Chestertown Nursing and Rehab: Care Plan Failures - MD
Inspectors documented the lapse during a complaint survey completed August 13, 2025, at the facility on Morgnec Road. The resident, identified in inspection records only as Resident 69, had no care plan in place for the behaviors at the time of the inspection.
When a staff member was asked what should have been in that care plan, she said she would have included agitation and wandering into other residents' rooms. She confirmed the gap herself by checking through the Director of Nursing's laptop.
The Director of Nursing, interviewed at 12:12 p.m. on August 7, was asked what he expected staff to do after an incident involving a resident. He said the care plan would be updated depending on the findings of an investigation, and that it would reflect the incident, along with goals and interventions going forward.
That update had not happened for Resident 69.
Inspectors rated the violation as causing minimal harm or the potential for actual harm, with few residents affected. But the situation Resident 69 was in, moving through a facility without a documented plan for managing agitation or keeping that resident out of other people's rooms, carried risks that extended beyond one person. Other residents in those rooms had no documented protection from the intrusions either.
Care plans exist precisely because memory care and behavioral symptoms do not resolve on their own. A resident who wanders into occupied rooms without any structured response from staff, without documented goals, without recorded interventions, is a resident whose behavior is being managed informally, if at all. What that looks like in practice, on a night shift, with a different aide than the one who knows the resident by instinct, is a question the inspection report leaves open.
The Director of Nursing described a system that should have caught this. An incident happens, an investigation follows, the care plan gets updated. Resident 69's situation suggests that system did not run its course.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 25, 2026 · Our methodology
CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD was cited for violations during a health inspection on August 13, 2025.
Inspectors documented the lapse during a complaint survey completed August 13, 2025, at the facility on Morgnec Road.
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.