Chestertown Nursing: Colostomy Care Documentation Gaps - MD
The facility's skilled nursing charts showed colostomy bag changes through February 22, 2024, but no documentation existed for the period leading up to the resident's March 20, 2024 discharge. The gap represented 26 days without recorded care for a medical device that facility leadership said should be changed weekly or when soiled.
Federal inspectors reviewing the resident's electronic records found the last skilled nursing chart entry coincided with the final documented colostomy change on February 22. After that date, no records existed showing staff monitored, cleaned, or changed the resident's colostomy bag despite the person remaining at the facility for nearly another month.
The documentation pattern before February showed consistent care. Staff recorded colostomy changes on December 29, 2023, then regularly throughout January 2024 on the 18th, 22nd, 23rd, 24th, 25th, 27th, 28th, and 30th. The frequency suggested daily or near-daily attention to the medical device during that period.
But something changed after February 22.
When inspectors questioned the Assistant Director of Nursing about the facility's colostomy care standards, she outlined comprehensive expectations. Staff should empty, clean, monitor, and change colostomy bags as appropriate while maintaining accurate documentation, she said. Charge nurses or unit managers were responsible for reviewing admissions with physicians and obtaining necessary orders for residents with colostomies.
The problem became clearer when inspectors revealed the resident had no physician order for colostomy care at all.
The Assistant Director acknowledged the oversight. There should have been a physician order specifying colostomy care requirements, including change schedules and appropriate interventions, she told inspectors.
The Director of Nursing expanded on what should have happened when inspectors brought the case to his attention. A proper physician order would specify monitoring the ostomy site and color, tracking fecal output, determining the frequency of bag changes, and selecting appropriate bag sizes. The facility should have developed a care plan detailing specific nursing interventions for colostomy care.
For documentation, the Director said he expected daily records while the resident received skilled services. After skilled care ended, the colostomy care order should have transferred to the Treatment Administration Record and been documented appropriately.
When inspectors asked how often colostomy bags should be changed, the Director said weekly or as needed if soiled.
The documentation gap raised questions about what actually happened during those undocumented weeks. Without records, inspectors could not verify whether staff provided any colostomy care between February 22 and the March 20 discharge.
The facility's own leadership had established clear expectations. Colostomy bags required emptying, cleaning, monitoring, and changing. Staff needed physician orders. Documentation had to be accurate and consistent.
None of that happened for Resident 98 during the final month of care.
The case illustrated a breakdown at multiple levels. The facility failed to obtain physician orders for a resident's basic medical needs. Staff either provided undocumented care or potentially neglected the resident's colostomy entirely for weeks. Supervisors failed to catch the documentation gap or the missing physician orders.
Federal regulations require nursing homes to provide necessary care and maintain accurate records. The colostomy case violated both requirements, inspectors determined, though they classified the harm level as minimal.
The timing made the violations particularly concerning. The documentation stopped precisely when skilled nursing services ended, suggesting the facility may have reduced attention to the resident's medical needs as discharge approached.
For a resident with a colostomy, proper care prevents serious complications including skin breakdown, infection, and psychological distress. The device requires regular attention and monitoring by trained staff following specific physician orders.
The inspection found that Chestertown Nursing and Rehab failed to meet those basic standards for nearly a month before sending the resident home.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chestertown Nursing and Rehab from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD was cited for violations during a health inspection on August 13, 2025.
The gap represented 26 days without recorded care for a medical device that facility leadership said should be changed weekly or when soiled.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.