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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G2 | H· | I· |
| Potential harm | D66 | E25 | F17 |
| Minimal | A· | B1 | C2 |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Jul 21, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jun 16, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| May 18, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Mar 6, 2026 | Health | Health Complaint | 3 | Actual harm | — | Open → |
| Nov 26, 2025 | Fire safety | Fire Safety Standard | 10 | Potential harm | — | Open → |
| Nov 26, 2025 | Health | Health Standard | 12 | Potential harm | — | Open → |
| Oct 23, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Jul 25, 2025 | Health | Health Complaint | 2 | Actual harm | — | Open → |
| Dec 22, 2023 | Fire safety | Fire Safety Standard | 8 | Potential harm | — | Open → |
| Dec 22, 2023 | Health | Health Complaint, Health Standard | 28 | Potential harm | — | Open → |
| Apr 8, 2019 | Fire safety | Fire Safety Standard | 8 | Potential harm | — | Open → |
| Apr 8, 2019 | Health | Health Standard | 37 | Immediate jeopardy | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Mar 6, 2026 | Civil money penalty (fine) | $10,358 | — | 215336|Fine|137639 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K· | L· |
| Actual harm | G2 | H· | I· |
| Potential harm | D66 | E25 | F17 |
| Minimal | A· | B1 | C2 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jul 21, 2026 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Aug 18, 2026 | Complaint |
| Jul 21, 2026 | F-0803 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Aug 18, 2026 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
Not part of a CMS-reported chain.
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Hagerstown SNF Holdco LLC | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Apr 1, 2026 |
| Jack Shelby | Individual | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | Apr 1, 2026 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Hagerstown SNF Holdco LLC | Organization | Direct owner | DIRECT OWNERSHIP INTEREST | not provided | Apr 1, 2026 |
| Jack Shelby | Individual | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | Apr 1, 2026 |
| Robert Simmers | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 28, 2026 |
| Addisu Temesgen | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 1, 2026 |
| Robert Simmers |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Julia Manor Nursing and Rehabilitation Center 333 Mill Street, Hagerstown, MD 21740 CCN 215321Abuse icon | 0.9 km | 130 | May 1, 2026 | 993 IJ3 harm | — | |
| Creekside Center for Rehabilitation and Nursing 1183 Luther Drive, Hagerstown, MD 21740 CCN 215113 | 2.3 km | 80 | Feb 6, 2026 | 1224 IJ2 harm | $148k | |
| Coffman Nursing Home 1304 Pennsylvania Avenue, Hagerstown, MD 21742 CCN 215352 | 3.1 km | 59 | Aug 5, 2026 | 552 open | — | |
| Western Md Hospital Center 1500 Pennsylvania Avenue, Hagerstown, MD 21742 CCN 215110 | 3.6 km | 63 | Dec 2, 2025 | 541 IJ1 harm1 open | $24k | |
| Complete Care at Hagerstown 14014 Marsh Pike, Hagerstown, MD 21742 CCN 215365 | 7.4 km | 60 | Jul 14, 2026 | 1311 IJ2 harm | $43k | |
| Homewood Living Williamsport 16505 Virginia Avenue, Williamsport, MD 21795 CCN 215225 | 8.3 km | 82 | Aug 10, 2026 | 474 harm1 open | $42k | |
| Williamsport Health and Rehabilitation Center 154 North Artizan Street, Williamsport, MD 21795 CCN 215198Abuse icon | 10.2 km | 121 | Aug 26, 2026 | 1161 IJ1 harm4 open | — | |
| Fahrney-Keedy Memorial Home 8507 Mapleville Road, Boonsboro, MD 21713 CCN 215337 | 11 km | 106 | Mar 26, 2026 | 46 | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 215336 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 215336 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
| Maryland OHCQ Long Term Care MD | 0121AL0095 | state_license, licensed_beds, licensee Linked to the CMS record by exact normalized street address and ZIP (the state roster does not publish the CCN). | Inferred | Jul 22, 2025 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Jun 16, 2026 | F-0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 3, 2026 | Complaint |
| May 18, 2026 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 10, 2026 | Complaint |
| Mar 6, 2026 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Apr 13, 2026 | Complaint |
| Mar 6, 2026 | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 13, 2026 | Complaint |
| Mar 6, 2026 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 13, 2026 | Complaint |
| Nov 26, 2025 | K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 26, 2026 |
| Nov 26, 2025 | K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 26, 2026 |
| Nov 26, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 26, 2026 |
| Nov 26, 2025 | K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 26, 2026 |
| Nov 26, 2025 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 26, 2026 |
| Nov 26, 2025 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 26, 2026 |
| Nov 26, 2025 | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 26, 2026 |
| Nov 26, 2025 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 26, 2026 |
| Nov 26, 2025 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 26, 2026 |
| Nov 26, 2025 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 26, 2026 |
| Nov 26, 2025 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 27, 2026 |
| Nov 26, 2025 | F-0637 | Assess the resident when there is a significant change in condition Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 27, 2026 |
| Nov 26, 2025 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 27, 2026 |
| Nov 26, 2025 | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 27, 2026 |
| Nov 26, 2025 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 27, 2026 |
| Nov 26, 2025 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 27, 2026 |
| Nov 26, 2025 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 27, 2026 |
| Nov 26, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 27, 2026 |
| Nov 26, 2025 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Jan 27, 2026 |
| Nov 26, 2025 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Jan 27, 2026 |
| Nov 26, 2025 | F-0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Jan 27, 2026 |
| Nov 26, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jan 27, 2026 |
| Oct 23, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 29, 2025 | Complaint |
| Oct 23, 2025 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 29, 2025 | Complaint |
| Jul 25, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Past non-compliance Aug 5, 2024 | Complaint |
| Jul 25, 2025 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Past non-compliance Aug 5, 2024 | Complaint |
| Dec 22, 2023 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Mar 5, 2024 |
| Dec 22, 2023 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 24, 2024 |
| Dec 22, 2023 | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 24, 2024 |
| Dec 22, 2023 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Mar 5, 2024 |
| Dec 22, 2023 | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 24, 2024 |
| Dec 22, 2023 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 24, 2024 |
| Dec 22, 2023 | K-0921 | Ensure that testing and maintenance of electrical equipment is performed. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 24, 2024 |
| Dec 22, 2023 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 24, 2024 |
| Dec 22, 2023 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0578 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0584 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 2, 2024 | Complaint |
| Dec 22, 2023 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 2, 2024 | Complaint |
| Dec 22, 2023 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 2, 2024 | Complaint |
| Dec 22, 2023 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Feb 2, 2024 | Complaint |
| Dec 22, 2023 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Feb 2, 2024 | Complaint |
| Dec 22, 2023 | F-0661 | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 2, 2024 | Complaint |
| Dec 22, 2023 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0801 | 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. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0803 | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Dec 22, 2023 | F-0909 | Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Feb 2, 2024 |
| Apr 8, 2019 | F-0678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Corrected Jun 24, 2019 |
| Apr 8, 2019 | K-0100 | Meet other general requirements. Construction Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 31, 2019 |
| Apr 8, 2019 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 31, 2019 |
| Apr 8, 2019 | K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 31, 2019 |
| Apr 8, 2019 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 31, 2019 |
| Apr 8, 2019 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected May 31, 2019 |
| Apr 8, 2019 | K-0541 | Install properly constructed and protected linen or trash chutes. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 31, 2019 |
| Apr 8, 2019 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Aug 27, 2019 |
| Apr 8, 2019 | F-0553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0584 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0622 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Aug 27, 2019 |
| Apr 8, 2019 | F-0624 | Prepare residents for a safe transfer or discharge from the nursing home. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Aug 27, 2019 |
| Apr 8, 2019 | F-0635 | Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 27, 2019 |
| Apr 8, 2019 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 27, 2019 |
| Apr 8, 2019 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 27, 2019 |
| Apr 8, 2019 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0685 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Aug 27, 2019 |
| Apr 8, 2019 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Aug 27, 2019 |
| Apr 8, 2019 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Aug 27, 2019 |
| Apr 8, 2019 | F-0759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0838 | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Aug 27, 2019 |
| Apr 8, 2019 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 24, 2019 |
| Apr 8, 2019 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 24, 2019 |
| Apr 8, 2019 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected May 31, 2019 |
| Apr 8, 2019 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | C · Minimal Widespread | Corrected May 31, 2019 |
| Apr 8, 2019 | F-0625 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | B · Minimal Pattern | Corrected Jun 24, 2019 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.42 (case-mix index 1.17).
| Individual |
| Additional disclosable party |
| ADP OF THE SNF |
| not provided |
| May 8, 2026 |
| Addisu Temesgen | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 22, 2026 |