Frostburg Rehab Center

In the surveyor’s words

From the most serious findings on record at Frostburg Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 13, 2025

  Based on medical record reviews, interviews, and review of facility investigation documents, it was determined that the facility failed to ensure residents were free from accidents as evidenced by the resident sustaining an injury while being assisted by staff in transferring. This was evident for 1 (Resident #104) of 12 residents reviewed for accidents. The deficient practice resulted in actual harm to resident # 104.The findings include:A review of Resident #104’s medical records on 8/7/25 at 11:40 AM, revealed a comprehensive assessment with a reference date of 1/7/25 that indicated the resident had severely impaired cognition and was dependent on staff for transfers and mobility. […]

• No harm, potential for more than minimal, widespreadF727Aug 13, 2025

  Based on review of pertinent documentation and interviews it was determined that the facility failed to ensure a registered nurse was working for at least 8 consecutive hours every day. This was found to be evident for 3 out of 16 weekends of staffing reviewed during the survey but has the potential to affect all residents.The findings include: On 8/11/25 surveyor reviewed the staffing sheets for the weekends during January, February and March of 2025, as well as the staffing sheets for 7/15 -7/30/25 for the presence of a registered nurse (RN). These schedules reflected 24 hour periods that started and ended at 7:00 AM. […]

• No harm, potential for more than minimal, widespreadF730Aug 13, 2025

  Based on review of pertinent documentation and interviews it was determinted that the facility failed to ensure annual evaluations were being completed for geriatric nursing assistants (GNA). This was found to be evident for three (GNA #48, #18 and #49) out of three GNAs who were selected for review of annual training.The findings include: Review of a list of employees with their hire dates revealed GNA #48 was hired in March of 2023; GNA #18 was hired in June of 2004; and GNA #49 was hired in March of 2021. On 8/7/25 surveyor requested from the Human Resource Director documentation of the the annual evaluations for these three GNAs.On 8/11/25 review of the documentation provided failed to reveal documentation to indicate an annual review had been completed for GNA #48. […]

• No harm, potential for more than minimal, widespreadF838Aug 13, 2025

  Based on review of the facility assessment, medical records and contracts, and interviews it was determined that the facility failed to ensure the facility assessment addressed all of the required components of this regulation. This deficient practice has the potential to affect all residents.The findings include: Review of the Facility Assessment, which was provided for review at the beginning of the survey, revealed it was most recently updated on 2/24/25, however it failed to reflect the actual current name of the facility. […]

• No harm, potential for more than minimal, patternF609Aug 13, 2025

  Based on record review and interview, it was determined that the facility failed to report injuries of unknown origin. This was evident for one facility reported incident (#358490) of sixteen facility reported incidents and 1 of 1 grievance binder reviewed during the recertification survey.The findings include:1) A review of the facility’s grievances/concerns binder on 8/6/2025 revealed a resident concern form dated 3/3/25 for Resident #23. The form indicated that on the night of 3/2/25 into 3/3/25, Resident #23’s roommate observed that a GNA (Geriatric nurse aid) had answered Resident #23’s call light. […]