Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chestertown Nursing And Rehab during CMS and state inspections, most recent first.
The facility did not ensure a homelike dining environment by keeping the dining room locked during breakfast and dinner, resulting in residents having their meals delivered to their rooms instead of dining communally. The NHA confirmed this practice was due to residents not being ready in the morning and the dining room only being opened for lunch.
Facility staff did not maintain sufficient weekend nursing staff coverage, as shown by PBJ data indicating multiple weekends with staffing below the facility's established HPPD goal. The Staffing Coordinator confirmed the low staffing levels and acknowledged that agency staff had not been used for support during this period. The deficiency was identified through review of staffing records and interviews, and leadership was notified of the findings.
Surveyors identified unsanitary conditions in the kitchen, including uncovered seasonings, dirty sinks, and food stains on surfaces. Additionally, multiple food items in the walk-in refrigerator were found without required labels or dates, and staff could not confirm when these items were prepared or stored.
A resident was subjected to rough and aggressive handling by a GNA, resulting in bruising on the ankle. The incident was identified after another staff member observed the injury and the resident reported the abuse. The facility's investigation confirmed the allegation based on collected statements and physical evidence.
A GNA observed bruising on a resident's ankle and, after the resident reported rough treatment by staff, the facility did not report the suspected abuse to authorities within the required two-hour window. The delay in reporting was confirmed by the administrator during the survey.
Facility staff did not conduct a thorough investigation or maintain proper documentation after a resident reported inappropriate comments by a staff member during medication administration. The facility's conclusion relied solely on a nurse practitioner's note, despite no documented behavioral history to support the assessment, and failed to provide evidence of follow-up evaluations or social work involvement as claimed.
A deficiency was cited when a resident's care plan did not address all assessed needs and lacked measurable timetables and specific actions. Review of documentation showed incomplete planning and missing details necessary for comprehensive care.
A resident's care plan was not updated after an increase in Seroquel dosage and following a behavioral incident involving agitation and wandering into other residents' rooms. Despite documentation of these changes and staff acknowledgment that the care plan should have been revised, no updates were made to address the resident's altered condition and behaviors.
A resident with a colostomy did not have a physician order or care plan for colostomy care, and documentation of colostomy bag changes was inconsistent, with no records for several weeks prior to discharge. Facility leadership confirmed that proper orders and daily documentation were expected but not present, resulting in a deficiency in colostomy care.
Staff failed to knock before entering a resident's room on two observed occasions, despite facility expectations to do so, resulting in a failure to honor resident rights to privacy and dignity.
A resident's required Advanced Beneficiary Notice of Noncoverage (ABN) was not provided or documented when Medicare Part A services ended. The business office manager could not find evidence of the ABN or documentation of any contact with the resident's representative, and the DON confirmed that such documentation should have been present.
Two residents were administered additional or continued psychotropic medications without documented attempts at non-pharmacological interventions or timely response to pharmacy recommendations for gradual dose reduction. Staff and medical director interviews confirmed the lack of documentation and intervention prior to medication changes.
Facility staff did not complete the required electronic transfer form and bed hold notice in the EMR for a resident's hospital transfer. While these forms were completed for a previous transfer, the responsible nurse failed to document them for a subsequent transfer, as confirmed by the DON and Regional Policy Nurse.
A resident's MDS assessment failed to accurately document two pressure ulcers as present on admission, despite medical records indicating their existence prior to entry. The error was identified during a survey and confirmed by the MDS Coordinator.
Facility staff did not provide evidence that a Level 1 PASARR was completed prior to or at the time of admission for a resident with paranoid schizophrenia, as required for individuals with mental disorders or intellectual disabilities. Documentation of the required screening was not available during the survey, and only a later PASARR was produced.
Staff did not consistently obtain or document blood pressure readings prior to administering Metoprolol to a resident, as required by physician's orders. The medication was given throughout the month despite limited documentation of blood pressure checks, and interviews with an LPN and the DON confirmed that readings were likely not performed when not recorded.
A resident's decreased hearing was evaluated by an audiologist, who recommended Debrox for impacted cerumen. Facility staff did not obtain a physician order for Debrox or document a reason for not following the recommendation, resulting in a failure to address the resident's hearing concerns.
A resident dependent on staff for ADLs did not consistently receive scheduled showers, with staff substituting bed baths and inconsistently documenting care and refusals. Review of records showed gaps in shower provision and lack of proper documentation explaining missed showers or refusals.
Staff failed to monitor and assess urinary output for a resident with a Foley catheter, resulting in missed signs of infection and delayed physician notification, while another resident with liver cell carcinoma did not receive pain assessments or PRN morphine as ordered. Documentation was incomplete or missing for both urinary monitoring and pain management, and staff interviews confirmed lapses in following physician orders.
A resident who was unable to reposition independently developed two new pressure ulcers after staff failed to consistently turn and reposition the resident as required by facility protocol. Despite having a low air loss mattress and orders for frequent turning, documentation revealed multiple missed repositioning intervals, and staff interviews confirmed that both interventions were necessary to prevent new wounds.
Staff failed to label and date oxygen delivery equipment and did not adhere to the prescribed oxygen flow rate for a resident on oxygen therapy. An LPN was unable to confirm when the equipment was last changed, and the oxygen was being administered at a higher rate than ordered, without clinical justification. The DON confirmed that equipment should be labeled and dated after changes and that oxygen flow rates must match physician orders.
Two residents did not receive appropriate pain management as required by their care plans and physician orders. One resident's chronic pain complaints were not addressed by staff, and another resident with cancer did not receive regular pain assessments or PRN morphine as ordered. Staff failed to document pain assessments and did not administer pain medication when needed, as acknowledged by the DON.
A resident who experienced ongoing back pain was readmitted after hospitalization, but the attending physician did not address the hospital's recommendation for a transdermal fentanyl patch in the follow-up note. Both the attending physician and medical director confirmed that the discharge summary and its recommendations were not reviewed or incorporated into the resident's care plan as required.
Surveyors found that annual performance reviews for five GNAs were not conducted or documented, as confirmed by both the ADON and HR. The facility's process relied on verbal reminders to supervisors, with no evidence of completed reviews in the employee files.
Staff did not post the actual hours worked per shift for RN, LPN, CMA, and GNA on two units. Observations showed that while staff names and assignments were listed, the required hours worked section was left blank. Interviews indicated that the unit manager was unaware of the requirement to post actual hours worked.
Surveyors identified that narcotic record books were not consistently signed by both incoming and outgoing nurses, as required by protocol. Multiple missing signatures were found across several units and shifts, and staff confirmed the expectation for dual signatures at each shift change. Review of personnel files showed repeated corrective actions for similar failures by a nurse, and the DON acknowledged the ongoing issue.
The facility did not ensure that MRR recommendations from the consulting pharmacist were addressed by providers for multiple residents. In several cases, recommendations for gradual dose reduction of psychotropic medications were not acted upon, and increases in medication dosages were made without documented rationale or response to the pharmacist's input. Documentation of provider decisions and non-pharmacological interventions was also lacking.
A resident with cognitive impairment and multiple diagnoses was not re-evaluated by psychiatry after a pharmacy recommended gradual dose reduction (GDR) of psychotropic medications. The Medical Director increased the resident's Seroquel dosage without documenting the rationale, discussion of the GDR recommendation, or use of non-pharmacological interventions, and staff confirmed that no such interventions or documentation were provided.
Surveyors found that opened bottles of house stock medications, such as Melatonin, Vitamin B12, Magnesium Oxide, Guaifenesin, Aspirin, and Bisacodyl, were not dated as required on two medication carts. Additionally, a medication room refrigerator log showed missing temperature checks and documentation for several days and shifts, despite facility expectations for twice-daily monitoring. These deficiencies were confirmed through staff interviews and review of temperature logs.
A resident with worn down dentures experienced ongoing difficulty chewing and sore gums, repeatedly reporting these issues to staff. Although the RD documented the concerns and notified the kitchen, SLP, and activities personnel, no timely dental referral was made. The SLP recommended a pureed diet, but the SW was not informed of the dental issues until months later, and the DON acknowledged delayed interventions.
Staff failed to ensure complete and accurate PASARR documentation for three residents, with missing or incomplete sections and absent follow-up records for required screenings. Additionally, a resident's medical record lacked skin and wound documentation after discharge to a hospital, and the facility could not provide information about the receiving hospital. These deficiencies reflect failures in maintaining required medical records.
Surveyors observed that dirty linen was stored in bins in one room while clean, uncovered linen was kept on tables in an adjacent room, with the door between the two rooms left open. The Director of Housekeeping stated that the door had always been kept open and was unaware this was an infection control issue. The DON was informed of the concern.
Surveyors identified that two residents did not have proper documentation for pneumococcal and influenza vaccinations. One resident lacked records for both vaccines, while another was missing documentation for the pneumococcal vaccine. The DON confirmed the facility did not have an adequate process for tracking immunization records.
Two residents were not screened for or offered the COVID-19 vaccine, and there was no documentation of this process in their records. The DON confirmed the facility lacked an effective process for immunization screening and documentation.
Surveyors observed multiple environmental deficiencies, including a damaged closet door with an exposed latch, cracked floor tiles in a soiled utility room, a shower stall with a dark substance between tiles, and several room doors with cracked or missing coating. These issues compromised the safety and comfort of residents, staff, and the public.
Surveyors observed multiple flies in food service and resident care areas, including in a resident's room and the kitchen, with staff attributing the issue to an open kitchen door near the refuse area. Despite biweekly pest control visits and the use of fly traps, flies were present around food carts and in hallways, and staff relied on reports from others to identify pest problems.
Surveyors found that required annual QAPI training was not documented for several staff members, including GNAs, an LPN, and an RN. Despite claims of ongoing training and an annual skills fair, the facility could not provide evidence that these staff completed the mandated QAPI education.
Surveyors found that required infection prevention and control training was not documented for multiple staff members, including GNAs, an LPN, and an RN. Despite claims of ongoing training and an annual skills fair, no records were available to verify completion of the mandatory education.
Surveyors found that documentation of compliance and ethics training was missing from the files of all sampled staff, including GNAs, an LPN, and an RN. Despite claims of ongoing training and an annual skills fair, no records could be produced to verify that required compliance and ethics education had been completed for the current year.
Surveyors found that required annual in-service training documentation was missing for five GNAs. Despite ongoing training sessions and a skills fair, the facility could not provide evidence that the annual in-service training had been completed for these staff members, as confirmed by a review of employee files and additional records provided by the ADON.
Surveyors found that documentation of dementia training was missing from the files of all reviewed staff, including GNAs, an LPN, and an RN. Despite claims of ongoing education and an annual skills fair, no records could be produced to verify that required dementia training had been completed.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide residents with a homelike dining environment as required. During the annual survey, it was observed that the dining room on the Chesapeake unit was locked and not used for breakfast, with residents instead receiving their breakfast meals delivered to their rooms. An interview with the Nursing Home Administrator confirmed that the dining room remained locked for both breakfast and dinner, only being opened for lunch. The administrator explained that the dining room was kept locked in the morning because residents were not up and ready by breakfast time, and it was locked again for dinner.
Failure to Maintain Adequate Weekend Nursing Staff Levels
Penalty
Summary
Facility staff failed to ensure sufficient weekend nursing staff coverage, as evidenced by a review of the Payroll-Based Journal (PBJ) report and facility assessment. The PBJ report for the second quarter of 2025 flagged the facility for excessively low weekend staffing levels. The facility's own staffing goal was set at 3.15 Hours Per Patient per Day (HPPD), but data from March, April, and May 2025 showed that this standard was not met on multiple weekends. Specifically, the HPPD fell below the facility's goal on 4 out of 5 weekends in March, all weekends in April, and 2 out of 5 weekends in May. During an interview, the Staffing Coordinator acknowledged the low weekend staffing and confirmed that the facility had not used agency staff since April 2024. The deficiency was further substantiated by the facility assessment, which was updated in 2025 and outlined the need for adequate staffing to provide continuity of care. The Administrator and Director of Nursing were made aware of the PBJ report findings during the survey entrance conference.
Unsanitary Kitchen Conditions and Improper Food Labeling
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen operations during a recertification survey. Five open jars of seasonings were found uncovered on a shelf, with seasoning particles scattered around. The food preparation sink had visible white oily stains, and the three-compartment sink showed white lime deposits on the faucets. Three handwashing sinks in the kitchen were dirty with brown stains. Additionally, dried and wet food stains were present on the kitchen walls, counters, and tables. These unsanitary conditions were confirmed by facility staff during the survey. Further inspection of the walk-in refrigerator revealed several food items, including bowls of lettuce, cheese, raw ham, desserts, and bread rolls, that were not labeled or dated. When questioned, the Assistant Food Service Director was unable to provide information on when these items were prepared or stored, acknowledging that all food items should have been labeled and dated. The dietary aide confirmed that the desserts were from a previous meal and that the staff responsible had not labeled them, making it unclear when the items were made or when the raw ham was moved from the freezer.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
A deficiency occurred when a geriatric nursing assistant (GNA) was observed to have been rough and aggressive with a resident, resulting in bruising on the resident's right ankle. The incident was initially identified when another staff member noticed the bruising and questioned the resident, who then reported the aggressive behavior by the GNA. The facility conducted an investigation, which included reviewing statements and physical findings, and verified the allegation of abuse. The Nursing Home Administrator was aware of the verified abuse incident.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe. On 4/20/25 at 11:30 AM, a Geriatric Nursing Assistant observed bruises on a resident's right ankle and, upon inquiry, the resident stated that a GNA had been rough and aggressive with them the previous day. Although this information was documented, the facility did not report the incident to the Office of Health Care Quality until 1:10 PM, exceeding the mandated reporting window. The Nursing Home Administrator acknowledged that the incident was not reported within the required timeframe during the surveyor's review.
Failure to Thoroughly Investigate and Document Abuse Allegation
Penalty
Summary
Facility staff failed to conduct a thorough investigation into an allegation of staff-to-resident abuse and did not maintain adequate documentation. A resident reported to a nurse supervisor that a staff member made inappropriate comments during medication administration, which made the resident feel uncomfortable and embarrassed. The facility's initial response included contacting the police, suspending the alleged perpetrator, and arranging for a psychiatric nurse practitioner and social worker to meet with the resident. Statements were collected from involved parties. However, the facility's follow-up investigation relied solely on a nurse practitioner's progress note, which attributed the resident's report to attention-seeking behavior and fantasies, despite no documented history of such behaviors in the resident's medical or psychiatric records. The facility was unable to provide documentation supporting its conclusion that the incident could not be substantiated, including evidence of behavioral concerns, records of a psychological evaluation related to the incident, or verification that the social worker met with the resident as claimed. The administrator acknowledged that the decision not to substantiate the incident was based only on the nurse practitioner's note and that resident records were not reviewed. The lack of thorough investigation and supporting documentation led to the cited deficiency.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where it was noted that the care plan did not comprehensively cover all assessed needs or include clear, measurable goals and interventions.
Failure to Revise Care Plan After Medication Change and Behavioral Incident
Penalty
Summary
The facility failed to revise a resident's care plan following significant changes in the resident's medication regimen and after a facility-reported incident. Specifically, a resident was prescribed an additional dose of Seroquel (Quetiapine Fumarate) by the Medical Director, but the care plan was not updated to reflect this medication change. Progress notes indicated that the resident exhibited agitation and aggression, and although the DON stated that the care plan should have been updated with new goals and interventions, the care plan remained unchanged at the time of review. Additionally, after an altercation between two residents, both diagnosed with dementia, the care plan for the involved resident was not revised to address new behavioral concerns. Documentation and staff statements confirmed that the resident frequently became agitated and wandered into other residents' rooms, yet there was no care plan in place to address these behaviors. The Unit Manager and DON both acknowledged that the care plan should have included interventions for agitation and wandering following the incident, but no such updates were made.
Failure to Provide and Document Colostomy Care
Penalty
Summary
The facility failed to provide and document appropriate colostomy care for a resident who had a colostomy. The resident, who was cognitively intact and admitted for wound care and rehabilitation, had a history of a laparoscopic diverting sigmoid colostomy and sacral debridement. Despite the presence of other medical orders, there was no physician order for colostomy care or documentation specifying the frequency and interventions for colostomy management. Review of the resident's medical records showed sporadic documentation of colostomy bag changes, with the last entry occurring nearly a month before the resident's discharge, and no records of colostomy care during the final weeks of the resident's stay. Interviews with facility leadership confirmed that the expectation was for colostomy care to be provided, monitored, and documented according to physician orders, which should have included details such as site monitoring, output, and bag change frequency. Both the ADON and DON acknowledged that there should have been a physician order and a care plan for colostomy care, and that daily documentation was expected while the resident was under skilled services. The lack of a physician order, care plan, and consistent documentation led to the identified deficiency in colostomy care for the resident.
Failure to Knock Before Entering Resident Rooms
Penalty
Summary
The facility failed to maintain resident rights by not ensuring staff knocked before entering residents' rooms. During two separate observations on the Chesapeake unit, a registered nurse entered a resident's room without knocking, both during an interview with the resident and again shortly after, as witnessed by the surveyor. The Director of Nursing confirmed that the facility's expectation is for staff to knock prior to entering any resident's room. These incidents demonstrate that staff did not follow established protocols to respect residents' privacy and dignity.
Failure to Provide and Document Advanced Beneficiary Notice of Noncoverage
Penalty
Summary
The facility failed to provide the required Advanced Beneficiary Notice of Noncoverage (ABN) to a resident or their representative prior to the end of Medicare Part A coverage. Documentation reviewed for one resident showed that the last day of covered services was recorded, but there was no evidence that the ABN was given. The Business Office Manager was unable to locate any documentation of the ABN and stated that, since the resident was unable to sign, the representative would have been contacted by phone or mail. However, the Business Office Manager was unaware of the process for documenting such contact, and there was no record of a phone call or letter being sent. The Director of Nursing confirmed that documentation should exist if a phone call or letter was made or sent to the representative.
Failure to Attempt and Document Non-Pharmacological Interventions Before Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that less restrictive alternatives were attempted and documented prior to administering additional antipsychotic medication for two residents reviewed for unnecessary medications. In one case, a medical director ordered an increased dose of Seroquel for a resident exhibiting agitation and aggression, but there was no documentation of non-pharmacological interventions being attempted before the medication increase. The medical record and staff interviews confirmed that no such interventions were provided or documented, and the medical director acknowledged the omission of both rationale and non-pharmacological orders. In another case, monthly pharmacy reviews identified irregularities in the medication regimen of a resident prescribed Seroquel, Lexapro, and Haldol. The pharmacist recommended evaluating the eligibility for gradual dose reduction (GDR) and monitoring for symptoms, but the recommended adjustments to the medications were not addressed for several months. The DON confirmed that while pharmacy reviews and recommendations were made, there was no documentation to show that non-pharmacological interventions were provided to the resident during this period.
Failure to Complete Required Transfer Forms and Bed Hold Notices
Penalty
Summary
Facility staff failed to ensure that required electronic transfer forms and bed hold notices were completed in the electronic medical record system (Point Click Care) for a resident who was transferred to the hospital. During a review of the resident's medical record, it was found that while an electronic transfer form and bed hold notice were completed for one hospital transfer, there was no documentation of these forms for a subsequent transfer. The surveyor requested proof of the required documentation for the second transfer, but none was provided. Interviews with the DON and Regional Policy Nurse confirmed that the nurse responsible for the resident's care during the second hospital transfer did not complete the electronic interact transfer form or the bed hold notice as required. The DON explained that the process is typically completed at the time of transfer and is the responsibility of the nurse sending the resident to the hospital, regardless of the day or time the transfer occurs.
Inaccurate MDS Assessment of Pressure Ulcers on Admission
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status regarding pressure ulcers and wounds. Specifically, a review of one resident's medical record showed that a skin check documented four wounds, with two of them (on the left hip and right heel) noted as present on admission. However, the corresponding MDS assessment did not indicate that these two wounds were present on admission, instead marking all four wounds as not present on admission. This discrepancy was identified during a surveyor's review of the records, and the error was acknowledged by the Regional MDS Coordinator, who confirmed that the MDS should have reflected the wounds as present upon admission.
Failure to Complete PASARR Prior to Admission for Resident with Mental Disability
Penalty
Summary
Facility staff failed to provide evidence that a Level 1 preadmission screening and resident review (PASARR) was completed prior to or at the time of admission for a resident with a mental disability. The requirement is that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders, intellectual disabilities, and related conditions before admission. In this case, a resident admitted with a diagnosis of paranoid schizophrenia did not have documentation of a completed PASARR at the time of admission. During the survey, a review of the resident's paper and electronic medical records did not show a PASARR completed prior to or at the time of admission. When requested, the social worker was unable to provide the PASARR from the time of admission and only produced a PASARR dated nearly two years after the resident's admission. The deficiency was identified during the annual survey for one of two residents reviewed for PASARR compliance.
Failure to Follow Physician's Orders for Blood Pressure Medication Administration
Penalty
Summary
Facility staff failed to follow physician's orders and professional standards of quality when administering blood pressure medication to Resident #9. The physician's order required Metoprolol 25 mg to be given twice daily with instructions to hold the medication if the systolic blood pressure was less than 100 mmHg. Despite this, the medication was administered twice daily throughout July 2025, while blood pressure readings were only documented on four occasions during the month. Interviews with an LPN revealed that blood pressure should be checked prior to administration when parameters are ordered, and the DON confirmed that undocumented readings were likely not performed. This indicates that the required blood pressure monitoring prior to medication administration was not consistently completed or documented as ordered.
Failure to Follow Audiologist Recommendation for Earwax Removal
Penalty
Summary
Facility staff failed to provide appropriate treatment to maintain a resident's ability to perform activities of daily living, specifically regarding vision and hearing concerns. A resident reported that their concerns about vision and hearing were not addressed by the facility. Medical records showed that the resident was referred for an ear exam due to decreased hearing, and the audiologist found impacted cerumen and recommended Debrox for earwax removal. However, there was no physician order for Debrox or documentation explaining why the recommendation was not followed. The Assistant Director of Nursing confirmed that the staff responsible did not place the order for Debrox as recommended by the audiologist.
Failure to Provide Scheduled Showers and Accurate Documentation for Dependent Resident
Penalty
Summary
Facility staff failed to provide appropriate assistance with activities of daily living (ADLs) for a resident who was dependent on staff for showers. The resident reported that scheduled showers were not provided as expected on Wednesdays and Saturdays during the evening shift, and instead, staff offered bed baths. The resident also stated that staff sometimes documented refusals for showers that did not occur, indicating a discrepancy between the resident's account and staff documentation. A review of the facility's shower log and electronic medical records revealed inconsistent documentation of shower provision, with only a few dates recorded for showers over several months. There was no documentation explaining why the resident did not receive showers on other scheduled days, nor was there evidence of documented refusals. The Assistant Director of Nursing confirmed that staff were expected to provide showers and document any refusals, but this was not consistently done for the resident in question.
Failure to Monitor Urinary Output and Manage Pain per Physician Orders
Penalty
Summary
Staff failed to adequately monitor and assess urinary output and did not ensure pain was assessed and managed according to physician orders for two residents. For one resident with a Foley catheter, there were repeated instances of dark, bloody, and cloudy urine with clots, and staff did not irrigate the catheter tubing as needed. The resident was hospitalized twice, first for a urinary tract infection and later for sepsis, acute kidney injury, and diabetic ketoacidosis. Medical record reviews showed a lack of documentation regarding urinary monitoring, assessment, and timely notification to the physician about catheter blockage and changes in urine. A urinalysis ordered by the nurse practitioner was not collected, and staff interviews revealed inconsistent assessment and monitoring of urinary output. Another resident with liver cell carcinoma had a physician's order for pain evaluation every shift and PRN morphine for comfort care. Documentation showed that pain assessments were not consistently completed as ordered, with a gap of several days without any pain assessment recorded. Morphine was administered only sporadically, and there was no documentation explaining the lack of pain assessments or administration of PRN medication during the specified period. Staff interviews confirmed that pain assessments and documentation were not performed as required by the physician's orders. These deficiencies were identified through interviews, observations, and record reviews, and were acknowledged by facility staff, including the DON and unit manager. The lack of proper monitoring, assessment, and documentation directly contributed to the residents' unmet care needs and hospitalizations.
Failure to Consistently Reposition Dependent Resident Leads to New Pressure Ulcers
Penalty
Summary
A resident who was unable to reposition independently and was dependent on staff for turning and repositioning developed two new pressure ulcers while in the facility. The resident reported that staff did not consistently turn him/her every two hours as required. Medical record review confirmed that the resident had two wounds upon admission and was under the care of a Wound Nurse Practitioner, with preventative measures including turning/repositioning and use of a low air loss mattress. Despite these interventions, documentation showed multiple instances where the resident was not turned or repositioned according to protocol over several dates and time periods. The facility's own policy required that residents unable to reposition themselves be turned every hour. Interviews with staff confirmed that both turning/repositioning and the use of a low air loss mattress were necessary and that one did not replace the need for the other. Documentation and interviews indicated that staff failed to consistently implement these preventative measures, resulting in the development of new pressure ulcers for the resident.
Failure to Label Respiratory Equipment and Follow Oxygen Orders
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care to a resident receiving oxygen therapy. During observation, it was found that the oxygen tubing, nasal cannula, and humidifier bottle in use for the resident were not labeled or dated as required. The LPN present was unable to state when the equipment was last changed and acknowledged that it should be changed weekly and labeled accordingly. The Director of Nursing confirmed that the facility's expectation is for equipment to be labeled and dated immediately after being changed, with changes occurring weekly. Additionally, the staff did not follow the physician's order for oxygen administration. The resident was observed receiving oxygen at approximately 2.25 liters per minute, while the active physician order specified 2 liters per minute to maintain oxygen saturation above 92%, with titration up to 6 liters per minute only as needed. The LPN confirmed there was no clinical indication for the increased flow rate and subsequently adjusted it to the prescribed amount. The most recent oxygen saturation documented for the resident was 99%.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents by not following professional standards of practice and the residents' person-centered care plans. One resident consistently reported chronic back pain due to arthritis, which was documented by a nurse practitioner, but there was no evidence that the pain was addressed or that the care plan goal of being free from discomfort was met. The resident's medical record confirmed an active diagnosis of pain, yet the pain management regimen was not adjusted in response to the resident's ongoing complaints until after surveyor intervention. Another resident with multiple medical diagnoses, including liver cell carcinoma, was admitted with frequent, moderate pain that affected sleep and was not relieved by non-pharmacologic interventions. Despite physician orders for pain assessments every shift and PRN morphine for comfort care, pain assessments were not consistently documented, and PRN medication was not administered as ordered. Staff failed to document ongoing pain assessments and did not provide pain medication as directed, even when the resident was observed to be uncomfortable and agitated. The Director of Nursing acknowledged these findings during the survey.
Physician Failed to Address Hospital Discharge Recommendations After Resident Readmission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician reviewed a resident's total plan of care at each required visit. Specifically, after a resident was hospitalized and subsequently readmitted, the attending physician documented a follow-up note acknowledging the recent hospital stay but did not address the hospital's recommendation for a transdermal fentanyl patch to manage the resident's ongoing back pain. The discharge summary from the hospital, which included this recommendation, was present in the resident's medical record but was not acted upon by the physician during the first post-readmission visit. Interviews with both the attending physician and the medical director confirmed that the expectation was for physicians to review the entire plan of care, including discharge summaries and any recommendations or medication changes, upon a resident's readmission. Both acknowledged that the fentanyl patch recommendation was missed and not incorporated into the resident's care plan, and the facility did not identify this oversight until it was brought to their attention during the survey.
Failure to Conduct and Document Annual Nursing Aide Performance Reviews
Penalty
Summary
Facility staff failed to conduct annual performance reviews for nursing aides, as evidenced by the absence of such documentation in the employee files of five geriatric nursing assistants (GNAs) reviewed during the annual survey. The Assistant Director of Nursing (ADON) was unable to provide evidence of completed performance reviews for these GNAs within the past 12 months, despite being given the opportunity to search for the missing documentation. The ADON confirmed that the annual performance reviews could not be located. Further inquiry with the Human Resources (HR) representative revealed that the process for performance reviews involved notifying supervisors of upcoming due dates and expecting completed forms to be returned. However, the HR representative relied primarily on verbal reminders and did not have a system to ensure completion or follow-up if reviews were not received. Both the Director of Nursing and ADON were informed of the missing annual performance reviews for the five GNAs.
Failure to Post Actual Nursing Staff Hours Worked
Penalty
Summary
Facility staff failed to post the actual hours worked per shift for Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Medication Aides (CMA), and Geriatric Nursing Assistants (GNA) on two units. During multiple observations between 08/04/25 and 08/13/25, surveyors noted that while staff names and assignments were listed on the whiteboard and Resident Care Staffing Report sheets, the section designated for actual hours worked was consistently left blank. Interviews with the Unit Manager revealed a lack of awareness regarding the requirement to post actual hours worked for each nursing staff member. These findings were communicated to the Director of Nursing at the conclusion of the survey period.
Failure to Consistently Sign Narcotic Record Books by Nursing Staff
Penalty
Summary
The facility failed to ensure that narcotic record books were consistently signed by both incoming and outgoing nurses, as required by facility protocol. During a medication administration observation, surveyors found multiple missing signatures in the narcotic record books, with omissions dating back several months and including recent weekend shifts. Staff confirmed that the protocol required both nurses to sign the narcotic record book at each shift change, but acknowledged that this was not consistently done. In one instance, an LPN admitted to counting narcotics with the outgoing nurse but failed to sign the record book until prompted by the surveyor. Further review of employee files revealed that at least one RN had a history of corrective action notices related to failure to perform narcotic count sign-off with the off-going nurse, with documentation of repeated incidents before and after a specific date. The Director of Nursing confirmed awareness of the issue and reiterated the facility's expectation for both nurses to sign the narcotic record book to ensure accountability and prevent discrepancies.
Failure to Address Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that medication regimen review (MRR) recommendations made by the consulting pharmacist were addressed by the provider for several residents. In one case, a resident was prescribed multiple psychotropic medications, including Alprazolam, Gabapentin, and Quetiapine. The pharmacist recommended a gradual dose reduction (GDR) for these medications, but there was no evidence that the resident was re-evaluated by psychiatry after the recommendation. Additionally, the medical director increased the resident's Seroquel dosage without documenting the rationale or addressing the pharmacist's GDR recommendation. Interviews with the DON and medical director confirmed that no documentation was available to support the clinical decisions or to show that the pharmacist's recommendations were considered. For another resident, the facility's records showed that the pharmacist identified irregularities in the MRRs on two separate occasions. However, there was no documentation in the medical record indicating that these irregularities were addressed by the provider. The DON acknowledged the concern when interviewed and confirmed that the provider did not respond to the pharmacist's recommendations. A third resident's records revealed that the pharmacist recommended a GDR for several psychotropic medications, but the provider did not respond to these recommendations or make adjustments to the medications until several months later. There was also no documentation from the physician indicating agreement or disagreement with the pharmacist's recommendations, nor evidence of non-pharmacological interventions being provided. The DON was unable to provide documentation of such interventions when asked.
Failure to Ensure Resident Was Free from Unnecessary Psychotropic Medications
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including dementia, depression, anxiety, and cerebral aneurysm, was not ensured to be free from unnecessary psychotropic medications. The resident was unable to complete the BIMS assessment, indicating significant cognitive impairment. Pharmacy medication regimen review in June recommended a gradual dose reduction (GDR) for several psychotropic medications, including Alprazolam, Gabapentin, and Quetiapine. Despite this recommendation, there was no evidence that the resident was re-evaluated by psychiatry after the pharmacy's suggestion, and the GDR was not implemented. Additionally, the Medical Director increased the resident's Seroquel dosage without documenting the rationale, the discussion regarding the pharmacy's GDR recommendation, or the use of non-pharmacological interventions prior to the medication increase. Progress notes did not reflect any attempt at non-pharmacological interventions when the resident exhibited agitation and aggression. Interviews with the DON and Medical Director confirmed that there was no documentation supporting the need for the additional medication or evidence of attempted non-pharmacological interventions, and the Medical Director acknowledged the lack of documentation and intervention as an error.
Medication Labeling and Storage Deficiencies with Incomplete Refrigerator Temperature Monitoring
Penalty
Summary
Surveyors identified that the facility failed to ensure proper labeling and storage of medications, as well as consistent temperature monitoring for medication refrigerators. During medication administration observations, several opened bottles of house stock medications, including Melatonin, Vitamin B12, Magnesium Oxide, Guaifenesin, Aspirin, and Bisacodyl, were found without open dates on two medication carts. Interviews with nursing staff confirmed that the facility's expectation was for all opened house stock medications to be dated upon opening, but this was not consistently followed. Additionally, in one medication storage room, the refrigerator temperature log was found to be incomplete, with missing signatures and entries for several days and shifts across multiple months. The unit manager confirmed that temperatures were expected to be checked and documented twice daily, but this was not consistently done, as evidenced by gaps in the June and July logs. These findings demonstrate lapses in medication management practices as observed and documented by surveyors.
Failure to Timely Refer Resident for Dental Services
Penalty
Summary
Facility staff failed to refer a resident with worn down dentures for dental services in a timely manner. The resident repeatedly reported issues with chewing, sore gums, and difficulty eating due to ill-fitting dentures. These concerns were documented by the Registered Dietitian (RD) on multiple occasions, who also notified the kitchen, speech language pathologist (SLP), and activities personnel. However, there was no documentation indicating that any dental follow-up was initiated by these staff members. The SLP assessed the resident and recommended a change to a pureed diet due to the denture issues, but did not document any referral for dental services. The Social Worker Assistant (SW) was unaware of the resident's dental concerns until several months after the initial reports, indicating a breakdown in communication among staff. The Director of Nursing (DON) acknowledged that interventions to address the resident's dental needs were delayed. Despite the resident's ongoing complaints and requests for new dentures, no timely action was taken to ensure the resident received appropriate dental care, resulting in a deficiency related to the provision and coordination of dental services.
Incomplete PASARR and Medical Record Documentation
Penalty
Summary
Facility staff failed to ensure that resident medical records were complete and accurate, and that records were properly maintained, as evidenced by several deficiencies in the handling of Preadmission Screening and Resident Review (PASARR) documentation and wound care records. For three residents reviewed for PASARR, there were incomplete or missing sections in the required forms. In one case, a PASARR form had an entire section left blank despite instructions to complete it if certain criteria were met. Another resident's PASARR form was missing a required section, and staff acknowledged that the form should have been completed in its entirety. For a third resident, documentation indicated a need for a Level II screening, but the facility did not have the necessary follow-up documentation on file, despite staff expectations that such records should be maintained. Additionally, for one resident reviewed during the annual survey, the facility failed to maintain complete skin and wound documentation following the resident's discharge to a hospital. The medical record lacked any skin and wound documentation after a specific date, and the facility was unable to provide information about the hospital to which the resident was sent. These findings demonstrate lapses in the facility's processes for maintaining accurate and complete medical records in accordance with professional standards.
Failure to Prevent Cross-Contamination in Laundry Room
Penalty
Summary
The facility failed to ensure proper storage and processing of linen to prevent the spread of infection. During an observation of the laundry room, it was noted that dirty linen was stored in bins in one room, while clean, folded linen was left uncovered on tables in an adjacent room. The door separating the two rooms was left open, allowing for potential cross-contamination between clean and dirty linens. An interview with the Director of Housekeeping revealed that the door had routinely been kept open, and he was unaware that this practice posed an infection control concern. The Director of Nursing was made aware of the issue during the survey.
Failure to Document and Administer Required Immunizations
Penalty
Summary
The facility failed to ensure that residents were properly screened for and/or received pneumococcal and influenza vaccinations as required. During record review, it was found that one resident did not have any documentation of receiving either the pneumococcal or influenza vaccines, while another resident lacked documentation for the pneumococcal vaccine. The Director of Nursing acknowledged during an interview that there was not an effective process in place for maintaining resident immunization records and was aware of the issue.
Failure to Screen and Offer COVID-19 Vaccination to Residents
Penalty
Summary
The facility failed to ensure that all residents were screened for and offered the COVID-19 vaccination, as required. During a review of immunization records for five residents, it was found that two residents did not have any documentation indicating they had been screened for or offered the COVID-19 vaccine. This lack of documentation was confirmed during an interview with the Director of Nursing, who acknowledged that the facility did not have an adequate process in place for resident immunization screening and documentation. The deficiency was identified through both record review and staff interview, with specific reference to the absence of required documentation for two residents regarding COVID-19 vaccination screening and offering.
Environmental Safety and Cleanliness Deficiencies Identified
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for residents and staff, as evidenced by several observed deficiencies. On the Chesapeake unit, a locked closet with a damaged door revealed an exposed latch visible from the hallway, and a soiled utility room was found to have cracked floor tiles in front of a drain. Additionally, a shower stall on another unit contained a dark or black substance between the tiles, extending from the floor up to the steel grab bar, with the substance being more pronounced in the corners. Further observations on the Chesapeake unit revealed that the entrance doors to several rooms were cracked and missing coating near the lower door hinge. These findings were based on direct observations during the annual survey and indicate multiple areas where the physical environment was not adequately maintained for safety and comfort.
Deficiency in Pest Control Measures for Flies in Food Service and Resident Care Areas
Penalty
Summary
Surveyors identified a deficiency in the facility's pest control program, specifically related to the presence of flies in both food service and resident care areas. Multiple flies were observed in a resident's room while the resident was resting in bed, and the resident confirmed that flies were often present. Additional flies were seen in the kitchen during food service operations, with staff attributing the issue to the kitchen exit door being left open, which allowed flies to enter from the refuse area located directly outside. Flies were also observed in the hallway and around food carts as meals were being delivered to residents. Interviews with staff revealed that the pest control company visited the facility biweekly or as needed, and that sticky traps were used in various parts of the building. The Maintenance Director stated that pest control services included spraying chemicals in hallways and near doorways, as well as treating the exterior of the building, but only once in the spring and once in the fall. He also indicated that he relied on staff and residents to report pest sightings and was not previously aware of the fly issue in the kitchen. During a walk-through, several fly traps were observed, but flies remained present in the food preparation area and resident care areas.
Lack of Documented QAPI Training for Staff
Penalty
Summary
The facility failed to provide required annual Quality Assurance and Performance Improvement (QAPI) training to its staff, as evidenced by the absence of documentation in the employee files of seven staff members reviewed during the annual survey. During interviews, the Assistant Director of Nursing (ADON) stated that ongoing training occurs twice per month and that an annual competency skills fair was held, but was unable to produce records verifying completion of QAPI training for the specified staff. Despite a subsequent search and provision of additional education records, there remained no evidence of QAPI training for the employees in question. Both the Director of Nursing and the ADON were informed of the missing documentation.
Lack of Documented Infection Control Training for Staff
Penalty
Summary
The facility failed to provide mandatory infection prevention and control training to its staff as required by its infection prevention and control program. During the annual survey, interviews with the Assistant Director of Nursing (ADON) revealed that ongoing training was conducted twice per month and an annual competency skills fair was held. However, upon review of the employee files for seven staff members, there was no documentation verifying completion of the required infection prevention and control training for the current year. Despite additional attempts by the ADON to locate the records, no evidence of the required training was found in the files provided to the surveyor. Both the Director of Nursing and the ADON were informed of the missing documentation.
Lack of Compliance and Ethics Training Documentation for Staff
Penalty
Summary
The facility failed to provide staff with compliance and ethics training, as evidenced by the absence of documentation in the employee files reviewed during the annual survey. Seven employee files, including those of geriatric nursing assistants, an LPN, and an RN, were examined at the request of the surveyor. The Assistant Director of Nursing (ADON) stated that ongoing training occurs twice per month and that an annual competency skills fair was held, but was unable to produce records verifying that compliance and ethics training had been completed for the current year. Despite a subsequent search and provision of additional education records, no evidence of compliance and ethics training was found for any of the sampled staff. Both the Director of Nursing and the ADON were informed of these findings.
Failure to Provide Required Annual In-Service Training for GNAs
Penalty
Summary
The facility failed to provide geriatric nursing assistants (GNAs) with the required annual in-service training, as evidenced by a review of five GNA employee files during the annual survey. The Assistant Director of Nursing (ADON) stated that ongoing training was conducted twice per month and that an annual competency skills fair was held, but when asked to provide documentation of annual in-service training for the GNAs, no such records were found in the employee files. Despite a subsequent search and provision of additional education records, there was still no evidence of the required annual in-service training for the five GNAs reviewed. Both the Director of Nursing and the ADON were informed of the missing documentation. No information was provided regarding the medical history or condition of any residents at the time of the deficiency, and the report focuses solely on the lack of required staff training documentation.
Lack of Documented Dementia Training for Staff
Penalty
Summary
The facility failed to provide required dementia training to its staff, as evidenced by the absence of documentation in the employee files of all seven staff members reviewed during the annual survey. The Assistant Director of Nursing (ADON) stated that ongoing training occurs twice per month and that an annual competency skills fair was held, but when asked to provide records verifying completion of dementia training for the current year, no such documentation was found in the files of the geriatric nursing assistants, LPN, or RN reviewed. Despite a subsequent search and provision of additional education records by the ADON, there remained no evidence of dementia training for these staff members. Both the Director of Nursing and ADON were informed of these findings by the surveyor.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 218 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chestertown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Resorts At Chester River Manor Corp | 0.2 mi | ★★★★★ | 19 | 0 |
| Willow Brooke Ct Skilled Care Ctr At Heron Point | 0.5 mi | ★★★★★ | 5 | 0 |
| Complete Care At Corsica Hills Llc | 12 mi | ★★★★★ | 21 | 0 |
| Sterling Care Riverside | 19.5 mi | ★★★★★ | 0 | 0 |
| Oakwood Snf Llc | 21.9 mi | ★★★★★ | 59 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Chestertown Nursing And Rehab.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.