Chestertown Nursing and Rehab: Care Plan Failures - MD
Federal inspectors documented both failures during an August 2025 complaint inspection at the facility on Morgnec Road.
C. difficile is a bacterial infection of the colon that spreads easily through contact with contaminated surfaces and hands. The facility's own protocol, as described by staff during the inspection, called for placing any resident with the infection on contact and isolation precautions to prevent it from spreading. When inspectors reviewed the care plan for the resident known in records as Resident #20, who had an active C. diff infection, there was nothing there. No goals. No interventions. No documentation that the infection was being managed in any coordinated way.
The nurse who reviewed the care plan during the inspection acknowledged it on the spot. She told inspectors that a care plan should have been in place.
The facility's President of Clinical Operations joined the interview shortly after noon. She confirmed the same thing: a care plan should have been developed while the infection was ongoing. The Director of Nursing, interviewed separately, said the facility's expectation was that any active diagnosis should generate a care plan with specific goals and interventions. He called the omission a concern and said a care plan would be started immediately.
Nobody explained why it hadn't been started before inspectors arrived.
The second case had a longer and more troubling history. Resident #98, described in records as cognitively intact with a BIMS score of 14 out of 15, filed a complaint with the state agency on January 23, 2024, stating that her colostomy bag had not been changed. The complaint sat in state records. When inspectors pulled her clinical file in August 2025, more than a year and a half after she raised the alarm, they found care plans for other conditions but nothing for the colostomy.
A colostomy is a surgical opening in the abdomen that diverts waste into an external bag. Managing one requires regular emptying, cleaning, monitoring for changes in output and skin condition, and timely bag changes. The Assistant Director of Nursing told inspectors that the facility expected colostomy bags to be emptied, cleaned, monitored, and changed as appropriate, with accurate documentation, and that charge nurses and unit managers were responsible for coordinating care with physicians at the time of admission.
When inspectors pointed out that no care plan existed for Resident #98's colostomy, the ADON acknowledged there should have been one.
The Director of Nursing went further. He told inspectors that there should have been a physician order specifying how to monitor the ostomy site and color, the fecal output, how often the bag should be changed, and what size bag to use, along with nursing interventions in the care plan. None of that was in place when inspectors reviewed the record.
Resident #98 had been cognitively sharp enough to recognize that something was wrong, to know that her bag wasn't being changed, and to contact the state about it. The facility's response, as reflected in what inspectors found more than a year later, was a care plan that still didn't exist.
CMS rated both deficiencies as causing minimal harm or potential for actual harm, and noted that few residents were affected. The care plan failures fell under a standard requiring facilities to develop and implement comprehensive care plans for each resident's conditions.
What the inspection doesn't answer is how long Resident #20 went without documented interventions for an infectious disease that the facility's own protocol required isolation precautions to contain, or whether anyone at Chestertown Nursing and Rehab reviewed Resident #98's complaint in the months after she filed it and found her colostomy care plan before inspectors did.
The records suggest they did not.
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.
Download the official CMS inspection PDF from Medicare.gov
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: November 3, 2026 · Our methodology
CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD was cited for violations during a health inspection on August 13, 2025.
Federal inspectors documented both failures during an August 2025 complaint inspection 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.