Inspection Reports for Coffman Nursing Home
1304 Pennsylvania Ave, Hagerstown, MD 21742, United States, MD, 21742
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% better than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 23, 2025
Visit Reason
The inspection was conducted based on complaint 316958 to investigate concerns regarding the care of residents, including unnecessary medication administration and failure to provide meals and assistive devices according to residents' preferences and needs.
Complaint Details
Complaint 316958 alleged issues with unnecessary medication administration and pain assessments. The investigation found substantiated concerns regarding medication administration without proper nurse assessment and documentation, as well as failure to notify physicians of care issues.
Findings
The facility failed to ensure a resident received care according to professional standards, including improper medication administration and lack of physician notification. Additionally, the facility failed to serve meals according to predetermined menus reflecting resident preferences and failed to provide special eating utensils to a resident who required them.
Deficiencies (3)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, including improper port flush timing and lack of physician notification.
Failure to ensure menus met nutritional needs and reflected resident preferences, with multiple observations of missing food items on meal trays.
Failure to provide special eating equipment and utensils for residents who need them and appropriate assistance.
Report Facts
Residents reviewed for unnecessary medication: 5
Dining observations: 4
Residents affected by deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Nurse | Named in medication administration and port flush findings; signed order changes and provided interviews. |
| Nurse #9 | Nurse | Documented unsuccessful port access attempts on 7/3/25. |
| Nurse #10 | Registered Nurse | Attempted port access and documented resident's reaction on 7/3/25. |
| Nurse #12 | Nurse | Reported awareness of port flush but uncertainty about frequency and lack of personal completion. |
| CMA #14 | Certified Medication Aide | Reported communication process for PRN medication administration. |
| CMA #15 | Certified Medication Aide | Administered PRN acetaminophen and documented pain assessments. |
| Staff #17 | Dietary Aid | Confirmed concerns about missing food items on trays. |
| Dietary Manager | Dietary Manager | Acknowledged and confirmed concerns about meal tray discrepancies. |
| Staff #6 | Geriatric Nurse Aid | Reported giving Resident #40 regular utensils instead of weighted utensils. |
| Staff #19 | Occupational Therapist | Reported Resident #40's need for weighted utensils due to decreased motor strength. |
| Director of Nursing | Director of Nursing | Discussed concerns about medication administration and port flush documentation. |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Jul 23, 2025
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements and ensure resident safety and quality of care.
Findings
The facility was found deficient in multiple areas including environmental safety hazards, inaccurate resident assessments, incomplete care planning, medication administration issues, staffing information posting, unnecessary antibiotic use, unsecured medication storage, meal service deficiencies, infection control practices, and failure to maintain and review infection prevention policies.
Deficiencies (12)
Facility failed to provide a home-like environment due to cracked and damaged floor tiles and bathroom fixtures.
Failed to ensure Minimum Data Set (MDS) assessments were accurately recorded for residents.
Failed to conduct interdisciplinary team care plan meeting for a resident within required timeframe.
Failed to provide appropriate treatment and care according to orders and professional standards, including port flush and pain assessment documentation.
Failed to post nurse staffing information daily in a readily accessible format.
Failed to ensure residents were free from unnecessary antibiotics; antibiotic administered for 10 days instead of 7 days as ordered.
Failed to ensure drugs and biologicals were stored securely in locked compartments.
Failed to serve meals according to predetermined menus reflecting resident preferences; missing food items observed.
Failed to ensure meals were delivered at safe and appetizing temperatures; food temperature logs were incomplete.
Failed to provide special eating equipment and utensils to a resident who required them.
Failed to store and prepare food in accordance with professional standards; expired and improperly labeled food items found.
Failed to ensure staff maintained standard and enhanced barrier precautions during care; infection prevention policies not reviewed or revised annually.
Report Facts
Deficiencies cited: 12
Antibiotic treatment days: 10
Antibiotic order days: 7
Food temperature: 57
Survey completion date: Jul 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #5 | Maintenance Director | Confirmed environmental deficiencies and stated they would address them |
| Staff #13 | MDS Coordinator | Reported missed diagnosis updates on MDS assessments and confirmed plans to correct |
| Staff #4 | Social Services Director | Reported missed scheduling of care plan meeting for Resident #48 |
| Nurse #1 | Nurse | Involved in medication administration and port flush issues |
| Staff #9 | Nurse | Documented unsuccessful port access attempt |
| Staff #10 | Nurse | Documented unsuccessful port access attempt and resident distress |
| Staff #12 | Nurse | Reported awareness of port and flushing but unsure of frequency |
| Staff #14 | Certified Medication Aide | Reported communication process for PRN medication administration |
| Staff #15 | Certified Medication Aide | Reported process for pain reporting and medication administration |
| Staff #17 | Dietary Aid | Confirmed concerns about missing food items on trays |
| Staff #18 | Dietary Manager | Acknowledged expired food items and initiated performance improvement plan |
| Staff #20 | Licensed Practical Nurse | Discarded expired thickened orange juice from nutrition room refrigerator |
| Staff #21 | Culinary Operations Manager | Provided training to dietary staff on labeling and rotating perishable food items |
| Staff #6 | Geriatric Nurse Aide | Observed not providing weighted utensils to Resident #40 |
| Staff #7 | Geriatric Nurse Aide | Observed not wearing gown during high-contact care for Resident #3 |
| Staff #8 | Licensed Practical Nurse | Confirmed Resident #3 had a wound requiring gown use during care |
| Staff #11 | Infection Preventionist Nurse | Reported awareness of infection control concerns and planned corrective steps |
| Staff #16 | Physician | Provided orders and clarification regarding antibiotic treatment |
| Staff #19 | Occupational Therapist | Reported on Resident #40's need for weighted utensils |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 26, 2024
Visit Reason
The inspection was conducted based on a complaint alleging that a resident (Resident #6) had fallen and was not assessed or treated for 6 hours.
Complaint Details
Complaint MD00183144 alleged that Resident #6 had fallen and was not assessed or treated for 6 hours. The complaint was substantiated by review of medical records and staff interviews.
Findings
The facility staff failed to immediately notify Resident #6's physician and responsible party after the resident fell and sustained injuries. The resident was found on the floor with bruising and skin tears, and notification to the physician and family was delayed by several hours.
Deficiencies (1)
Failure to immediately notify a resident's physician and responsible party when a resident had fallen and received an injury.
Report Facts
Residents reviewed: 6
Time delay in notification: 6
Fall time: 3.5
Notification time: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #7 | Registered Nurse | Observed Resident #6 on the floor and documented injuries |
| Resident #6's attending physician | Physician | Interviewed and stated delayed notification of fall; instructed emergency room evaluation |
Inspection Report
Annual Inspection
Deficiencies: 17
Date: Apr 26, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home operations, including resident care, safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide required notices to residents, inadequate abuse prevention policies and procedures, failure to timely report injuries of unknown origin, incomplete care plans, medication errors, improper medication storage, inadequate infection control practices, failure to maintain food at safe temperatures, and failure to update facility-wide assessments and quality assurance plans.
Deficiencies (17)
Failed to provide residents/representatives with Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN).
Failed to develop and implement policies and procedures to prevent abuse, neglect, and theft.
Failed to develop and implement policies and procedures to ensure employees report suspicion of crime timely and prohibit retaliation.
Failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities.
Failed to provide timely notification to resident and representative before transfer or discharge including appeal rights.
Failed to coordinate assessments with pre-admission screening and resident review program (PASARR II referral).
Failed to develop and implement a complete care plan that meets all resident's needs related to activities.
Failed to revise interdisciplinary care plans to reflect accurate approaches for pressure ulcer treatment.
Failed to provide activities to meet all residents' needs with adequate documentation and observations.
Failed to ensure medication error rate less than 5%; crushed enteric coated and extended release medications.
Failed to store medications in locked compartments and limit access; medication cart left unlocked and unattended with keys accessible.
Failed to serve food and beverages at safe and appetizing temperature; food and coffee served cold to residents in rooms.
Failed to ensure clean dishes were stored properly to prevent contamination, maintain ice machine cleaning schedule, label and date bulk food items, and monitor nourishment refrigerator temperature.
Failed to conduct and document a facility-wide assessment review at least annually.
Failed to develop effective plans of correction to address previously cited deficiencies related to abuse reporting.
Failed to implement an effective infection prevention and control program including proper storage of insulin pens and glucometers, visitor screening, policy updates, hand hygiene, equipment storage, and COVID-19 symptom assessments.
Failed to ensure staff were fully vaccinated for COVID-19 with comprehensive policies and procedures including tracking, exemptions, and additional precautions.
Report Facts
Medication administration opportunities: 28
Medication error rate: 6.9
Residents reviewed for activities: 3
Residents reviewed for PASARR II referral: 14
Residents reviewed for dining concerns: 14
Residents reviewed for respiratory care: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #11 | Confirmed SNFABN form was not provided to resident/representative | |
| Assistant Director of Nursing #13 | Assistant Director of Nursing | Reported need to review and update abuse policies and procedures; acknowledged concerns about medication cart and infection control |
| Licensed Practical Nurse #10 | Licensed Practical Nurse | Involved in bruise investigation and confirmed injury of unknown origin was not reported |
| Licensed Practical Nurse #20 | Licensed Practical Nurse | Documented bruise on Resident #22 and interviewed about bruise investigation process |
| Geriatric Nursing Assistant #21 | Geriatric Nursing Assistant | Interviewed about bruise investigation process |
| Geriatric Nursing Assistant #22 | Geriatric Nursing Assistant | Interviewed about bruise investigation process |
| Social Work Director | Social Work Director | Reported facility's complete policy for resident abuse and neglect; interviewed about PASARR II referral |
| Nurse #4 | Licensed Practical Nurse | Observed signing medication count prior to end of shift; responsible for medication cart |
| Certified Medication Aide #5 | Certified Medication Aide | Observed crushing enteric coated and extended release medications |
| Certified Medication Aide #6 | Certified Medication Aide | Observed improper hand hygiene and medication administration |
| Certified Dietary Manager #8 | Certified Dietary Manager | Observed wet nesting of dishes and residue on cups |
| Registered Dietitian #20 | Registered Dietitian | Reported on food temperature concerns and plate warming system |
| Quality Assurance Nurse Staff #13 | Quality Assurance Nurse | Acknowledged failure to develop effective plan of correction for abuse reporting |
| Infection Control Preventionist Staff #13 | Infection Control Preventionist | Reported unawareness of improper storage of glucometers and insulin pens; acknowledged infection control policy deficiencies |
| Social Worker Staff #9 | Social Worker | Interviewed about transfer notification practices |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Dec 10, 2018
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with federal regulations related to resident rights, notification of injury, environment maintenance, transfer/discharge procedures, assessment accuracy, care planning, treatment and medication management, range of motion care, bed rail use, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during dining assistance, delayed injury notification, inadequate housekeeping and maintenance, failure to notify residents/families of transfers, inaccurate resident assessments, incomplete and non-measurable care plans, failure to provide ordered treatments and devices, improper bed rail maintenance and assessment, and ineffective quality assurance processes.
Deficiencies (13)
Failure to treat residents with dignity by not timely accommodating dining needs for residents #6 and #7.
Failure to timely notify physician and resident's representative of resident #6's injury.
Failure to provide housekeeping and maintenance services to keep environment clean and in good repair on 3 hallways.
Failure to notify resident #37 and family in writing of transfer/discharge and failure to document resident preparation for transfer.
Failure to ensure accurate Minimum Data Set (MDS) assessments for multiple residents (#4, #21, #31, #47).
Failure to develop and implement comprehensive, measurable, person-centered care plans for multiple residents (#4, #6, #7, #24, #31, #33, #35).
Failure to review and revise care plans to reflect changes and evaluate progress for residents (#4, #7, #14, #24).
Failure to provide care according to orders and resident preferences; resident #7 not wearing ordered geri sleeves and edema glove.
Failure to provide appropriate care to maintain/improve range of motion for resident #7; no care plan for hand contracture.
Failure to properly maintain bed rails, conduct and document resident bed rail assessments, and evaluate alternatives for resident #16.
Failure to ensure medication regimen free from unnecessary drugs; unclear acetaminophen dosing for resident #35.
Failure to maintain accurate medical records; nursing staff signed off treatments not performed for resident #7.
Failure to implement effective quality assessment and assurance program to correct identified deficiencies.
Report Facts
Residents reviewed: 18
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 7
Residents affected: 2
Skin tears documented: 5
Date of survey completion: Dec 10, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed findings related to care plans, treatment, and bed rail assessments | |
| Assistant Director of Nursing | Interviewed regarding transfer notification and preparation documentation | |
| MDS Coordinator | Confirmed inaccuracies in Minimum Data Set assessments | |
| Occupational Therapist | Evaluated resident #7's hand contracture and range of motion | |
| Activity Director | Acknowledged care plan evaluations not based on stated goals | |
| Director of Maintenance | Discussed environmental concerns and maintenance work orders | |
| Staff #1 | Confirmed failure to notify family of injury and care plan review findings | |
| Staff #4 | Made aware of findings related to care plan for auditory hallucinations | |
| Staff #16 | Provided information on range of motion care for resident #7 | |
| Staff #17 | Reviewed Quality Assessment and Improvement program | |
| Staff #18 | Involved in feeding residents during dining observation | |
| Staff #19 | Involved in feeding residents during dining observation |
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