Frostburg Rehab: Aide Breaks Resident's Leg - MD
Resident 104 was classified as a "full lift" patient at Frostburg Rehab Center, meaning all transfers required a mechanical lift device and two staff members to complete safely. The resident's care plan and Kardex both documented these requirements.
On February 20, 2025, nursing aide GNA 36 attempted the transfer alone.
The resident suffered a lower leg fracture.
Director of Nursing interviews revealed the facility initially planned to bring GNA 36 back for transfer education. Corporate staff intervened and ordered the aide's termination instead.
"I keep a soft file in my office," the director told inspectors, promising evidence that all clinical staff received transfer education following the incident.
The director provided attendance sheets from February 25, 2025, showing facility-wide education that included transfers as a topic. He insisted all clinical staff attended.
"If they failed to attend, they would have been written up," he said.
Inspection records told a different story.
Eleven clinical staff members never attended the mandatory transfer education. The list included seven nurses and four nursing aides. None received disciplinary action for missing the training.
"No," Human Resources Staff 9 confirmed when asked if absent employees were written up.
GNA 36's employment record revealed additional gaps in training and oversight. The aide's last transfer education occurred January 13, 2021 — more than four years before the incident. The most recent performance evaluation was dated September 5, 2022.
No performance evaluation had been conducted in the two years preceding the resident's injury.
The facility's investigation documents contained no evidence of the promised facility-wide education. When pressed about staff who missed training, the director referred inspectors to Human Resources for a list of absent employees.
The director acknowledged during final interviews that GNA 36 had failed to follow proper transfer procedures, directly causing Resident 104's lower leg fracture. He also admitted the facility had no evidence that all clinical staff received transfer education after the February incident.
Federal inspectors classified the violation as causing actual harm to residents, affecting few patients but demonstrating systematic failures in staff training and supervision protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Frostburg Rehab Center 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
FROSTBURG REHAB CENTER in FROSTBURG, MD was cited for violations during a health inspection on August 13, 2025.
The resident's care plan and Kardex both documented these requirements.
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.