Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Coffman Nursing Home during CMS and state inspections, most recent first.
The facility did not consistently serve meals at appropriate temperatures, as evidenced by missing temperature logs, resident complaints about cold food, and direct observation of food items being out of the safe temperature range. Residents also reported that warming liners were rarely used, and staff had not been trained on their use, contributing to the deficiency.
Surveyors found multiple instances of expired and improperly labeled food items in facility refrigerators and freezers, including spoiled produce, expired juice, and prepared foods lacking use-by dates. Staff confirmed that dietary personnel were responsible for managing these items, but failed to consistently follow professional standards for food storage and preparation.
Surveyors found that several residents did not receive all items listed on their meal tickets, with missing foods such as ice cream, milk, yogurt, and fruit. Residents and staff confirmed that meal trays often lacked items based on which dietary staff prepared them, and concerns were raised during food committee meetings. The dietary manager acknowledged the issue during the survey.
Surveyors identified multiple environmental deficiencies, including cracked and discolored tiles, a detached trim guard, and a rusted P-trap in several hallways and rooms. These issues were confirmed by the Maintenance Director and indicate a failure to maintain a safe, clean, and homelike environment for residents.
Staff failed to consistently use required gowns and gloves during high-contact care for residents with wounds or pressure ulcers, and a nurse did not wear gloves while handling IV equipment. Multiple staff were unaware of or did not follow EBP protocols, and infection control policies had not been reviewed or updated to reflect current standards or the facility's resident population.
A resident who required special eating utensils and adaptive equipment due to decreased fine motor strength and coordination was not provided with the necessary assistive devices during a meal. Instead, regular utensils were given because the required items were not supplied by dietary staff, as confirmed by staff and an occupational therapist.
Two residents had inaccurate MDS assessments: one received an antipsychotic for dementia with behavioral disturbance, but the MDS listed dementia without behavioral disturbance; another had psychotic disorder documented on the MDS without supporting provider documentation or recent treatment.
A resident did not have an interdisciplinary team (IDT) care plan meeting conducted within 7 days of their comprehensive MDS assessment. The care plan meeting was missed due to a scheduling oversight after the MDS date was changed, and the resident was not aware of any care plan meeting.
A resident was prescribed and administered levofloxacin for 10 days to treat a respiratory condition, despite the physician's intention for a 7-day course and a chest x-ray showing no active disease. The extended duration was due to a misunderstanding, resulting in unnecessary antibiotic use.
Surveyors found that clean utility rooms on two halls, containing OTC medications and biologicals, were left unlocked and accessible. A nurse confirmed that these rooms did not remain locked, and a handwritten sign on one door did not prevent access. The DON acknowledged the issue.
The facility did not maintain daily posted nurse staffing information in a readily accessible format. Staffing details, including hours worked by RNs, LPNs, and CNAs, were only available on a wipe board and not included on the saved assignment sheets, which are required to be kept for 18 months. The DON confirmed that hours worked were stored on other reports, not with the posted assignment sheets.
A resident who was unsteady and on anticoagulant medication fell and sustained injuries. The facility staff failed to immediately notify the resident's physician and family, delaying necessary medical assessment and intervention.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were delivered to residents at appropriate and palatable temperatures. Multiple sources, including a complaint, food committee meeting notes, and resident interviews, indicated ongoing concerns about food being served cold, half-cooked, and lacking in presentation and taste. Review of food service temperature logs revealed numerous instances where required temperature records were missing for various meals, and some logs were undated or incomplete. The facility's own policy required foods to be served at proper temperatures for safety, but documentation did not show that this was consistently achieved before serving residents. During direct observation, residents reported that food was always cold and that liners intended to keep food warm were rarely used. A test tray obtained during a dinner tray line observation showed that milk was served at 57 degrees, above the acceptable maximum of 41 degrees, confirming the temperature concern. The dietary manager acknowledged the issue and noted that staff had not yet been trained to use the food warming liners. The administrator was informed of these concerns during the survey.
Improper Food Storage and Labeling Practices Identified
Penalty
Summary
Surveyors observed multiple instances of improper food storage and preparation within the facility. In the walk-in refrigerator, nine cabbages were found with a grayish substance growing on them, indicating spoilage, and a bag of broccoli was present past its labeled 'best if used by' date. Additionally, a bag of shredded cheese was found with an open date but no use-by date, and an opened container of buttermilk ranch dressing was labeled only with a received date, lacking both an open and use-by date. In the walk-in freezer, a container of prepared spaghetti sauce was found with a preparation date but no use-by date, and it had been stored beyond the time frame staff indicated was appropriate for use. Further inspection of the nutrition room refrigerator on the nursing unit revealed a carton of thickened orange juice with a use-by date that had already passed. Staff confirmed that expired and improperly labeled food items were present and acknowledged that dietary staff were responsible for managing these items. These findings demonstrate that the facility failed to consistently follow professional standards for labeling, dating, rotating, and disposing of perishable food items.
Failure to Serve Meals According to Residents' Menu Preferences
Penalty
Summary
Surveyors identified that the facility failed to serve meals according to predetermined menus that reflected residents' preferences, as evidenced by multiple dining observations and record reviews. Residents' meal trays were missing items listed on their meal tickets, such as vanilla ice cream, salt, pepper, milk, low-fat yogurt, cottage cheese, and bananas. These omissions were confirmed through direct observation, resident statements, and interviews with dietary staff. Residents also voiced concerns and grievances during food committee meetings about not consistently receiving meals as ordered. Staff interviews revealed that the occurrence of missing food items depended on which dietary staff member loaded the meal cart. The dietary manager and a dietary aide both acknowledged the issue of missing items on residents' trays. The deficiency was observed across several meals and residents, indicating a pattern of not following the established menu and residents' documented preferences.
Environmental Deficiencies Compromise Homelike Setting
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by multiple environmental deficiencies across three hallways. Specifically, cracked tiles were found in the 200, 300, and 400 hallways, with six cracked tiles between a resident room and the nurses' station in the 200 hallway, and eight cracked tiles in a resident room in the 300 hallway. Additional issues in the 300 hallway included two tiles with bubbles under the head of the first bed, six tiles with black discoloration, a detached trim guard from a bathroom door post, and a rusted P-trap under a bathroom sink. In the 400 hallway, four broken tiles were observed between resident rooms, and two cracked tiles were found behind the door in the unit shower room. These findings were confirmed by the Maintenance Director during an environmental tour. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Maintain Enhanced Barrier Precautions and Update Infection Control Policies
Penalty
Summary
The facility failed to ensure staff consistently maintained standard and enhanced barrier precautions (EBP) during resident care and did not review or revise infection prevention and control policies annually. Observations revealed that staff provided high-contact care to a resident with a wound without donning required gowns, despite posted EBP signage and a care plan specifying this requirement. Staff involved were unaware of the resident's wound status and the necessity for gowns, even though the infection preventionist later confirmed the resident did have a wound requiring such precautions. In another instance, a nurse performed a dressing change for a resident with a stage 3 pressure ulcer without wearing a gown, despite EBP signage and the infection preventionist's confirmation that gown and glove use was required for such cases. The nurse admitted uncertainty about EBP requirements during the surveyor's inquiry. Additionally, a nurse was observed preparing and priming an intravenous line and pump for another resident without wearing gloves, failing to adhere to standard infection control precautions. The facility's Director of Nursing acknowledged that infection prevention and control policies had not been reviewed or updated in the past year, and no documentation was available to demonstrate that policies had been evaluated or revised based on the current facility assessment or resident population. The policies provided were outdated, generic, and lacked facility-specific information.
Failure to Provide Required Assistive Eating Devices
Penalty
Summary
A deficiency was identified when a resident who required special eating utensils, specifically a weighted fork and spoon with built-up handles, an anti-spill cup, and a yellow-lipped plate due to decreased fine motor strength and coordination, was not provided with these assistive devices during a meal. Record review indicated that these items were required for every meal. However, during a dinner observation, the resident was given regular utensils instead of the prescribed weighted utensils because the dietary staff had not supplied them. Staff present at the time confirmed the omission, and the occupational therapist later verified that the specialized utensils were necessary to help the resident manage eating tasks and limit spillage.
Inaccurate MDS Assessments for Diagnoses and Medication Use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded for two residents. For one resident, the medical record showed an attending provider's order for an antipsychotic medication with a diagnosis of dementia with behavioral disturbance. However, the MDS assessments documented the diagnosis as dementia without behavioral disturbance, which did not reflect the updated diagnosis in the resident's record. This discrepancy was confirmed by the MDS Coordinator, who acknowledged missing the update in the resident's diagnosis. For another resident, MDS assessments documented a diagnosis of psychotic disorder, but there was no supporting documentation in the medical record. Specifically, there was no evidence of treatment for psychotic disorder in the seven days prior to the assessment, nor was there an attending provider's note documenting the diagnosis in the previous sixty days. The MDS Coordinator confirmed that these MDS assessments were recorded inaccurately.
Failure to Conduct Timely IDT Care Plan Meeting After MDS Assessment
Penalty
Summary
The facility failed to ensure that an interdisciplinary team (IDT) care plan meeting was conducted for a resident following the completion of the comprehensive Minimum Data Set (MDS) assessment. The resident had been admitted in June 2025, and the admission MDS assessment was completed on July 1, 2025. However, there was no documentation or evidence that a care plan meeting took place within the required 7 days after the MDS assessment, as mandated by federal regulations. During interviews, the resident stated they were not aware of any care plan meeting, and the Social Services Director (SSD) confirmed that the meeting had not been scheduled due to a change in the MDS assessment date. The SSD acknowledged missing the scheduling of the care plan meeting for this resident, which resulted in the care plan not being developed and reviewed by the required interdisciplinary team within the specified timeframe.
Unnecessary Prolonged Antibiotic Administration
Penalty
Summary
A deficiency was identified when a resident, who had resided in the facility for over a year, was prescribed and administered levofloxacin (Levaquin) for 10 days to treat a cough with phlegm, which was initially assessed as bronchitis and possible pneumonia. The physician's progress note indicated that the antibiotic was to be started for 7 days, pending chest x-ray results to determine if a change in antibiotics was necessary. The chest x-ray, performed the same day, showed no active cardiopulmonary disease. Despite this, the resident received the antibiotic for 10 days, as documented in the Medication Administration Record. During an interview, the physician clarified that the antibiotic should have been prescribed for only 7 days and attributed the 10-day administration to a misunderstanding. The facility's antibiotic stewardship policies, last revised in December 2016, were reviewed in relation to this incident. The failure to ensure the resident was free from unnecessary antibiotics, specifically the administration of an antibiotic for longer than intended, constituted the deficiency.
Medications and Biologicals Not Securely Stored in Utility Rooms
Penalty
Summary
Surveyors observed that the facility failed to ensure drugs and biologicals were stored securely in accordance with professional standards. Specifically, the clean utility supply rooms on both the 200 and 300 halls, which contained over-the-counter medications and biologicals such as vitamin A&D ointment, saline enemas, iodoform packing strips, hydrogel wound dressing, calcium alginate dressings, Silvasorb, and COVID-19 test kits, were found to be unlocked and accessible. The 300 hall clean utility room was observed to be unlocked and accessible at 11:08 AM, and the 200 hall clean utility room was also found to be freely accessible without a lock or keypad. During interviews, a nurse confirmed that the clean utility rooms did not remain locked and demonstrated that the 200 hall room could be opened without restriction. A handwritten sign on the 300 hall room door instructed staff to see the nurse for the key, but the room remained accessible. The Director of Nursing was informed of these observations and acknowledged the deficiency. No information was provided regarding any residents' medical history or condition at the time of the deficiency.
Failure to Maintain Readily Accessible Daily Nurse Staffing Information
Penalty
Summary
The facility failed to maintain daily posted nurse staffing information in a readily accessible format as required. During an observation on the nursing unit with the DON, it was found that staffing information for the current day shift, including hours worked by RNs, LPNs, and CNAs, as well as the resident census, was posted on a large white wipe board. Separate paper documentation with specific staff room assignments was also posted, but this did not include the actual hours worked for nurses and aides. The surveyor noted that the required information regarding hours worked was only available on the wipe board and not on the saved posted assignment sheets, and the DON confirmed that hours worked were kept on other reports rather than with the posted assignment sheets, which are required to be kept for 18 months.
Failure to Immediately Notify Physician and Family After Resident Fall
Penalty
Summary
The facility staff failed to immediately notify a resident's physician and responsible party when a resident had fallen and received an injury. This deficiency was identified during a complaint survey for one resident who had been admitted for rehabilitation after neck surgery. The resident was noted to be unsteady on their feet and required maximum assistance from two staff members while ambulating with a walker. Additionally, the resident was on anticoagulant medication, which increased the risk of complications from falls. On the night of the incident, the resident was found on the floor by a registered nurse at 3:30 am, with new bruising and skin tears. Despite the facility's policy requiring immediate notification of the physician and the resident's representative in such cases, the physician and the resident's family were not informed until later in the morning. The physician, upon being notified, instructed the nursing staff to send the resident to the emergency room to rule out bleeding in the brain. The delay in notification and subsequent medical assessment constituted a failure to adhere to the facility's policy and ensure timely medical intervention.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hagerstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Western Md Hospital Center | 0.3 mi | — | 20 | 0 |
| Hagerstown Healthcare Center | 1.9 mi | — | 27 | 0 |
| Julia Manor Nursing And Rehabilitation Center | 2.1 mi | — | 41 | 0 |
| Complete Care At Hagerstown | 3.2 mi | — | 23 | 1 |
| Creekside Center For Rehabilitation And Nursing | 3.2 mi | — | 34 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.