General Information: WESTERN MD HOSPITAL CENTER
Nursing home name WESTERN MD HOSPITAL CENTER
Address1500 PENNSYLVANIA AVENUE
HAGERSTOWN, MD 21742
Phone number (301) 745-4200
Located within a hospital No
Type of ownership Government - State
Owner operates multiple homesNo
Accept Medicare or Medicaid Medicare and Medicaid
Continue Care Retirement CommunityNo
Resident and family councils Both
Certified number of beds 63
Total number of residents 43
Perc of occupied beds 68
Sprinkler status Yes
Number of Facility Reported Incidents7
Number of Substantiated Complaints2
Number of Fines0
Total Amount of Fines$0
Total Number of Penalties0
Total Number of Penalties0
Ratings Summary: WESTERN MD HOSPITAL CENTER
Overall rating 4
4
Nursing Home Staffing 5
5
Registered Nurses only 5
5
Health Inspections 3
3
Quality Measures 2
2
Nursing Home Staffing Info: WESTERN MD HOSPITAL CENTER
National AverageMaryland AverageWESTERN MD HOSPITAL CENTER
Overall staff rating NA NA 5
5
Registered Nurses only rating NANA 5
5
Total Number of Residents NA NA 43
Total Number of Nurse Staff Hours per Resident per Day 4.11 hours 4.24 hours 6.23 hours
Total Number of Licensed Nurse Staff Hours per Resident per Day 1.64 hours 1.82 hours 3.43 hours
Registered Nurses Hours per Residents per Day 0.81 hours 0.9 hours 2.2 hours
Licensed Practical or Vacation Nurses Hours per Resident per Day 0.83 hours 0.91 hours 1.23 hours
Certified Nursing Assistants Hours per Residents per Day 2.47 hours 2.42 hours 2.8 hours
Physical Therapy Staffing Hours per Resident Per Day 0.1 hours 0.13 hours 0.12 hours
Health Survey: WESTERN MD HOSPITAL CENTER
Heath Survey Summary on 2013-03-05
Total Number of Health Deficiencies 9
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Heath Survey Summary on 2011-11-17
Total Number of Health Deficiencies 6
Scope and Severity of most Severe Health Deficiency Isolated/Minimal harm or potential for actual harm
Heath Survey Summary on 2010-08-09
Total Number of Health Deficiencies 2
Scope and Severity of most Severe Health Deficiency Isolated/Minimal harm or potential for actual harm
Health Survey Details: WESTERN MD HOSPITAL CENTER
Inspection Results: 03/05/2013
Corrected Deficiency Scope and Severity
04/25/2013 Keep each resident free from drugs that restrain them, unless needed for medical treatment. Isolated/Minimal harm or potential for actual harm
04/25/2013 Conduct initial and periodic assessments of each resident's functional capacity. Pattern/Minimal harm or potential for actual harm
04/25/2013 Allow residents the right to participate in the planning or revision of care and treatment. Pattern/Minimal harm or potential for actual harm
04/25/2013 Provide care by qualified persons according to each resident's written plan of care. Isolated/Minimal harm or potential for actual harm
04/25/2013 Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated/Minimal harm or potential for actual harm
04/25/2013 Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances. Isolated/Minimal harm or potential for actual harm
04/25/2013 Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated/Minimal harm or potential for actual harm
04/25/2013 Store, cook, and serve food in a safe and clean way. Isolated/Minimal harm or potential for actual harm
04/25/2013 Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated/Minimal harm or potential for actual harm
Inspection Results: 11/17/2011
Corrected Deficiency Scope and Severity
11/29/2011 1) Hire only people with 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
12/01/2011 Ensure each resident receives an accurate assessment by a qualified health professional. Isolated/Minimal harm or potential for actual harm
12/12/2011 Ensure residents maintain acceptable nutritional status. Isolated/Minimal harm or potential for actual harm
11/22/2011 Operate and provide services according to Federal, State, and local laws and professional standards. Pattern/Potential for minimal harm
12/05/2011 Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated/Minimal harm or potential for actual harm
12/12/2011 Make sure that special or therapeutic diets are ordered by the attending doctor. Isolated/Minimal harm or potential for actual harm
Inspection Results: 08/09/2010
Corrected Deficiency Scope and Severity
09/06/2010 1) Hire only people with 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
09/06/2010 Store, cook, and serve food in a safe and clean way. Isolated/Minimal harm or potential for actual harm

Fire Safety Survey: WESTERN MD HOSPITAL CENTER
Fire Safety Survey Summary on 2013-05-14
Total Number of Fire SafetyDeficiencies 2
Scope and Severity of most Severe Health Deficiency Isolated/Minimal harm or potential for actual harm
Fire Safety Survey Summary on 2011-09-13
Total Number of Fire SafetyDeficiencies 1
Scope and Severity of most Severe Health Deficiency Widespread/Potential for minimal harm
Fire Safety Survey Summary on 2010-08-20
Total Number of Fire SafetyDeficiencies 5
Scope and Severity of most Severe Health Deficiency Widespread /Minimal harm or potential for actual harm
Fire Safety Survey: WESTERN MD HOSPITAL CENTER
Fire Safety Survey Results: 05/14/2013
Corrected Deficiency Severity
07/09/2013 Automatic sprinkler systems that have been maintained in working order. Isolated/Minimal harm or potential for actual harm
07/09/2013 Exits that are free from obstructions and can be used at all times. Widespread/Potential for minimal harm
Fire Safety Survey Results: 09/13/2011
Corrected Deficiency Severity
09/16/2011 Corridor and hallway doors that block smoke. Widespread/Potential for minimal harm
Fire Safety Survey Results: 08/20/2010
Corrected Deficiency Severity
10/01/2010 Smoke barrier doors that can resist smoke for at least 20 minutes. Isolated/Minimal harm or potential for actual harm
10/01/2010 Corridor and hallway doors that block smoke. Widespread /Minimal harm or potential for actual harm
10/01/2010 An approved installation, maintenance and testing program for fire alarm systems. Widespread/Potential for minimal harm
10/01/2010 Portable fire extinguishers. Pattern/Potential for minimal harm
10/01/2010 Properly installed electrical wiring and equipment. Pattern/Minimal harm or potential for actual harm

Resident Complaints: WESTERN MD HOSPITAL CENTER
Date Complaint Substantiated: 07/26/2013
CorrectedCategoryDeficiencySeverity
09/18/2013Make sure that a working call system is available in each resident's room or bathroom and bathing area. D
09/18/2013Make sure that a doctor approves a resident's admission in writing and that each resident remains under the care of a doctor. E
09/18/20131) Hire only people with 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. D

Quality Measures: WESTERN MD HOSPITAL CENTER
Quality Measures National Average Maryland Average WESTERN MD HOSPITAL CENTER
Overall quality rating NA NA 2
2
Long-Stay Residents
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased 15.4% 18.1% 20.4%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain 8.3% 5.2% 18.0%
Percent of High Risk Long Stay Residents With Pressure Ulcers 6.1% 7.1% 6.8%
Percent of Long Stay Residents Who Lose Too Much Weight 7.2% 6.2% 5.9%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder 43.9% 53.2% %
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder 3.2% 2.6% 7.1%
Percent of Long Stay Residents With a Urinary Tract Infection 6.2% 5.2% 21.2%
Percent of Long Stay Residents Who Have Depressive Symptoms 6.3% 3.8% 9.6%
Percent of Long Stay Residents Who Were Physically Restrained 1.4% 0.9% 0.0%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury 3.2% 2.6% 0.0%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine 92.7% 92.8% 71.9%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 94.3% 94.8% 89.3%
Percent of Long Stay Residents Who Received an Antipsychotic Medication 20.7% 16.4% 21.6%
Short-Stay Residents
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain 19.2% 14.5% %
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened 1.2% 1.1% 6.9%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine 83.4% 82.9% 64.0%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 82.4% 83.1% 56.0%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication 2.6% 2.3% %

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