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 Frostburg Rehab Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and total dependence for transfers sustained a leg fracture when a GNA performed a transfer alone, contrary to the care plan requiring a full lift and two staff. The incident was identified after a PTA noticed changes in the resident’s leg, and further review showed that not all clinical staff received required education on transfer procedures after the event.
The facility did not ensure an RN was present for at least 8 consecutive hours each day, with multiple weekends showing no RN coverage for extended periods. Staffing records and interviews confirmed that there were several instances where no RN was on duty for both day and night shifts, and the DON's occasional floor coverage did not meet the regulatory requirement.
Annual performance evaluations were not completed for several GNAs, with one not receiving an evaluation since hire and others lacking up-to-date appraisals. The HR Director confirmed that while a list of staff due for evaluation is generated and sent to nursing, the required evaluations were not completed as expected.
Facility Assessment Missing Required Staffing and Acuity Details: The facility assessment was incomplete because it still used the prior corporate name, did not document resident acuity or how staffing needs were determined, and did not identify how many residents needed Hoyer lifts or two-person transfers. The assessment also failed to show goal staffing numbers for RN, LPN, and GNA positions, did not specify RN needs on the daily staffing grid, and did not address the facility’s use of agency nurses and GNAs despite frequent agency coverage on multiple shifts.
Surveyors found that the facility did not immediately report multiple allegations of abuse and an injury of unknown origin to the state office as required. In several cases, residents or their roommates reported rough or painful care by a GNA, and in another case, a resident was found with a head laceration of unknown cause. Despite these incidents being brought to the attention of the DON and administrator, required notifications to authorities were delayed or not made.
The facility did not conduct thorough investigations into multiple allegations of abuse and injuries of unknown origin involving two residents and one incident of injury. In each case, there was a lack of comprehensive assessments, staff and resident interviews, and proper documentation, despite concerns being reported to the DON and NHA.
A resident who required assistance with transfers sustained a forehead bruise when struck by a mechanical lift bar during a transfer performed by two GNAs. Review of records showed that one of the GNAs, an agency staff member, lacked documented training or competency in mechanical lift use, with only a self-evaluation on file and no evidence of formal assessment.
Residents were not consistently provided with water or fluids overnight, as evidenced by empty or undated cups and resident reports of not receiving water between late evening and early morning hours. Staff interviews confirmed there was no standardized procedure for overnight water distribution, resulting in inadequate hydration support.
The facility did not ensure that all residents received appropriate evening snacks when meals were scheduled more than 14 hours apart. A resident reported not receiving nighttime snacks, and observations confirmed that only a limited number of individually labeled snacks were provided, with no additional snacks available for others. Staff sometimes brought in their own snacks due to lack of facility-provided options, which was not approved by administration or therapy staff.
A resident with dementia exhibited repeated violent and aggressive behaviors, including hitting, attempting to bite, and making threats toward staff and other residents. Despite multiple documented incidents and the need for 1:1 supervision, there was no evidence that the physician or psychiatric provider was notified of these behaviors or that orders for increased supervision were obtained.
The facility failed to protect residents from abuse, including a case where a staff member verbally and emotionally abused a resident, and another case where a resident with dementia repeatedly exhibited aggressive behaviors toward peers and staff. Despite multiple incidents of aggression, including physical assaults and hospitalizations, there was no evidence of increased supervision or timely updates to the care plan to address the ongoing risks.
Surveyors found that MDS assessments were inaccurately coded for two residents: one receiving hospice care and another with orders for BiPAP therapy. In both cases, the MDS nurse coordinator confirmed the errors, as the assessments did not reflect the residents' actual care and services provided.
Surveyors identified that care was not provided according to professional standards in three cases: a resident who fell did not have vital signs taken or documented at the time of the incident; two residents received insulin injections without proper site rotation, contrary to standard guidelines; and a pressure-reducing mattress was set incorrectly for a resident's current weight, with adjustments made only after surveyor intervention.
A resident with respiratory failure was observed receiving oxygen at 4L/min via nasal cannula, despite a physician's order for continuous oxygen at 5L/min. Multiple LPNs and surveyors confirmed the discrepancy between the ordered and administered oxygen flow rates, and staff acknowledged the difference.
A resident with dementia and hypertension received metoprolol on multiple occasions despite physician orders to hold the medication for low systolic blood pressure or heart rate. Review of records showed the medication was administered six times when the resident's vital signs were below the specified parameters, contrary to the order and facility expectations.
Late Medicare coverage notices and incomplete SNFABNs were found for two residents who remained in the facility after skilled Part A services ended. The NOMNCs were issued too late for one resident and only one day before coverage ended for the other, and both SNFABNs were missing required details about non-covered services, reasons Medicare may not pay, and estimated costs; staff said the delay was related to being on vacation and noted lack of SNFABN training.
A facility failed to send the minimum required transfer information to the receiving hospital for two residents. For one resident, the SNF-to-ED checklist showed only the MOLST, facesheet, and medication list were printed and sent, and the nurse did not document what was included; the unit manager stated care plan goals and advance directive information were typically not sent. For another resident, the checklist again showed only those three items were sent, with no documentation that the nurse included the required transfer information.
A newly admitted resident with generalized weakness, ambulatory dysfunction, and a fall risk score of 9 did not have a completed baseline care plan within 48 hours of admission. The care plan was started, but the nursing sections were left blank, the lift/transfer assessment did not show whether interventions were developed, and the clinical admission assessment remained in progress. The resident also used a wheeled walker and had balance issues when ambulating.
Inaccurate controlled medication reconciliation was found when narcotic records on two units were incomplete or improperly signed, including an unsigned Lorazepam sheet and a Lorazepam sheet signed by only one nurse. Staff also could not match one of three liquid morphine bottles to the correct narcotic sheet, and the morphine remained on the cart after the resident had been discharged. The DON was aware of the discrepancies, and the facility policy required controlled substances to be counted and signed by two nurses and disposed of within three days after discontinuation of use.
The facility failed to ensure pharmacy MRR recommendations were addressed and documented for two residents. For one resident, a pharmacist identified drug therapy problems after a fall, but the report was not in the chart and the attending physician did not respond. For another resident with dementia, pharmacist recommendations for GDR of clonazepam and Lexapro were noted, but the physician left the rationale blank when indicating no change. The MRR policy also did not specify timeframes for the review process.
A resident had four pills left in a clear cup on the bedside table next to a breakfast tray, and the resident stated the nurse had given the pills and that they were taken after breakfast. The DON observed the pills at the bedside and confirmed they were there. The DON stated meds should not be left at the bedside unless the care plan authorizes self-administration, and the resident's care plan and MD orders showed no authorization for self-administration.
A resident’s medical record was incomplete because the MOLST form showed No CPR but left the decision-maker fields blank. The resident had been admitted in 2022 and was later deemed capable of making their own decisions. During survey review, the unit clerk, social services director, and DON all confirmed that the MOLST form contained blank spaces where the decision maker should have been identified.
QAA meetings did not have the required IP nurse attendance for 2 consecutive quarters. Review of attendance records showed the IP nurse missed 6 of 12 monthly meetings, and the NHA confirmed the facility had no IP nurse for a couple of months before the new IP nurse was hired and acknowledged the quarterly attendance requirement.
A resident with an unstageable left heel pressure ulcer underwent a dressing change in which an LPN removed dirty gloves after taking off the soiled dressing but did not perform hand hygiene before donning clean gloves and continuing the procedure. The LPN acknowledged the omission, and the facility policy required hand hygiene before putting on clean gloves during dressing changes.
Call Device Not Kept Within Reach: A resident was observed in bed with the call device lying on the floor and not within reach on two separate observations. An GNA later confirmed the device was out of reach and secured it to the resident's gown. The resident's care plan already included an intervention to keep the call device within reach and encourage use for assistance as needed.
Failure to post nurse staffing information daily and include the facility’s full name. Surveyors observed the staffing posting in the lobby was several days old and did not list the official facility name. The HRD stated the posting is usually done before 10 AM, the DON or NHA posts it when she is absent, and it does not get done on weekends.
Failure to Ensure Safe Transfer Procedures Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severely impaired cognition and total dependence on staff for transfers and mobility sustained a left leg fracture during a transfer. The resident’s care plan specified the use of a full mechanical lift and required two staff members for all transfers. However, on the day of the incident, a Geriatric Nursing Assistant (GNA) attempted to transfer the resident alone, resulting in the resident’s leg becoming twisted and subsequently fractured. Medical record review and staff interviews confirmed that the GNA was aware of the resident’s transfer status but failed to seek assistance from another staff member as required. The incident was discovered when a Physical Therapy Assistant noticed changes in the resident’s leg during a therapy session, which led to further assessment by an LPN and confirmation of the fracture at the emergency department. Further investigation revealed that not all clinical staff had received education on proper transfer procedures following the incident. Attendance records showed that several nurses and GNAs did not attend the post-incident education session, and there was no documentation of disciplinary action for those who missed the training. Additionally, the GNA involved had not received recent education or performance evaluations related to transfers.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was present and working for at least 8 consecutive hours every day, as required. Review of staffing sheets for selected weekends in January, February, March, and July revealed multiple instances where no RN was on duty for both day and night shifts. Specifically, there was a continuous 60-hour period in January and a 48-hour period in July with no RN coverage. Additionally, in August, there was a 36-hour period without an RN present in the facility. These findings were confirmed through documentation review and interviews with the Director of Nursing (DON), the Nursing Home Administrator, and the Human Resources Director. The DON acknowledged working on the floor occasionally to cover shifts, but the records indicated that RN coverage was still lacking during the identified periods. The absence of an RN on duty for the required hours was verified by both staffing sheets and direct confirmation from facility leadership. The deficiency was found to have the potential to affect all residents in the facility, as there was no RN coverage during several extended periods.
Failure to Complete Annual Evaluations for GNAs
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for geriatric nursing assistants (GNAs). A review of employee records showed that one GNA hired in March 2023 had not received an annual evaluation, while two other GNAs had not had evaluations completed within the past year, with their most recent appraisals dated prior to 2024. The Human Resource Director confirmed that although she generates a list of staff due for evaluation and sends it to nursing, it is nursing's responsibility to complete the evaluations, which had not occurred for the GNAs reviewed. These findings were confirmed through documentation review and interviews with facility staff.
Facility Assessment Missing Required Staffing and Acuity Details
Penalty
Summary
The facility failed to ensure its facility assessment addressed all required components. The most recent assessment, updated on 2/24/25, still listed the facility under the previous corporate ownership name at Frostburg Village rather than the current name. The section addressing resident needs and staffing did not include an assessment of resident acuity levels used to determine staffing needs, and the assessment did not document how many residents required Hoyer lifts or more than one staff member for transfers. Mechanical lifts were listed as physical equipment, but the assessment did not identify the number of lifts owned or used by the facility. During interview, the NHA stated the staffing grid was based on trying to maintain 3.0 HPPD and acknowledged that the department could always use more staff, referencing the number of Hoyer lifts in use. The NHA also stated the facility had assessed acuity to determine full-time RN and GNA needs, but that information was not documented in the facility assessment. A staffing review provided later included current open RN, LPN, CMA, and GNA positions and recruitment activity, but still did not include resident acuity data. The assessment listed RNs, LPNs, and GNAs as staff types and stated the departments were staffed appropriately, but it did not identify goal numbers needed to fully staff the facility. The daily staffing grid listed nurses but did not identify the need for RNs specifically, and the staffing plan stated call-outs and open shifts were replaced as needed via center staff. Review of staffing sheets showed frequent use of agency nurses and GNAs, including shifts where most nurses and several GNAs were agency staff, and the HR Director confirmed agency staff were currently used for both nurses and GNAs.
Failure to Timely Report Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
The facility failed to immediately report allegations of abuse and injuries of unknown origin to the state office as required. In one instance, a resident's roommate reported that a GNA used a paper towel to wipe the resident's peri area, causing the resident to cry due to pain. This concern was reported to the DON, who only cautioned the staff member about their communication and did not report the incident to the state office. A second, similar grievance was also reported by the same roommate, indicating repeated behavior by the same GNA, but the DON considered it a repetition and did not take further action or report it. Additionally, another resident voiced concerns about a GNA being rough and touching them in an unwelcome manner during care. This concern was brought to the attention of the DON and the Nursing Home Administrator, but again, there was no immediate report to the state office. The report also details an incident where a resident was found on the floor with a head laceration and required hospital treatment. The injury was of unknown origin, and although the DON was notified shortly after the incident, the report to the Office of Health Care Quality was not made until two days later. The DON acknowledged the delay in reporting and could not provide a reason for the late submission. These findings were based on record reviews and staff interviews, which confirmed that the facility did not follow required procedures for timely reporting of abuse allegations and injuries of unknown origin.
Failure to Thoroughly Investigate Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse and injuries of unknown origin involving several residents. For one resident, grievances were filed by a roommate regarding inappropriate and rough care by a GNA, including the use of a paper towel for incontinence care and causing the resident to cry. Despite these concerns being reported to the Director of Nursing (DON), there was no evidence of a comprehensive investigation, such as a head-to-toe assessment, staff interviews, or review of other residents under the care of the involved staff. The DON acknowledged only cautioning the staff member and did not initiate further investigation after a second, separate complaint. Another resident reported being handled roughly by a GNA, but again, the facility did not conduct a thorough investigation, as there was no documentation of a physical assessment, staff or resident interviews, or statements from the staff involved. Additionally, an incident involving a resident found on the floor with a fractured tibia was not fully investigated; the facility's file lacked comprehensive staff witness statements, resident assessments, and supporting documentation. The DON confirmed that the investigation was incomplete and that relevant information was missing from both the investigation file and the resident's medical record.
Failure to Ensure Mechanical Lift Competency for Agency GNA
Penalty
Summary
The facility failed to ensure that staff had adequate training and competency in the use of a mechanical lift, as required by facility policy. A review of a resident's clinical record showed that the resident, who required assistance to transfer from bed to wheelchair, sustained a forehead hematoma when struck by the mechanical lift bar during a transfer. The incident involved two geriatric nursing assistants (GNAs), and documentation confirmed that the mechanical lift bar hit the resident in the head, resulting in a bruise. Further investigation revealed that one of the GNAs involved, an agency staff member, did not have documented evidence of training or competency in the use of the mechanical lift. The only available documentation for this GNA was a self-evaluation, with no verification of training or competency assessment by facility staff. Both the unit manager and the Human Resources Director confirmed the lack of evidence for proper training or competency for this staff member.
Failure to Provide Consistent Overnight Hydration
Penalty
Summary
The facility failed to ensure that residents consistently received water and other fluids in accordance with their needs and preferences, resulting in insufficient hydration support. Resident council minutes indicated that residents were not provided with ice or water between 11:00 PM and 7:00 AM. A review of a complaint also revealed concerns about the lack of water provision. During nighttime observations, staff were seen delivering water starting around 5:00 AM, but several residents were found with empty or nearly empty water cups, some of which were not dated or contained beverages from the previous day. These findings were confirmed by staff present during the observations. Interviews with the Administrator and DON revealed that there was no consistent procedure in place to ensure water was distributed to residents throughout the night. The DON believed new water cups were distributed around 5:00 AM, while the Administrator thought they were provided at the beginning of the night shift. The lack of a standardized process led to residents not having adequate access to water during overnight hours, as evidenced by multiple observations and resident reports.
Failure to Provide Required Evening Snacks Between Meals
Penalty
Summary
The facility failed to provide nutritional snacks to residents when meals were scheduled more than 14 hours apart, as required. On one unit, dinner was served at 5:00 PM and breakfast at 7:35 AM, exceeding the 14-hour interval. Residents reported not receiving evening snacks, and review of food and resident council meeting minutes confirmed these reports. Observations showed that only a limited number of individually labeled snacks were delivered with dinner trays, and no additional snacks were available on the unit. Staff confirmed that only these labeled snacks were provided, and there were not enough snacks for all residents who required them. Further investigation revealed that some staff, in the absence of facility-provided snacks, brought in their own snacks for residents, which was not approved by the facility administration or the speech therapist. The speech therapist emphasized that all snacks should be approved for residents' specific dietary and safety needs. Documentation showed discrepancies between the number of snacks delivered and the number of residents documented as having received snacks, indicating that not all residents had access to appropriate evening snacks as required.
Failure to Notify Provider of Resident's Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that staff notified the physician or psychiatric provider when a resident with dementia exhibited repeated violent and aggressive behaviors. The resident, who had a history of aggression towards both staff and other residents, was admitted with a diagnosis of dementia and was prescribed multiple psychotropic medications. Despite multiple documented incidents of the resident hitting, attempting to bite, and making verbal threats towards staff and other residents, there was no evidence in the medical record that these behaviors were reported to the primary care or psychiatric provider on the days they occurred. The resident was also sent to the hospital for aggressive behaviors, but upon return, there was no documentation of changes in medication or increased supervision, nor was there evidence that the provider was informed of the ongoing aggression. Nursing notes detailed several episodes where the resident required 1:1 supervision, attempted to harm staff, and made threatening statements, yet there was no documentation of provider notification or orders for increased supervision. Interviews with nursing staff and the DON confirmed that such incidents should have been reported to the provider, but the medical record lacked evidence of timely communication. The deficiency was identified during a survey review of abuse prevention and reporting practices, with cross-reference to F 600.
Failure to Protect Residents from Abuse and Inadequate Supervision of Aggressive Behaviors
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two substantiated incidents involving both staff-to-resident and resident-to-resident abuse. In the first incident, a cognitively intact resident reported that a staff member threatened to remove them from the facility following a resident-to-resident altercation. The resident became visibly upset, exhibited behavioral changes, and withdrew from activities. The facility's investigation confirmed that the staff member had verbally and emotionally abused the resident. In the second incident, a resident with dementia and a history of aggressive and agitated behaviors repeatedly exhibited physical aggression toward other residents and staff. Despite multiple documented episodes of aggression, including hitting, biting, and making threats, as well as being sent to the hospital for these behaviors, there was no evidence that the facility increased supervision or updated the care plan with new interventions upon the resident's return. The resident continued to display aggressive behaviors, culminating in an incident where the resident physically assaulted another resident, resulting in injury. Throughout the period reviewed, documentation failed to show that the primary care or psychiatric providers were consistently notified of the resident's escalating behaviors, nor was there evidence of orders for increased supervision or implementation of 1:1 monitoring as an ongoing intervention. The care plan addressing aggressive behavior was not updated after significant incidents, and staff interviews confirmed that increased supervision was not documented or ordered following hospitalizations for aggressive behavior.
Inaccurate MDS Coding for Hospice and BiPAP Therapy
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for two residents. For one resident under hospice care since March, the quarterly MDS assessment incorrectly indicated that the resident was not receiving hospice care, despite medical records and staff interviews confirming ongoing hospice services. The error was identified during a review of the MDS assessment and confirmed by the MDS nurse coordinator, who acknowledged the resident should have been coded as receiving hospice care. In a separate case, another resident with chronic respiratory failure, CHF, and COPD had an active order and care plan for BiPAP therapy. However, the annual MDS assessment did not reflect the use of BiPAP therapy, despite documentation and physician orders supporting its use. The MDS nurse coordinator confirmed responsibility for completing the relevant MDS section and acknowledged the omission, verifying that the assessment was inaccurately coded.
Failure to Follow Professional Standards in Post-Fall Assessment, Insulin Administration, and Pressure Mattress Settings
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for three residents. In the first instance, a resident with dementia and high blood pressure experienced a fall, but there was no documentation that a set of vital signs was obtained at the time of the initial assessment or prior to physician notification. The only vital signs recorded were from before the fall, and the first post-fall vital signs were not documented until several hours later. The DON confirmed that the expectation is for vital signs to be taken immediately after a fall, but this was not done or documented in this case. In the second instance, insulin administration practices did not adhere to standards of care regarding site rotation. Two residents received insulin injections in the same location repeatedly, as documented in the MAR, and staff interviews confirmed that there was no standard practice for rotating injection sites. This was contrary to established guidelines, which recommend systematic rotation within an area to prevent complications. The Nursing Home Administrator acknowledged the lack of adherence to a standard of care for insulin administration and site rotation. The third deficiency involved the use of a pressure-reducing mattress for a resident with a history of significant weight loss. The mattress was set for a weight range much higher than the resident's current weight, as confirmed by both observation and staff interviews. The settings were only adjusted after surveyor intervention, despite the care plan specifying that mattress settings should be based on the resident's weight and checked for proper functioning.
Failure to Administer Oxygen as Ordered
Penalty
Summary
Surveyors determined that the facility failed to administer oxygen therapy as ordered by the physician for a resident with respiratory failure. The physician's order specified continuous oxygen at 5 liters per minute via nasal cannula. However, on multiple occasions, the resident was observed receiving only 4 liters per minute. These observations were confirmed by two LPNs and a second surveyor, and the discrepancy between the ordered and administered oxygen flow rates was acknowledged by staff. The resident's medical record and treatment administration record both reflected the physician's order for 5 liters, but the actual administration did not match the prescribed amount.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the administration of metoprolol despite specific physician-ordered parameters to hold the medication. The resident, who had diagnoses including dementia and hypertension, had an order for metoprolol extended release 25 mg daily, with instructions to hold the medication if the pulse was less than 60 or if the systolic blood pressure (SBP) was less than 130. Review of the Medication Administration Record for March 2025 showed that the medication was administered on six occasions when the resident's SBP was below the ordered threshold, and in one instance, the heart rate was also below the specified parameter. The DON confirmed that staff are expected to follow medication order parameters, and the surveyor verified that the medication was given contrary to these instructions.
Late Medicare Coverage Notices and Incomplete SNFABNs
Penalty
Summary
The facility failed to ensure that Beneficiary Protection Notifications were issued at least two calendar days before the end of Medicare Part A coverage for residents who remained in the facility after skilled services ended and still had benefit days remaining. For Resident #43, Medicare Part A services began on 4/3/25 and ended on 5/2/25, but the NOMNC and SNFABN were not signed until 5/6/25, four days after Medicare coverage ended. The SNFABN for this resident also had the D, E, and F columns left blank, with no listed services, reasons Medicare may not pay, or estimated costs. For Resident #76, Medicare Part A services began on 3/4/25 and ended on 4/30/25, and the resident remained in the facility after skilled coverage ended. The facility initiated discharge from Medicare Part A before benefit days were exhausted, and the NOMNC and SNFABN were signed on 4/29/25, one day before Medicare services ended. The SNFABN for this resident also had the D, E, and F columns blank. During interview, staff #5 stated the NOMNC for both residents was issued late because she was on vacation, and she also stated she had not been trained on how to complete the SNFABN before giving it to residents or their representatives.
Incomplete Transfer Information Sent With Hospitalized Residents
Penalty
Summary
The facility failed to ensure that appropriate information was communicated to the receiving healthcare institution when two residents were transferred to the emergency department. For Resident #110, the record showed a hospital transfer on 6/29/25, and the SNF to ED transfer checklist indicated only items 1, 2, and 4 were checked as printed and sent: MOLST, facesheet, and medication list. The nurse unit manager confirmed that the nurse’s progress note did not identify which documents were printed and sent, and stated that care plan goals and advance directive information were typically not sent and that she was not aware they were required to be sent. The DON acknowledged that the minimum required information had not been sent. For Resident #25, who had been a resident since 2018 and was hospitalized on 2/28/25, the transfer checklist again showed only MOLST, facesheet, and medication list were checked as printed and sent. During interview, the nurse unit managers stated they would review the record, and Staff #2 later confirmed that the nurse on duty did not document which transfer documents were sent with the resident. Staff #2 also confirmed that the checklist only indicated those three items were printed and sent, and the NHA and DON acknowledged that the information sent to the receiving healthcare institution did not meet the minimum federal requirement.
Baseline Care Plan Not Completed Within 48 Hours
Penalty
Summary
The facility failed to develop and complete a baseline care plan within 48 hours of admission for Resident #96, a newly admitted resident with generalized muscle weakness and difficulty walking. The resident’s hospital discharge summary noted generalized weakness with ambulatory dysfunction. A fall risk assessment completed by an LPN showed a fall risk score of 9, and the resident’s record also documented use of a wheeled walker and balance issues when ambulating. The baseline care plan was initiated on the day of admission, but the only documented sections were social services, therapy, and signatures; the nursing sections were left blank. A lift/transfer/reposition assessment showed the resident needed one-person assistance for repositioning in bed, but the section indicating whether care plan interventions were developed was left blank. The clinical admission assessment was created but remained in progress and could not be printed because it had not been completed. The Nurse Unit Manager reviewed the record and confirmed that interventions should have been initiated in the baseline care plan for the resident’s fall risk.
Inaccurate Controlled Medication Reconciliation
Penalty
Summary
The facility failed to establish systems to accurately reconcile controlled medications using acceptable standards of practice. During review of the narcotic reconciliation book on the 200-hall unit, an unsigned sheet for Lorazepam was found, and an LPN acknowledged that the sheet was incomplete. Unit Managers reviewed the sheet and confirmed it was unsigned, and the sheet was later corrected after surveyor intervention. The facility policy stated that the nurse coming on duty and the nurse going off duty must count together and sign the designated controlled substance record. A review of the narcotic book on the 100-hall unit found a Lorazepam narcotic sheet dated 6/15/25 signed by only one nurse. In addition, surveyor observation and interview with an RN identified inaccurate reconciliation and documentation for 1 of 3 bottles of liquid morphine, and the RN stated she had no clue which sheet went to which bottle. An LPN acknowledged that the narcotic sheets and corresponding bottles of morphine were not accurately reconciled and documented, and also stated the liquid morphine and accompanying sheets should not have remained on the cart because the resident had been discharged the prior week. The DON stated that narcotics did not have to be pulled from a medication cart according to a timeline as long as they were double locked, while the facility policy for discarding and destroying medications stated controlled substances must be disposed of immediately, no longer than three days after discontinuation of use.
MRR Recommendations Not Timely Addressed or Documented
Penalty
Summary
The facility failed to ensure that pharmacy recommendations from the monthly medication regimen review (MRR) were addressed by the attending physician in a timely manner, that the physician documented a rationale when no action was taken, and that the MRR policy specified timeframes for the steps in the review process. This was identified for 2 residents reviewed for unnecessary medications. The consultant pharmacist identified irregularities and drug therapy problems, but the facility did not have an effective system to ensure the recommendations were consistently documented, reviewed, and responded to in the medical record. For one resident with a history of muscle weakness and difficulty walking, a MRR completed after a fall identified 3 drug therapy problems. The resident’s medical record did not contain the report at the time of review, and the report later provided showed no indication that the concerns had been addressed by the attending physician. The DON stated the report had been placed in the physician’s box, but no response was received, and there had been no change in the resident’s medication orders. For another resident admitted with dementia, monthly MRRs were documented, but the most recent report in the chart was from several months earlier. Staff later provided reports showing pharmacist recommendations for gradual dose reduction of clonazepam and Lexapro. The attending physician indicated no change in the current order or that dose reduction was contraindicated, but the space for the physician’s reason for disagreeing with the recommendation was left blank, and the medical record did not contain documentation explaining the decision. Review of the facility’s MRR policy showed that it required the prescriber to provide an explanation for disagreeing with a recommendation, but it did not specify a timeframe for the steps in the MRR process.
Medications Left at Bedside Without Self-Administration Authorization
Penalty
Summary
The facility failed to maintain medications in a locked storage container until they were administered to a resident. During an observation in Resident #4's room, four white pills were seen in a clear plastic cup on the bedside table next to a breakfast tray. The resident stated that the nurse had given the pills and that they were taken after breakfast. The same pills were later observed in the cup by the surveyor and the DON, and the DON confirmed their presence. When asked where the pills came from, the resident again stated they were given by the nurse. The DON stated that medications should not be left at the bedside unless the care plan authorizes self-administration, and review of the resident's care plan and physician's orders showed no documentation or authorization for self-administration.
Incomplete MOLST Documentation
Penalty
Summary
Medical record documentation was incomplete for one resident reviewed for advance directives. The resident was admitted to the facility in 2022 and was later deemed by a physician to be capable of making their own decisions. During record review, the resident’s paper chart contained a Maryland MOLST form dated [DATE] that indicated No CPR, but the spaces designated to identify a decision maker were left blank. A unit clerk reviewed the form during the survey and verified that the decision-maker fields were blank. The social services director stated that she was responsible for reviewing MOLST forms and described the facility’s process for ensuring accuracy of MOLST documents. When shown the resident’s MOLST form, she acknowledged that the decision-maker section had not been completed. She further stated that she had not worked at the facility when the form was created, but later reviewed all residents’ MOLST documents and must have missed this one. The DON also reviewed the form and confirmed that the blank spaces should have been completed, confirming the incomplete medical record documentation.
QAA Meetings Lacked Required Infection Preventionist Attendance
Penalty
Summary
The facility failed to have the infection preventionist attend 2 consecutive quarters of the Quality Assessment and Assurance (QAA) meetings. During record review on 8/12/25, attendance sheets for the last 12 months of QAA meetings were requested from the Nursing Home Administrator, and it was reported that the infection preventionist nurse was new and had been hired in March 2025. Review of the attendance sheets showed that the IP nurse did not attend 6 of the 12 months reviewed for QAA meetings. During an interview on 8/12/25, the NHA confirmed that the facility did not have an IP nurse for a couple of months before Staff #52 was hired and acknowledged that an IP nurse was required to attend at least the quarterly QA meetings.
Failure to Perform Hand Hygiene During Wound Dressing Change
Penalty
Summary
The facility failed to provide proper infection control strategies during a dressing change for a resident with a left heel pressure ulcer. The resident had an order for dressing changes for the left heel wound, and a wound specialist documented that the resident’s left heel pressure ulcer was unstageable with necrosis, measured 7 x 5 x 0.2 cm, had poor healing potential, and was present on admission. During observation of the dressing change, the LPN removed the old dirty dressing and then removed her dirty gloves, but did not perform hand hygiene before putting on a clean pair of gloves and continuing the dressing procedure. The LPN acknowledged that hand hygiene was not performed. The facility’s dressing change policy stated that staff were to perform hand hygiene after removing the soiled dressing and soiled gloves and before putting on clean gloves and completing the dressing change. The DON acknowledged the finding and stated he had no further evidence to provide.
Call Device Not Kept Within Resident Reach
Penalty
Summary
The facility failed to ensure that a resident's call device was kept within reach. During the initial tour, Resident #25 was observed in bed watching TV, and the call device was laying on the floor and not within reach. A second observation later the same day showed the call device still on the floor. When the GNA was called to the room, she confirmed the device was not within the resident's reach and picked it up from the floor, securing it to the resident's gown. The resident's care plan included an intervention to ensure the call device was within reach and to encourage use of it for assistance as needed, with the intervention last revised on 2/22/24.
Failure to Post Nurse Staffing Information Daily
Penalty
Summary
The facility failed to ensure that Nurse Staffing Information was posted every day and failed to ensure that the posted information included the facility’s full name. During a surveyor observation on 7/31/25 at 8:30 AM, the staffing information posted at the front reception desk in the main lobby was dated 7/23/25, and the official name of the facility was not included on the form; only the first word of the name, which is also the town name, appeared. On 8/11/25 at 1:01 PM, the Human Resource Director stated that she usually posts the staffing information before 10 AM, that the DON or NHA posts it when she is not present, and that it does not get done on weekends. On 8/13/25 at 8:40 AM, the NHA was informed of the concern regarding the failure to post the nurse staffing information daily and the failure to include the facility’s actual name.
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What surveyors actually found near you
We read the 240 citations issued within 25 miles in the last 12 months — including the 3 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.
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Nursing homes near Frostburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mountain City Rehab Center | 1.5 mi | ★★★★★ | 33 | 0 |
| Lions Rehab Center | 5.9 mi | ★★★★★ | 34 | 0 |
| Devlin Manor Nursing And Rehabilitation Center | 6.7 mi | ★★★★★ | 29 | 0 |
| Egle Nursing Home | 6.8 mi | ★★★★★ | 31 | 0 |
| Allegany Health Nursing And Rehab | 7.8 mi | ★★★★★ | 19 | 0 |
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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 July 2026) and official state health department websites.