Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Allegany Health Nursing And Rehab during CMS and state inspections, most recent first.
Surveyors found that the facility failed to hold and document an interdisciplinary care plan meeting after completion of an MDS assessment for a resident with a urinary catheter. The social worker reported that care conferences are usually scheduled about 2 weeks after MDS assessments and documented in the EHR. Record review showed an MDS completed for the resident, but the only documented care conference was several months earlier, with no subsequent meeting held. The social worker and NHA confirmed that no care plan meeting had occurred since that earlier date, attributing this to the resident’s transition from LTC to skilled care.
A resident was readmitted from the hospital with an indwelling Foley catheter placed for urinary retention, with instructions for outpatient urology follow-up. The facility documented ongoing catheter orders and noted the device on the MDS, but failed for several months to include the catheter in the resident’s care plan or to develop interventions related to its use. No timely urology appointment was arranged, and there was no documentation of any attempt to discontinue the catheter, even after the resident developed hematuria and was treated for cystitis. The facility also lacked a facility-specific policy addressing catheter use and plans for discontinuation.
A resident was admitted without a clear physician's order for end-of-life care, and facility staff failed to initiate CPR when the resident was found not breathing. Despite prior education on CPR and MOLST forms, an LPN and RN supervisor did not act due to the absence of a completed MOLST form, leading them to wait for EMS. The facility's policy required staff to treat residents as full code in emergencies without a completed MOLST form.
Two residents suffered injuries due to staff failing to follow care plans in a LTC facility. One resident fell out of bed during incontinence care, resulting in bilateral femoral neck fractures, as the GNA did not use the required two-person assist. Another resident sustained a fractured humerus during a manual transfer to a shower chair, contrary to the care plan requiring a lifting device. Staff did not verify care plans before performing tasks, leading to improper handling and supervision.
A resident was subjected to abuse when a staff member, GNA2, kicked them on the leg, causing a skin tear, after the resident attempted to remove food trays. The incident was witnessed by an LPN who reported it to a supervisor. GNA2 was verbally aggressive and attempted to move the resident backward before the physical altercation occurred.
The facility failed to implement its abuse policy when two staff members reported an allegation of sexual abuse between two residents. An anonymous complaint indicated that the administration required a nurse to retract documentation of the incident, and the facility did not report the abuse to the State Survey Agency. Despite the facility's policy requiring immediate reporting and investigation, no formal documentation or notification to authorities occurred.
A facility failed to report an allegation of resident-to-resident sexual abuse to the State Survey Agency. The incident involved two residents, with one observed touching the other's genitals. Despite being reported to the Director of Social Work and the facility Administrator, no proper documentation or investigation was conducted, and the incident was not reported to authorities as required by facility policy.
A facility failed to investigate an allegation of resident-to-resident sexual abuse when it was reported by staff. The incident involved two residents, with one observed touching the other's genitals. Despite being informed, the facility's leadership did not document or investigate the incident, nor did they notify the local police or State Survey Agency, contrary to their policy.
A resident was improperly restrained in a geriatric chair and wheelchair with a lap tray, preventing her from standing up, which was done for staff convenience. The facility's policy requires restraints to be used only as a last resort with proper documentation, which was not followed. The resident, who was cognitively intact, expressed anxiety due to the inability to move freely, and staff interviews revealed a lack of awareness and assessment regarding the use of these devices as restraints.
A facility failed to update a resident's care plan to include the use of a geriatric chair and lap trays, which were used as restraints. The resident, cognitively intact, was placed in these devices after a fall, but the care plan did not reflect this. Staff confirmed the oversight, and the DON and Administrator did not recognize these as restraints, leading to potential safety risks.
Failure to Hold Interdisciplinary Care Plan Meeting After MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an interdisciplinary care plan meeting was held to review and revise a resident’s care plan following completion of a Minimum Data Set (MDS) assessment. Care conferences, also known as care plan meetings, are required interdisciplinary team meetings that are to occur after MDS assessments, which provide the information needed to develop and modify the resident’s care plan. Interview with the social worker revealed that MDS nurses send out a schedule and social work typically schedules care plan meetings 14 days after the assessment date, with documentation of these meetings maintained in the electronic health record. Medical record review for a resident with a urinary catheter showed an MDS with an assessment reference date of 1/9/26. Further review of the record revealed documentation of a care conference on 10/15/25, but no documentation of any care conference occurring after the 1/9/26 MDS assessment. When questioned, the social worker and the Nursing Home Administrator confirmed that no care plan meeting had been held since October, and the NHA stated this was due to the resident transitioning from long-term care to skilled care. This failure to hold and document an interdisciplinary care plan meeting after the MDS assessment constituted the cited deficiency.
Failure to Care Plan and Reassess Indwelling Foley Catheter Use
Penalty
Summary
Surveyors identified a failure to develop and implement a care plan addressing an indwelling urinary catheter and to assess for its possible removal for a resident who had been readmitted from the hospital with a Foley catheter in place. The resident had previously resided in the facility for more than a year and, prior to a hospital stay in late December, was documented on the discharge MDS as frequently incontinent of urine without any internal or external catheter. During the hospitalization, the resident developed urinary retention and urology placed a Foley catheter with the plan for it to remain in place at discharge and for the resident to follow up with urology as an outpatient. Upon the resident’s readmission in early January, facility records showed ongoing orders for an indwelling Foley catheter and catheter care every shift, and the MDS assessment dated shortly after readmission documented the presence of an indwelling urinary catheter. However, review of the care plan on April 1 revealed no documentation acknowledging the catheter or interventions related to its use, despite the catheter having been in place since January. The existing care plan only addressed occasional bladder and bowel incontinence and, even when it was reviewed and revised in March by an RN, it still did not address the indwelling catheter or the resident’s recent urinary issues. Further record review showed no orders for a urology appointment and no documentation that the resident had been seen by urology or that any attempt had been made to discontinue the catheter after readmission. Progress notes from primary care providers in early January referenced the difficult Foley placement and the need for outpatient urology follow-up, but this follow-up was not arranged at that time. In March, the resident developed hematuria and was treated for cystitis with hematuria, yet the care plan remained unchanged and still did not address the catheter or the recent urinary tract infection. The facility also lacked a facility-specific policy on catheter use and discontinuation, relying instead on a textbook reference that noted complications associated with indwelling catheter use.
Failure to Initiate CPR Due to Incomplete MOLST Form
Penalty
Summary
The facility staff failed to identify a newly admitted resident who was admitted without a clear physician's order for end-of-life care and did not follow the facility policy to initiate Cardiopulmonary Resuscitation (CPR). This deficiency was evident for one resident during an annual recertification survey. The resident was admitted from the community and had been evaluated in the emergency room earlier in the day. Upon admission, the resident was assessed by a physician and deemed incapable of understanding any information, necessitating a third party to make decisions on their behalf. During the night, the resident was found on a floor mat by the bed but showed no evidence of injury and was placed back in bed. Later, a staff member noticed changes in the resident's breathing pattern and alerted an LPN, who assessed the resident and found them not breathing with eyes rolled back. The LPN notified 911/EMS and applied oxygen but did not initiate CPR. The LPN and an RN supervisor reviewed the resident's medical record and could not find a completed MOLST form, leading them to wait for emergency services to arrive. CPR was not performed, and the resident was pronounced deceased by EMS upon arrival. Interviews with staff revealed that the LPN had received prior education on CPR and MOLST forms but did not act due to the absence of a completed MOLST form. The former Social Work Director stated that newly admitted residents without a completed MOLST form should be considered full code in emergencies. However, there was no documentation of advance directives or MOLST status in the resident's progress notes. The facility's policy indicated that in the absence of appropriate DNR identification or orders, staff should respond with CPR measures and treat the resident as a full code.
Failure to Follow Care Plans Leads to Resident Injuries
Penalty
Summary
The facility staff failed to provide adequate supervision and follow the resident's plan of care, resulting in harm to two residents. In the first incident, a resident with cognitive impairment and total dependence on staff for care fell out of bed during incontinence care, leading to bilateral femoral neck fractures. The GNA responsible for the resident's care did not adhere to the care plan, which required two staff members for bed mobility. The GNA turned the resident onto their side and left them unattended while seeking additional supplies, resulting in the resident rolling out of bed. In the second incident, another resident with a history of a fractured hip, dementia, and metabolic encephalopathy suffered a fractured humerus during a transfer to a shower chair. Two GNAs attempted to transfer the resident manually, contrary to the care plan that required the use of a lifting device. During the transfer, they heard a popping sound and lowered the resident to the floor. The GNAs had not reviewed the resident's updated care plan, which specified the use of a Hoyer lift for transfers. Both incidents highlight a failure to adhere to established care plans and protocols, resulting in significant injuries to the residents. The staff involved did not verify the residents' care plans before performing tasks, leading to improper handling and supervision. These deficiencies were identified during a survey, and the facility was found to have past noncompliance with a compliance date established after corrective measures were implemented.
Resident Abuse Incident Involving Staff Member
Penalty
Summary
The facility failed to ensure that a resident remained free of abuse, as evidenced by an incident involving a staff member, GNA2, who was witnessed kicking a resident on the right lower leg. This incident occurred when the resident attempted to remove food and meal trays from a food cart. GNA2, who was verbally aggressive, attempted to move the resident backward by holding the wheelchair handles and subsequently kicked the resident, resulting in a skin tear. The resident expressed distress by screaming and wheeling themselves down the hall, where they were later found crying by another staff member, LPN5, who observed the injury and reported the incident to a supervisor. The incident was substantiated through witness statements, including that of LPN5, who detailed the sequence of events leading to the abuse. The resident was initially told by GNA2 to return to their room after being informed they had already eaten. Despite the resident's request to be left alone, GNA2 persisted in trying to move the resident, leading to the physical altercation. The facility's investigation confirmed the abuse, and GNA2 was immediately suspended and subsequently terminated following the incident.
Failure to Implement Abuse Policy and Procedures
Penalty
Summary
The facility failed to implement its existing abuse policy and procedures when an allegation of sexual abuse was reported by two staff members. An anonymous complaint revealed that a resident was observed sexually assaulting another resident, and the facility administration allegedly required a licensed nurse to retract their documentation of the incident. Furthermore, the facility did not report the allegation of resident-to-resident sexual abuse to the State Survey Agency. Interviews with the Director of Social Work and the facility Administrator confirmed that an investigation was initiated, but there were no administrative documents or investigative records regarding the alleged abuse. Additionally, the local police and the State Survey Agency were not notified. The facility's leadership did not adhere to its policy, which mandates immediate reporting of alleged violations involving abuse, neglect, exploitation, or mistreatment. The policy requires reporting to the State Survey Agency within two hours of receiving an allegation and conducting a prompt investigation. However, the facility failed to document the incident properly, did not collect witness statements, and did not notify the appropriate authorities. The staff were aware of the resident's history of intrusive behaviors, yet no formal investigation or documentation was completed, leading to a deficiency in handling the reported abuse incident.
Failure to Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility administrative staff failed to report an allegation of resident-to-resident sexual abuse to the State Survey Agency. This incident involved two residents, where one was observed with their hands inside the other's brief, touching their genitals. The incident was initially reported by a GNA to the Director of Social Work, who then informed the facility Administrator and the Director of Nurses. However, the facility did not document or investigate the incident properly, and no report was made to the State Survey Agency or local police. The facility's policy requires immediate reporting of such allegations, but this was not adhered to. The nurse who documented the incident in the alleged perpetrator's medical record found that the progress note was later marked as invalid, and no formal witness statements were collected. The facility Administrator admitted that there were no administrative documents or investigative records regarding the alleged abuse, and the staff were aware of the resident's intrusive behaviors but failed to take appropriate action.
Failure to Investigate Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility administrative staff failed to investigate an allegation of resident-to-resident sexual abuse when it was reported by staff members. This incident involved two residents, where one was observed with their hands inside the other's brief, touching their genitals. The Director of Social Work was informed of the incident and reported it to the facility Administrator and the Director of Nurses. However, there were no administrative documents or investigative records regarding the alleged abuse, and the local police and State Survey Agency were not notified. The facility's policy requires immediate reporting and investigation of any allegations of abuse, but this was not followed. A staff nurse documented the incident in the alleged perpetrator's medical record, but the progress note was later marked as invalid without explanation. The nurse who reported the incident was not asked to provide a formal witness statement or interviewed by administrative staff. The facility's leadership failed to conduct a prompt investigation or implement immediate actions to safeguard the residents involved.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as observed with one resident who was placed in a geriatric chair and a wheelchair with a lap tray. These devices prevented the resident from standing up, which was done for staff convenience rather than medical necessity. The facility's policy clearly states that restraints should only be used as a last resort and must be documented with a physician's order reflecting a qualifying medical symptom, which was not done in this case. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, was observed multiple times in a geriatric chair and a wheelchair with a lap tray, unable to stand or move freely. The resident's care plan did not include any interventions or assessments for the use of these restrictive devices. Staff interviews revealed a lack of awareness and assessment regarding the use of these devices as restraints, and the resident expressed feelings of anxiety and nervousness due to the inability to move freely. Interviews with the Director of Nursing (DON) and the Administrator indicated that they did not consider the geriatric chair with an overbed table or the wheelchair with a lap tray as restraints, and no assessments or care planning were completed to ensure the resident's safety. The resident was often placed in these devices without attempts to allow her to sleep in her bed, further indicating the use of these devices for staff convenience rather than the resident's best interest.
Failure to Revise Care Plan for Restraint Use
Penalty
Summary
The facility failed to revise the care plan for a resident to include the use of a geriatric chair and lap trays, which were considered restraints. The resident, who was cognitively intact with a BIMS score of 14 out of 15, was admitted to the facility and later placed in a geriatric chair after a fall. However, the care plan did not reflect the use of these devices, which were intended to prevent falls. Observations revealed the resident was often placed in a geriatric chair or a wheelchair with a lap tray, and staff intervened to keep the resident seated, indicating the devices were used as restraints. Interviews with nursing staff, including LPNs and RNs, confirmed that the care plan had not been updated to include the use of these restrictive devices. The MDS nurses were unaware of the resident's placement in a geriatric chair and the use of a lap tray, and the Director of Nursing and Administrator did not consider these devices as restraints. This oversight placed the resident at risk for unmet care needs and safety risks, as there was no assessment or care planning to ensure the resident's safety with these devices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cumberland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Devlin Manor Nursing And Rehabilitation Center | 1.5 mi | — | 9 | 0 |
| Cumberland Healthcare Center | 1.8 mi | — | 22 | 0 |
| Lions Rehab Center | 2 mi | — | 8 | 0 |
| Frostburg Rehab Center | 7.8 mi | — | 14 | 0 |
| Mountain City Rehab Center | 8.7 mi | — | 33 | 0 |
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