, during an interview with Staff #59, he reported that he did not need to wear a hair net when washing the dishes. On 12/5/23 at 8:46 AM, the Food Service Director (FSD) Staff #48 was interviewed. [...]

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to maintain a complete resident medical record. This was evident for 2 (Resident #50, #31) of 64 residents investigated during the survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that staff sanitized their hands prior to the start of administering medications; and failed to keep a barrier in place between clean and dirty laundry. This was found to be evident during 1 out of 3 medication observations and 1 out of 1 observation of the laundry room.

Inspectors wroteBased on observation, record review, and staff interview, it was determined that the facility failed to have a preventative maintenance program to ensure that bed rails remained properly attached to the bed to ensure resident safety. This was evident for 3 (#81, #69, and #42) of 5 residents reviewed for bed rails.

Inspectors wroteBased on medical record review and resident and staff interviews, it was determined the facility 1) failed to ensure resident care plans were reviewed and revised by the interdisciplinary team after each assessment, and 2) failed to ensure that a resident and resident representative, if applicable, had the opportunity to participate in the development, review, and revision of the resident's care plan after each assessment. This was evident for 4 (#84, #81, #83, #26) of 5 residents reviewed for care plan timing and revision.

Inspectors wroteBased on review of resident medical records, interview with facility staff, interview with the staff of contracted Hospice services, and review of facility policy, it was determined that, when the facility was unable to immediately identify a resident's end-of-life wishes upon his her/cardiac arrest, the facility failed to perform Cardiopulmonary Resuscitation (CPR) while they attempted to clarify the resident's wishes. As a result of these findings, a state of immediate jeopardy was declared on [DATE] at 12:30 PM and the facility was provided with the Immediate Jeopardy Template at that time. The facility submitted a removal plan on [DATE] at 4:00 PM and the State Agency was unable to accept this plan. The facility submitted a second plan on [DATE] at 6:30 PM and the removal plan was accepted at 7:00 PM. [...]

Inspectors wroteBased on resident and staff interview and medical record review, it was determined that the facility failed to include the resident/representative in the development and implementation of the resident's person-centered care plan by failing to have a care plan meeting to review the updated care plan. This was evident for 2 (#42, #199) of 6 residents reviewed for care plans and 1 (#70) of 1 reviewed for hospice care.

Inspectors wroteBased on complaint allegations, resident and family interviews, observations and review of facility documents, it was determined that the facility failed to maintain sufficient staff to provide care to residents to maintain the highest practical physical, mental, and psychosocial well-being of each resident as evidenced by residents failing to receive sufficient help with activities of daily living (ADL) This was evident on 2 of 2 nursing units.

Inspectors wroteBased on observations of the facility's kitchen and food services, it was determined that the facility failed to maintain food service equipment in a manner that ensured sanitary food service operations and failed to utilize appropriate hair restraints for employees preparing meals for residents. This was identified during multiple observations of the facility's kitchen and food services operation.

Inspectors wroteBased on review of facility records and interview with staff, it was determined that the facility failed to document a facility-wide assessment that included staff competencies that were necessary to provide the level and types of care needed for the resident population. This was evident during sufficient staffing review.

Inspectors wroteBased on review of the facility's last recertification and complaint surveys, deficient practices identified during the current survey and interview with facility staff, it was determined that the facility was noted to have an ineffective Quality Assurance and Performance Improvement (QAPI) program by failing to monitor measures that were developed to correct deficient practices. This was evident during Quality Assurance review.

Inspectors wroteBased on surveyor observation, it was determined that the facility staff failed to maintain an effective infection control program by failing to ensure that resident care equipment and supplies were maintained in a in a manner to minimize the resident's exposure to infectious organisms. This was evident for 5 (#122, #29, 84, #96, #4) of 34 residents on both floors of the facility observed during the initial pool selection. These practices have the potential to affect all residents, staff, visitors, and volunteers in the facility.

Inspectors wroteBased on observation, record review, staff and resident interview, it was determined that the facility failed to maintain an effective pest control program. This was evident for 2 of 2 nursing units.

Inspectors wroteBased on surveyor observation, it was determined that the facility staff failed to protect and value residents' private space by failing to knock and request permission before entering a resident's room. This was evident, but not limited to, 3 (#69, #122, #174) residents observed on both units of the facility. Based on observation, record review and staff interview, it was determined that the facility failed to treat residents with dignity and respect by labeling and identifying resident's as feeders, hovering and standing over a resident, or staff conversing with other staff while assisting residents to eat, and failing to serve all residents at the same table at the same time. This was identified for 3 (#13, #41, #109) residents observed during dining observations.

Inspectors wroteBased on review of the medical record and interview with the resident and staff, it was determined that the facility failed to notify the physician when a resident's prescribed medication was not available to administer, failed to notify physician and family of a resident falling and failed to provide prior notification to a resident of a room change. This was evident for 3 (#178, #69, #112) of 40 residents reviewed during the investigative stage of the survey.

Inspectors wroteBased on surveyor observation, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable and homelike environment. This was evident throughout the survey on 2 of 2 nursing units.

Inspectors wroteBased on review of the medical record and interview with facility staff, it was determined that the facility failed to prepare residents for an orderly discharge or transfer from the facility. This was evident for 4 (#66, #126, #325, #4) of 7 residents reviewed for hospitalization and for 1 (#120) of 5 residents reviewed for accidents.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded . This was evident for 1 (#69) of 5 residents reviewed for activities of daily living (ADLs), 2 (#59, #120) of 2 residents reviewed for activities, for 1 (#112) of 9 residents reviewed for nutrition, and 1 (#7) of 4 residents reviewed for urinary catheter care

Inspectors wroteBased on review of the medical records and interviews with staff, it was determined that the facility staff failed to develop and implement baseline care plans that included instructions needed to provide effective and person-centered care of the resident with physicians' orders and initial goals. Additionally, the facility failed to provide the resident and/or their representative a summary of the baseline care plan including medications. This was evident for 5 (#122, #70, #23, #174 and #60) of 40 residents reviewed during the investigation phase of the survey. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.

Inspectors wroteBased on observations, medical record review and interviews with a resident and staff, it was determined that the facility failed to develop accurate, resident centered care plans with measurable goals and objectives and failed to follow a resident's care plan. This was evident for 13 (#108, #8, #23, #70, #122, #105, #69, #84, #14, #41, #76, #86 and #120) of 40 residents reviewed during the investigative phase of the survey.

Inspectors wroteBased on review of medical records and interview with residents and facility staff, it was determined that the facility failed to review and revise care plans as resident needs change and at least quarterly. This was evident for 11 (#42, #108, #8, #23, #53, #105, #109, #325, #120, #59, #82) of 40 residents reviewed during the investigation phase of the survey.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to store medications in a manner that protected the medications during storage. This was evident for 1 (2nd floor) of 2 medication storage rooms.

Inspectors wroteBased on review of medical record and interview with facility staff, it was determined that the facility failed to ensure that resident's medical records were maintained in an accurate and complete manner. This was evident for 5(Residents #53, #109, #178, #82, #122) of 40 residents reviewed during the investigation phase of the survey.

Inspectors wroteBased on observation, resident interview, and record review, the facility failed to assess a resident's preference for activities and promote their participation in those activities by not assisting Resident #86 out of bed to attend their preferred scheduled events. This was evident for 1 (#86) of 2 residents reviewed for activities.

Inspectors wroteBased on review of Medicare beneficiaries who were discharged from skilled therapy and nursing services and interview with staff, it was determined that the facility staff failed to provide 2 (#277, #278)) of 3 Medicare beneficiaries reviewed with a written notice of Medicare Provider Non-Coverage.

Inspectors wroteBased on review of resident, facility records, and staff interviews, it was determined that the facility staff failed to thoroughly investigate alleged abuse and prevent further potential abuse by failing to address an alleged staff to resident altercation. This was evident for 1 (#179) of 1 residents reviewed for abuse.

Inspectors wroteBased on medical record review, it was determined that the facility failed to document the hospital transfer in the medical record for 1 (#76) of 1 residents.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility: 1) failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer and, 2) failed to notify the Office of the State Long-Term Care Ombudsman of a transfer/discharge of a resident. This was evident for 4 (#102, #66, #4, and #76) of 7 residents reviewed for hospitalization and 1 (#120) of 5 residents reviewed for accidents.

Inspectors wroteBased on interview with residents and review of the medical record, it was determined that the facility failed to ensure that newly admitted residents had physician orders for the resident's immediate care at the time of admission. This was evident for 1 (Resident #328) of 40 residents reviewed during the investigation phase of the survey.

Inspectors wroteBased on observations, medical record review and staff interview, it was determined the facility failed to implement an ongoing resident centered activities program designed to meet the interests and support the physical, mental and psychosocial well-being of each resident for 2 (#59, #86) of 2 residents reviewed for activities.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to ensure that each resident received treatment and care in accordance with professional standards of practice by failing to ensurethat physician orders were accurately transcribed, medications were administered as prescribed, and failing to inform a resident when there was a change in his her treatment. This was evident for 2 (#82, #328) of 6 resident's reviewed for care plans.

Inspectors wroteBased on interview with the resident and facility staff and surgical center staff, and review of the medical record, it was determined that the facility staff failed to ensure that a resident received proper treatment to maintain vision abilities by failing to obtain required preoperative evaluations resulting in the cancellation of the resident's cataract surgery. This was evident for 1 (#8) of 2 residents reviewed for Communication-Sensory concerns.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to 1) maintain an environment free of environmental hazards for confused residents as evidenced by having treatment carts unlocked and unattended in the hallway of the second floor unit. This was evident for 2 of 2 carts observed on the 2nd floor on the day of survey entry.

Inspectors wroteBased on interviews with the resident and staff and review of the medical record, it was determined that the facility failed to ensure a resident admitted with an indwelling urinary catheter was assessed for removal of the catheter, or ensure that the record demonstrated that catheterization was necessary. This was evident for 1 (#122) of 3 residents reviewed for Urinary Catheter or UTI (Urinary Tract Infection).

Inspectors wroteBased on observation, medical record review and staff interview, it was determined that the facility staff: 1) failed to ensure that oxygen was administered at the rate ordered by the physician, 2) failed to accurately document the resident's oxygen rate in the treatment record and 3) failed to follow the resident's care plan related to oxygen administration. This was evident for 1 (#102) of 6 residents reviewed for respiratory care.

Inspectors wroteBase on random review of staff postings, and comparison to other daily staffing sheets, it was determined that the facility failed to accurately document staff posting, including the correct census at the beginning of each shift. This was exemplified by a review of 5 Federal staffing sheets with 3 days found to be inaccurate for the actual hours worked by licensed and unlicensed staff.

Inspectors wroteBased on medical record review and staff interview, it was determined that the pharmacist failed to identify excessive medication doses being administered to a resident who was to have medications tapered. This was evident for 1 (#20) of 3 residents reviewed for medical record accuracy.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by 1) failing to follow the physician's order to taper and discontinue a medication and 2) failing to follow physician ordered blood pressure parameters for administering blood pressure medication. This was evident for 1 (#20) of 3 residents reviewed for medical record accuracy and 1 (#6) of 3 new admissions reviewed.

Inspectors wroteBased on observation, it was determined that the facility failed to ensure that the medication error rate was not greater than 5%. This was evident from observations made during the medication administration observation facility task.

Inspectors wroteBased on review of facility records it was determined the facility failed to ensure that the required committee members attended the quality assessment and assurance meetings quarterly. This was evident during review of the quality assessment and assurance review.

Inspectors wroteBased on surveyor observation and interview with facility staff, it was determined that the facility staff failed to ensure that residents had a means of directly contacting caregivers by failing to ensure the call bell system was operational for each resident. This was evident for 1 of 32 resident rooms observed on the second floor of the facility.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to provide residents/resident representatives with a written notice of the facility's bed hold policy upon transfer or therapeutic leave. This was evident for but not limited to 2 (#4, #76) of 7 residents reviewed for hospitalization.