Chestertown Nursing And Rehab

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0550 during a standard health inspection conducted on 2025-08-13.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0582 during a standard health inspection conducted on 2025-08-13.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0584 during a standard health inspection conducted on 2025-08-13.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

F 0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Level of Harm - Minimal harm or potential for actual harm

Number of residents sampled:

Residents Affected - Few

Number of residents cited: Based on record review and interview, it was determined that the facility failed to ensure that a resident was free from abuse. This was evident for 1 (Incident #310745) of 3 Facility Reported Incidents (FRIs) reviewed

during the annual survey.The findings include:On 08/11/2025 at 10:34 AM, review of Incident #310745 investigation documentation revealed that on 4/20/25, Geriatric Nursing Assistant (Staff #34) observed bruises on Resident #24's right ankle. Further review of the investigation documentation revealed when Staff #34 asked Resident #24 about the bruising, he/she indicated that GNA was rough and aggressive with him/her on 4/19/25. On 08/11/2025 at 10:43 AM, review of the follow-up investigation report form revealed that the allegation was verified by the facility based on statements collected and physical findings.On 08/13/2025 at 8:39 AM, the surveyor reviewed the concern with the Nursing Home Administrator, who was aware that the allegation was verified by the facility.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chestertown Nursing and Rehab

415 Morgnec Road Chestertown, MD 21620

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0605 during a standard health inspection conducted on 2025-08-13.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

F 0609

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Level of Harm - Minimal harm or potential for actual harm

Number of residents sampled:

Residents Affected - Few

Number of residents cited: Based on record review and interview, it was determined that the facility failed to report an allegation of abuse within two hours. This was evident for 1 (Incident #310745) of 3 Facility Reported Incidents reviewed

during the annual survey.The findings include:On 08/11/2025 at 10:34 AM, review of Incident #310745 investigation documentation revealed that on 4/20/25 at 11:30 AM, Geriatric Nursing Assistant (Staff #34) observed bruises on Resident #24's right ankle. Further review of the investigation documentation revealed that on 4/20/25 at 11:30 AM, when Staff #34 asked Resident #24 about the bruising, he/she indicated that GNA was rough and aggressive with him/her on 4/19/25. On 08/11/2025 at 10:43 AM, review of the investigation documentation revealed that the facility failed to report the incident to the Office of Health Care Quality until 4/20/2025 at 1:10 PM.On 8/11/25 at 11:28 AM, the surveyor reviewed the concern with

the Nursing Home Administrator, she understood that the incident was not reported within two hours.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chestertown Nursing and Rehab

415 Morgnec Road Chestertown, MD 21620

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Number of residents sampled: Number of residents cited:

Residents Affected - Few Based on record reviews and interviews, it was determined that facility staff failed to ensure a thorough investigation was conducted for an allegation of staff to resident abuse and failed to maintain documentation. This deficient practice was evident for one resident (# 78) reviewed for facility reported investigations during the annual survey.The findings include:On 08/11/25, a review of the facility reported incident (FRI) # 310743 revealed that on 1/26/25, Resident #78 informed a nurse supervisor that a staff member made inappropriate comments while administrating medication on 01/24/25. The resident stated that the comments made them feel uncomfortable and embarrassed. A review of the facility's initial report form dated 01/27/25 indicated that the facility contacted the police. The alleged perpetrator was suspended,

a psychiatric nurse practitioner was requested to evaluate the resident, and social worker met with the resident to ensure the resident felt safe. In addition, statements were obtained from Resident #78, the alleged perpetrator, the nurse supervisor, and staff who were working at the time of the alleged incident.A

review of family nurse practitioner (NP) #37 progress note dated 01/28/25 indicated that NP #37 was requested to evaluate Resident #78 following an incident reported on 01/24/25. During the evaluation, the resident reported that a staff member exposed them, made inappropriate comments, and the incident made them feel embarrassed. NP #37 documented that that the resident's judgement and insight appeared intact.

NP #37 concluded that, in her professional opinion after speaking with the resident, the allegations appear to be example of the resident's attention seeking behaviors and her fantasies about relationships. A review of the resident's medical record did not show documentation of a prior history of such behavior. A review of Resident #78's psychiatric evaluation and consultation dated 01/17/25, indicates that the resident was seen at the request of the facility for medication management. During the examination, the resident was noted as calm, well-groomed and cooperative. The resident's thought process was listed as linear, logical, and goal directed, with no acute psychiatric features observed. Further review of psychiatric evaluation from 09/17/24 through 01/17/25 did not reveal a history of attention seeking behavior. In addition, there was no documentation indicating that the resident was evaluated following the incident on 01/24/25.On 08/11/25, a

review of the facility's follow-up investigation report form dated 01/30/25, indicated that the facility was unable to determine whether the incident actually occurred. The surveyor requested documentation to support the facility's conclusion, including evidence of the resident's behavioral concerns, documentation

the resident was evaluated by psychology in relation to the incident from 01/24/25, and records verifying that the social worker met with the resident daily as indicated on the follow up investigation report form.

During an interview with the Administrator (NHA), on 08/11/25 at 10:35 AM, the surveyor discussed the incident involving Resident #78 and asked about the basis of her conclusion regarding the incident. The NHA stated that her investigation was based on the nurse practitioners progress note. The surveyor explained that a review of Resident #78's care plan, progress notes, and psychiatric evaluations prior to the incident on 01/24/25 failed to reveal a history of attention seeking behavior, fantasies about relationships, or any other similar behaviors. The NHA acknowledged that she did not review the resident records and that her decision not to substantiate the incident was based on NP #37's progress note. On 08/11/25 at 11:06 AM, the Assistant Director of Nursing informed the surveyor that the facility was unable to provide the request

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chestertown Nursing and Rehab

415 Morgnec Road Chestertown, MD 21620

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0628 during a standard health inspection conducted on 2025-08-13.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0641 during a standard health inspection conducted on 2025-08-13.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Ensure each resident receives an accurate assessment.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0645 during a standard health inspection conducted on 2025-08-13.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: PASARR screening for Mental disorders or Intellectual Disabilities

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

treatment for C. diff and the physician was aware.On 08/05/2025 at 11:50 AM, review of the care plan did not show that Resident #20 had any care plan that addressed the ongoing infection.On 08/05/2025 11:57 AM in an interview with Licensed Practical Nurse (LPN) #17 in the presence of the Unit Manager Staff #5, when she was asked about Resident #20's recent health condition, she stated that the resident had C. Diff infection. When asked for the facility's protocol for a resident with such infection, she stated that such resident would be placed on contact/isolation precautions to keep the infection contained. When asked about the care plan for the ongoing infection, she stated that she would check. However, after reviewing the care plan, she acknowledged that no interventions were documented for the infection and stated that a care plan should have been in place.At 12:09 PM the same day, the [NAME] President of Clinical Operations (Staff #16) joined the interview. When asked about facility expectations regarding care planning for an active infection, she confirmed that a care plan should have been developed while the infection was ongoing.At 12:39 PM on the same day, in an interview with the Director of Nursing (DON), he stated that facility expectations include creating a care plan for any active diagnosis, including goals and interventions specific to the condition. He acknowledged that the omission of a care plan for Resident #20's C. Diff infection was a concern and confirmed that a care plan would be initiated immediately. 3) On 08/11/2025 at 7:12 AM, review of complaint 310701 showed that on 01/23/2024, Resident #98 filed a complaint with the state agency stating that his/her colostomy bag had not been changed. A review of the resident's clinical records by the surveyor revealed that the resident was originally admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED]. MDS admission review on 01/03/2024 indicated that the resident had a BIMS score of 14 out of 15, signifying that he/she was cognitively intact at the time of the complaint.On 08/11/2025 at 7:28 AM, a further review of Resident #98's medical records revealed that the resident had other care plans but there was no care plan seen for the colostomy.On 08/11/2025 at 11:15 AM, during an interview with the Assistant Director of Nursing (ADON), she stated that the facility's expectation for caring for a resident with

a colostomy was that the colostomy bag should be emptied, cleaned, monitored, and changed as appropriate, with accurate documentation. She further explained that attending physicians are contacted

during admission and that charge nurses or unit managers are responsible for reviewing admissions with physicians and obtaining orders for residents with colostomies. When informed that the resident did not have a care plan to care for the colostomy and asked if there should have been a care plan in place, the ADON acknowledged that there should have been a care plan in place to guide appropriate interventions.On 08/11/2025 at 1:15 PM, when the Director of Nursing (DON) was informed about the concerns with Resident #98's colostomy care, he stated that there should have been a physician order to monitor the site and color of the ostomy, the fecal output, the frequency of colostomy bag changes, and the size of the bag, along with a care plan specifying nursing interventions for colostomy care.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chestertown Nursing and Rehab

415 Morgnec Road Chestertown, MD 21620

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm

resident gets agitated, and wanders into residents’ rooms .When asked if the resident had a care plan in place for such behavior, she checked through the DON’s laptop and confirmed that Resident #69 did not have any care plan to address the behaviors. When she was asked what care plan she would have had in place for the resident, she stated that she would have included agitation and wandering into other resident’s rooms in the care plan update.

Residents Affected - Few At 12:12 PM on 08/07/2025, in an interview with the DON, he was asked about his expectations regarding updating a care plan after an incident, he stated that depending on the findings of the investigation, the care plan would be put in updated to reflect the incident, goals and intervention for the incident.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chestertown Nursing and Rehab

415 Morgnec Road Chestertown, MD 21620

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0658 during a standard health inspection conducted on 2025-08-13.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Ensure services provided by the nursing facility meet professional standards of quality.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-18.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0676 during a standard health inspection conducted on 2025-08-13.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0677 during a standard health inspection conducted on 2025-08-13.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide care and assistance to perform activities of daily living for any resident who is unable.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0684 during a standard health inspection conducted on 2025-08-13.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0686 during a standard health inspection conducted on 2025-08-13.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

F 0691

debridement.

Level of Harm - Minimal harm or potential for actual harm

On 08/11/2025 at 11:15 AM, review of the daily skilled nursing charts showed that the resident’s colostomy bag was changed on the following dates: 12/29/2023, 01/18/2024, 01/22/2024, 01/23/2024, 01/24/2024, 01/25/2024, 01/27/2024, 01/28/2024, 01/30/2024, and 02/22/2024. The last documented colostomy change was on 02/22/2024, which was also the last skilled nursing chart entry found in the resident’s electronic record. The resident was discharged from the facility on 03/20/2024, with no documentation available regarding colostomy bag changes between 02/22/2024 and discharge.

Residents Affected - Few

On 08/11/2025 at 12:21 PM, during an interview with the Assistant Director of Nursing (ADON), when asked for the facility’s expectation regarding caring for a resident with a colostomy, she stated that

the facility’s expectation for caring for a resident with a colostomy was that the colostomy bag should be emptied, cleaned, monitored, and changed as appropriate, with accurate documentation. When asked about physician involvement, she stated that attending physicians were contacted during admission and that charge nurses or unit managers were responsible for reviewing admissions with physicians and obtaining orders for residents with colostomies. When informed that the resident did not have an order for colostomy care, the ADON acknowledged that there should have been a physician order specifying colostomy care, including change times, and appropriate interventions.

On 08/11/2025 at 1:15 PM, when the Director of Nursing (DON) was informed about the concerns with Resident #98’s colostomy care, he stated that there should have been a physician order to monitor

the site and color of the ostomy, the fecal output, the frequency of colostomy bag changes, and the size of

the bag, along with a care plan specifying nursing interventions for colostomy care. When asked about his expectations for skilled nursing charting, he stated he would have expected daily documentation while the resident was under skilled services. He further explained that after the skilled days ended, the order for colostomy care should have been placed on the Treatment Administration Record (TAR) and documented as appropriate. When asked how often the colostomy bag should be changed, he stated it should be changed weekly or as needed (PRN) if soiled.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-08-13.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0697 during a standard health inspection conducted on 2025-08-13.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide safe, appropriate pain management for a resident who requires such services.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0711 during a standard health inspection conducted on 2025-08-13.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0725 during a standard health inspection conducted on 2025-08-13.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0730 during a standard health inspection conducted on 2025-08-13.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Observe each nurse aide's job performance and give regular training.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0732 during a standard health inspection conducted on 2025-08-13.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Post nurse staffing information every day.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0755 during a standard health inspection conducted on 2025-08-13.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0756 during a standard health inspection conducted on 2025-08-13.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0757 during a standard health inspection conducted on 2025-08-13.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure each resident’s drug regimen must be free from unnecessary drugs.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-13.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0791 during a standard health inspection conducted on 2025-08-13.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide or obtain dental services for each resident.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-13.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0842 during a standard health inspection conducted on 2025-08-13.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-13.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0883 during a standard health inspection conducted on 2025-08-13.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Develop and implement policies and procedures for flu and pneumonia vaccinations.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0887 during a standard health inspection conducted on 2025-08-13.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0921 during a standard health inspection conducted on 2025-08-13.

Category: Environmental Deficiencies

The facility was found deficient in the following area: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0925 during a standard health inspection conducted on 2025-08-13.

Category: Environmental Deficiencies

The facility was found deficient in the following area: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0944 during a standard health inspection conducted on 2025-08-13.

Category: Administration Deficiencies

The facility was found deficient in the following area: Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0945 during a standard health inspection conducted on 2025-08-13.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0946 during a standard health inspection conducted on 2025-08-13.

Category: Administration Deficiencies

The facility was found deficient in the following area: Provide training in compliance and ethics.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0947 during a standard health inspection conducted on 2025-08-13.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.

Federal health inspectors cited CHESTERTOWN NURSING AND REHAB in CHESTERTOWN, MD for a deficiency under regulatory tag F-F0949 during a standard health inspection conducted on 2025-08-13.

Category: Administration Deficiencies

The facility was found deficient in the following area: Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 41 deficiencies cited during this inspection of CHESTERTOWN NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-01.