PRINCE FREDERICK, MD - A federal complaint investigation completed on January 17, 2025, found that a nursing aide at Calvert County Nursing Center fractured a resident's arm by lifting the resident manually instead of using a required sit-to-stand transfer device. The same investigation revealed the facility failed to conduct trauma-informed care assessments for three residents who reported physical and sexual abuse by staff members.
Aide Lifted Resident Without Required Device, Fracturing Arm
The inspection, conducted by the Centers for Medicare & Medicaid Services (CMS), documented that Resident #417 was classified as a high-risk fall patient who required the assistance of two or more staff members and a mechanical sit-to-stand device for all transfers. That care plan had been in place since February 2022 and was active at the time of the incident.
On August 23, 2024, the resident was preparing to attend an activity when the assigned Geriatric Nursing Assistant (GNA) was occupied with another patient. Two other aides — identified in the report as GNA 2 and GNA 3 — entered the room to help the resident move from the bed to a wheelchair.
According to the inspection report, GNA 2 told the other aide that the two of them could simply lift the resident into the wheelchair. Both the resident and GNA 3 objected, stating that the resident's care plan required a sit-to-stand device for transfers. GNA 2 disregarded those objections.
The resident told investigators: "She felt the pain in her arm and heard the snap when she lifted her arms around the GNA's neck." GNA 3 confirmed the account, telling surveyors that GNA 2 "was in a hurry and lifted the resident" and that "they did hear the snap of the resident's arm."
The resident was transported to the emergency room, where medical staff confirmed a fractured right arm.
Why Proper Transfer Protocols Exist
A sit-to-stand device is a mechanical lift designed to replace manual stand-and-pivot transfers for residents who can bear some weight but lack the strength or stability to stand independently. These devices distribute the resident's weight across a secure harness system, reducing the risk of musculoskeletal injury to both the resident and the caregiver.
When a caregiver instead performs a "bear hug" lift — wrapping arms around a resident and pulling them upward — the resident's full body weight is concentrated through the arms and shoulders. For elderly residents, particularly those with osteoporosis or reduced bone density, this type of force can easily cause fractures. The upper extremities are especially vulnerable when the resident's arms are raised overhead and wrapped around the caregiver's neck, as described in this incident.
The resident's Minimum Data Set (MDS) assessment — a comprehensive evaluation that nursing facilities are required to maintain — explicitly documented that the resident depended on staff for transfers and required the support of two or more individuals along with mechanical assistance. This information is recorded in MDS Section GG, which covers functional abilities, and serves as the foundation for the facility's care plan.
Delayed Investigation and Staff Response
The inspection report revealed a significant gap between when the incident occurred and when the facility took corrective action. The resident reported the improper transfer to the Director of Nursing on August 23, 2024, the day it happened. However, facility-wide education on safe transfer protocols was not completed until September 27, 2024 — more than a month later.
When surveyors asked about the delay, the Director of Nursing stated that "the resident failed to inform staff at the time of the incident that the sit-to-stand device was not used in the transfer." However, the inspection record indicates the resident did report the incident to the DON on the same day it occurred.
The facility's Administrator told surveyors on January 16, 2025, that a Quality Assurance Performance Improvement (QAPI) action plan had been completed on September 27, 2024. The plan included facility-wide education — including for agency staff — and the permanent suspension of GNA 2, who was not permitted to return to the facility. The Administrator also stated that any new agency staff would receive education on resident transfer procedures before beginning work.
The deficiency was classified under F689 — Free of Accident Hazards/Supervision/Devices, at a level of "Actual Harm" affecting few residents. This classification indicates that the violation directly resulted in documented physical injury to a resident.
Facility Failed to Assess Residents Reporting Abuse
A second deficiency, classified under F699 — Trauma-Informed Care, revealed a pattern of failure to conduct required assessments after residents reported physical and sexual abuse by staff members. The violation affected three of three residents reviewed for trauma-informed care.
Resident Reported Inappropriate Touching
Resident #406 told a hospice volunteer that a male staff member had touched the resident inappropriately. The hospice volunteer documented the allegation in a written statement, and the facility reported the incident to the State of Maryland's Office of Health Care Quality on January 5, 2023.
Despite the severity of the allegation, surveyors who reviewed the resident's medical record on January 16, 2025, found no evidence that a trauma-informed assessment was ever performed following the report. Federal regulations require nursing facilities to evaluate whether residents who report traumatic experiences need modifications to their care to avoid re-traumatization — for example, adjusting bathing assistance or limiting contact with certain staff members.
Resident Reported Being Slapped by Staff
In a separate incident, Resident #407 told a spouse that a staff member had slapped the resident in the face on the evening of May 9, 2023. A hospice volunteer documented the allegation in a written statement, and the facility reported it to state regulators on May 10, 2023.
Again, surveyors found no trauma-informed assessment in the resident's medical record. Without such an assessment, the facility had no documented process for determining whether the resident's ongoing care needed adjustment in light of the reported physical abuse.
Sexual Trauma Disclosure Also Overlooked
A third resident, #421, had filed a complaint in April 2024 stating that she felt uncomfortable being bathed by a specific nursing assistant. During follow-up on April 10, 2024, the resident disclosed to the Director of Social Work that she had experienced sexual abuse in the past.
The Director of Social Work acknowledged to surveyors that this information should have prompted an update to the resident's trauma-informed care assessment. However, reviews of assessments completed on August 23, 2024, and November 11, 2024 — both after the disclosure — continued to indicate that the resident had not experienced any traumatic event.
The Director of Social Work told surveyors: "I should have updated the trauma informed care assessment when the information was revealed to me."
What Trauma-Informed Care Requires
Trauma-informed care assessments are a federally mandated component of nursing home operations. Facilities must evaluate each resident for a history of trauma at admission and whenever there is a change in condition — which includes new reports of abuse, assault, or other traumatic experiences.
The purpose of these assessments is not investigative but clinical. They determine whether a resident's daily care routines — bathing, dressing, transfers, medication administration — need to be modified to account for past trauma. A resident who has experienced sexual abuse, for instance, may require same-gender care staff during personal hygiene assistance.
By failing to conduct or update these assessments, the facility left three residents without the clinical protections that federal regulations are designed to provide.
Facility Accountability and What Comes Next
Both the Director of Nursing and the Administrator confirmed to surveyors on January 17, 2025, that the facility's policy requires trauma-informed assessments at admission and after any change in condition. Both acknowledged that the assessments were not completed for Residents #406 and #407 after their respective allegations.
The F699 deficiency was classified at a level of "Minimal Harm or Potential for Actual Harm" affecting few residents. While this is a lower severity level than the fractured arm finding, the pattern across three residents suggests a systemic gap in the facility's process rather than an isolated oversight.
Calvert County Nursing Center, located at 85 Hospital Road in Prince Frederick, Maryland, is required to submit a plan of correction addressing each deficiency identified during the survey. Facilities that fail to achieve compliance may face additional enforcement actions, including civil monetary penalties or restrictions on new admissions.
The full inspection report, including the facility's plan of correction, is available through the Centers for Medicare & Medicaid Services and the Maryland Office of Health Care Quality.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Calvert County Nursing Ctr. from 2025-01-17 including all violations, facility responses, and corrective action plans.
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