Chestertown Nursing: Missing Care Plans for Infections - MD
Federal inspectors found these care planning failures during an August complaint investigation at Chestertown Nursing and Rehab. The facility's own nursing leadership acknowledged both situations violated their expectations for patient care.
Resident #20 was receiving treatment for C. diff — a serious bacterial infection that causes severe diarrhea and can be life-threatening in elderly patients — but had no documented care plan addressing the condition. When inspectors reviewed the resident's records on August 5, they found treatment was ongoing and the physician was aware, but no care interventions were documented.
Licensed Practical Nurse #17 told inspectors that residents with C. diff infections should be placed on contact and isolation precautions to prevent spread. When asked about the care plan for this ongoing infection, she said she would check. After reviewing the records, she admitted no interventions were documented and "a care plan should have been in place."
The facility's President of Clinical Operations confirmed that expectation. "A care plan should have been developed while the infection was ongoing," she told inspectors.
Director of Nursing acknowledged the omission was "a concern" and said facility policy requires creating care plans for any active diagnosis, including specific goals and interventions. He confirmed a care plan would be started immediately.
The second case involved Resident #98, who filed a complaint with state regulators in January 2024 stating his colostomy bag had not been changed. The resident was cognitively intact with a BIMS score of 14 out of 15, meaning he was fully aware of the neglect.
Medical records showed the resident had various other care plans but nothing addressing colostomy care. Assistant Director of Nursing told inspectors that facility expectations require colostomy bags to be "emptied, cleaned, monitored, and changed as appropriate, with accurate documentation."
She explained that charge nurses and unit managers are responsible for reviewing admissions with physicians and obtaining orders for residents with colostomies. When told the resident had no care plan for colostomy care, she acknowledged "there should have been a care plan in place to guide appropriate interventions."
The Director of Nursing was more specific about what was missing. He said there should have been physician orders to monitor the ostomy site and color, track fecal output, determine frequency of bag changes, and specify bag size. All of this should have been backed by "a care plan specifying nursing interventions for colostomy care."
Care plans are fundamental nursing home documents that guide daily care decisions. They translate physician orders into specific nursing actions and help ensure consistent treatment across all shifts and staff members.
For C. diff infections, proper care planning typically includes isolation procedures to prevent transmission to other residents, specific cleaning protocols, monitoring for complications, and coordination with physicians on treatment progress. The infection is particularly dangerous in nursing home settings where it can spread rapidly among vulnerable elderly residents.
Colostomy care requires equally detailed planning. Bags must be changed regularly to prevent skin breakdown and infection. The stoma site needs monitoring for color changes that could indicate circulation problems. Output must be tracked to ensure proper digestive function.
Both residents' situations represented what inspectors classified as "minimal harm or potential for actual harm" affecting few residents. But the facility's own leadership acknowledged these were clear violations of their care standards.
The inspection was conducted in response to complaints, suggesting these problems came to light through resident or family concerns rather than internal quality assurance. Resident #98's complaint about unchanged colostomy bags had been filed seven months before the federal inspection occurred.
Neither care planning failure appeared to be isolated incidents of staff oversight. In both cases, the residents had ongoing medical needs that required sustained attention over time. The absence of formal care plans meant there were no documented protocols guiding staff on proper care procedures.
The facility's nursing leadership demonstrated clear awareness of what proper care planning should include, making the omissions more concerning. They knew the standards but failed to implement them for these vulnerable residents.
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.
Federal inspectors found these care planning failures during an August complaint investigation at Chestertown Nursing and Rehab.
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.