Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at 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.
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.
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.
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.
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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 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 | — | 8 | 0 |
| Devlin Manor Nursing And Rehabilitation Center | 6.7 mi | — | 9 | 0 |
| Egle Nursing Home | 6.8 mi | — | 31 | 0 |
| Allegany Health Nursing And Rehab | 7.8 mi | — | 2 | 0 |
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