Frostburg Rehab: Staff Failed to Report Violent Threats - MD
The incident unfolded on April 25, 2023, when Nurse 31 heard another resident yelling for help. The nurse found Resident 119 trying to push into the room, mistaking the distressed person for their spouse.
"Res thought the other resident was their spouse and was going to assist the other resident to bed," the nursing note stated. Staff provided one-on-one supervision and managed to redirect the resident long enough to remove the other person from the area.
What happened next escalated quickly. As the nurse helped the resident into a wheelchair, "res at that time grabbed this writers hand attempting bite."
The resident began swinging at staff. They charged toward the nurse, nearly falling in the process. Staff redirected the resident to the bathroom for toileting, but the aggressive behavior continued.
"Res making statements I'm going to kill you. Give me a gun because I am going to shoot you," the nurse documented in real time.
The resident's physical condition deteriorated during the episode. They appeared drowsy and couldn't walk independently in the hallway, with their knees buckling. Staff had to assist them to bed because they were unable to ambulate on their own.
Even then, the violence didn't stop. The resident "cont to punch staff in stomach and several attempts to hold hand to bite," according to the nursing notes written at 4:35 PM that day.
The resident finally slept until 3:00 PM, received medications, and was sitting calmly in a wheelchair when the nurse completed the documentation.
But nobody called the doctors.
Federal inspectors found no documentation indicating the primary care physician or psychiatric provider were made aware of the resident's attempts to bite staff or the death threats on April 25. The resident had exhibited multiple previous incidents of aggression with both staff and other residents, yet doctors consistently remained uninformed on the day these episodes occurred.
The psychiatric provider did see the resident the next day, April 26. However, the corresponding clinical note revealed the provider had no knowledge of the biting attempts or verbal threats from the previous day's violent episode.
When surveyors questioned the Director of Nursing on August 8, 2025, about the pattern of undocumented physician notifications following aggressive incidents, facility leadership couldn't produce evidence that proper protocols had been followed.
The inspection team gave administrators five additional days to provide documentation showing doctors had been notified appropriately. By the time surveyors completed their review on August 13 at 11:30 AM, no additional records had been provided.
The failure represents a breakdown in basic communication protocols for psychiatric patients experiencing behavioral crises. When residents make specific death threats against staff members and attempt to bite workers during episodes of confusion and aggression, immediate physician notification allows for medication adjustments, behavioral interventions, or emergency psychiatric evaluation.
The resident's physical symptoms during the April 25 episode — drowsiness, inability to walk independently, knee buckling — combined with the violent outbursts suggested a possible medical emergency requiring prompt clinical assessment.
Instead, the psychiatric provider arrived for a routine appointment the following day with no knowledge that their patient had spent the previous afternoon threatening to kill staff members and physically attacking nurses.
The documentation gap left the resident without appropriate medical intervention for over 24 hours following a significant behavioral crisis. It also left staff members vulnerable to continued violence without physician guidance on managing the resident's aggressive episodes.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. The citation cross-referenced additional deficiencies in the facility's notification procedures.
Frostburg Rehab Center operates at 1 Kaylor Circle in Frostburg, Maryland. The facility's failure to maintain proper physician communication protocols during psychiatric emergencies raises questions about staff safety and appropriate medical oversight for residents experiencing behavioral crises.
The resident who made death threats and attempted to bite multiple staff members during the April 2023 episode continues to live at the facility.
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 incident unfolded on April 25, 2023, when Nurse 31 heard another resident yelling for help.
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.