Frostburg Rehab Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

of a nursing note, written by Nurse #31 and dated 4/25/23 at 4:35 PM revealed that in the morning, the nurse heard another resident yell for help, nurse observed Resident #119 attempting to talk to the other resident and push into the room, Resident #119 thought the other resident was their spouse and was going to assist the other resident to bed. 1:1 given able to redirect res long enough to remove other res from area.

this writer managed to assist res to w/c. res at that time grabbed this writers hand attempting bite. res swinging at staff, res charged this writer nearly falling. res redirected and toileted. res making statements I'm going to kill you. Give me a gun because I am going to shoot you. res appears drowsy, res unable to ambulate in hallway knees buckling, staff assisted res to bed res unable at that time to amb [ambulate walk] on own. res cont [continue] to punch staff in stomach and several attempts to hold hand to bite. The note went on to state that the resident then slept until 3:00 PM, was given medications at that time and was at the time of the note sitting calmly in a wheelchair.No documentation was found to indicate the primary care physician, or the psychiatric provider were made aware on 4/25/23 of the resident's attempts to bite staff or the threatening statements made by the resident.Further review of the medical record revealed the resident was seen by the psychiatric provider on 4/26/23. Review of the corresponding note failed to reveal documentation to indicate the psychiatric provider was aware of the attempts to bite staff, or the verbal threats.On 8/08/25 at 1:19 PM surveyor reviewed the concern with the Director of Nursing of multiple documentation of incidents of the resident being aggressive with staff and residents but no indication that MD was notified on day of occurrences. As of time of survey exit on 8/13/25 at 11:30 AM no additional documentation was provided regarding notifications.Cross reference to F 600

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Facility ID:

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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

Frostburg Rehab Center

1 Kaylor Circle Frostburg, MD 21532

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 FROSTBURG VILLAGE REHAB CENTER in FROSTBURG, 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 26 deficiencies cited during this inspection of FROSTBURG VILLAGE REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-30.

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

a need for assistance with personal care. On 4/29/23 Resident #95 sustained a small scratch 0.4 cm in diameter on the left side of the neck from Resident #119.

On 8/8/25 at 12:15 PM an interview was conducted with the unit nurse manager (Nurse #2) about aggressive residents. When asked if there was an aggressive resident who was sent to the emergency room but then returned with no change in treatment, would they do anything different? Nurse #2 responded that they would look at doing every 15-minute checks or a 1:1. She went on to report a recent incident in which a resident pushed another resident down and they were going to implement a 1:1.

On 8/8/25 at 1:19 PM surveyor reviewed the concern with the Director of Nursing (DON) that the resident was having aggressive behaviors and no documentation to indicate an increase in supervision, even after

the resident was sent to the hospital for these behaviors. DON indicated he would check if there was documentation to indicate an increase in supervision after the hospitalization. The DON went on to report

they have a hard time with the locale hospital just giving Haldol and then sending the residents back rather than admitting to psychiatric unit. He reported a recent incident of this occurring and they had a 1:1 until the resident was transferred out.

On 8/13/25 at 8:40 AM the surveyor reviewed the concern regarding the facility's failure to protect resident to resident abuse in regard to the incident involving Resident #119 and #95. As of time of survey exit on 8/13/25 at 11:30 AM no additional documentation was provided to indicate additional supervision of Resident #119 was ordered or provided.

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

Frostburg Rehab Center

1 Kaylor Circle Frostburg, MD 21532

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

During an interview on 8/7/2025 at 10:17 AM, the Nursing Home Administrator stated that she had signed off on the concern form, indicating she was aware of the issue, but did not view it as an abuse allegation

before the surveyor’s intervention. 3) A review of the facility reported incident #358490 revealed that on 4/08/25 Resident #87 was observed

on the floor next to his/her bed and with a laceration to the head. The report included a statement that indicated that no witnesses were able to verify the alleged incident. The resident was transferred to a local hospital emergency room for sutures.

Further review revealed that staff became aware of the resident’s injury on 4/08/25 at 11:30 PM, and that the Director of Nursing (DON) was notified on 4/08/25 at 11:35 PM. Further review of the initial report revealed that the report of the injury of unknown origin was submitted to the Office of Health Care Quality (OHCQ) on 4/10/25 at 11:00 AM.

On 8/12/25 at 10:34 AM in an interview with the Director of Nursing (DON), he was asked about the initial report timeframe, which was two days after the incident. He said he was not sure why he did not report it sooner and acknowledged that it was reported later than the regulation required.

No further evidence was provided prior to the end of the survey.

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

Event ID:

Facility ID:

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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

Frostburg Rehab Center

1 Kaylor Circle Frostburg, MD 21532

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 Level of Harm - Minimal harm or potential for actual harm

on the floor in the hallway on 1/25/25 and was injured. The resident was sent to the emergency room where

it was determined that he/she had a fractured tibia. The report further stated that there were no witnesses, no perpetrator was identified, that both the resident and the resident’s roommate were deemed incapable, and that staff who were on duty the day the injury was identified were interviewed and none had knowledge of the injury.

Residents Affected - Some

A review of the facility’s investigation file revealed a witness statement written 1/25/25 at 2:00 pm by Staff #38 which indicated that she was the nurse who cared for the resident that day and that the resident refused to get out of bed, was assessed in the morning with no abnormal findings, but around noon/lunch time the resident complained of pain, the doctor was notified, an x-ray was ordered, and pain medication was administered.

Further review of the facility’s investigation file failed to reveal any other staff witness statements from that day. The file lacked evidence that other residents were interviewed or assessed. There were no staff assignment sheets or resident census documents to identify staff and residents who were present on that day. There was no documentation of Resident #107’s physical assessment other than the staff witness statement.

On 8/11/25 at 3:45 PM in an interview with the Director of Nursing (DON), he provided an explanation for how the resident’s injury occurred but acknowledged that this information was not included in the investigation file nor in the resident’s medical records. He confirmed the deficiency that the facility’s investigation was incomplete.

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

Event ID:

Facility ID:

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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

Frostburg Rehab Center

1 Kaylor Circle Frostburg, MD 21532

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 FROSTBURG VILLAGE REHAB CENTER in FROSTBURG, 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 26 deficiencies cited during this inspection of FROSTBURG VILLAGE REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-30.

F 0641

reflected that Resident #5 did not use BiPAP therapy.

Level of Harm - Minimal harm or potential for actual harm

In an interview on 8/7/2025 at 8:33 AM, the MDS nurse Coordinator (Staff #14) confirmed that she is responsible for completing section O on the MDS. Staff #14 verified that BiPAP therapy was not reflected on

the MDS and confirmed that there was an order for BiPAP as of 3/31/25. She acknowledged the MDS was coded inaccurately.

Residents Affected - Few

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

Frostburg Rehab Center

1 Kaylor Circle Frostburg, MD 21532

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 FROSTBURG VILLAGE REHAB CENTER in FROSTBURG, MD for a deficiency under regulatory tag F-F0655 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: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

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 26 deficiencies cited during this inspection of FROSTBURG VILLAGE REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-30.

F 0684

On 8/7/25 at 10:09 AM, LPN #12 acknowledged that the mattress was set for a weight interval of 220-290 and that she had adjusted the weight interval to 150-220 after surveyor intervention.

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

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

Frostburg Rehab Center

1 Kaylor Circle Frostburg, MD 21532

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 0689

showed the surveyor the Kardex which also indicated the required assistance for transfers, noting that she checks to verify that the information from the two matched.

Level of Harm - Actual harm Residents Affected - Few

Resident #104’s information was reviewed with GNA #18. She reported that the resident was a full lift for all transfers and indicated that it meant she would need to use a mechanical lift to perform the transfer and required two staff members to complete the task.

On 8/7/25 at 3:53 PM, the DON was interviewed about the incident. He confirmed that per his investigation, GNA #36 failed to secure assistance from another staff to safely transfer a dependent resident. He reported that the facility’s initial plan was to bring GNA #36 back for education about transfers but when the incident was forwarded and reviewed by corporate staff, they instructed the facility to terminate GNA #36.

He also reported that the facility did a whole house education but did not include it in the investigation documents. He stated, “I keep a soft file in my office” and indicated that he would provide the surveyor with evidence that all clinical staff were educated on transfers.

On 8/7/25 at 4:34 PM, the DON provided the surveyor with the attendance sheets for the employee education that included transfers as one of the topics, dated 2/25/25.

A review of the attendance sheets was conducted on 8/8/25 at 12:15 PM. The review revealed that not all clinical staff attended the education.

A subsequent interview with the DON was conducted on 8/8/25 at 12:53 PM. During the interview, the DON reported again that all clinical staff attended the education. He added, “if they failed to attend, they would have been written up.” The finding that not all clinical staff attended the education was discussed and the DON was asked if he had a list of staff who failed to attend. He indicated Human Resource (Staff #9) can give him that information.

On 8/11/25 at 9:23 AM, Staff #9 printed a list of staff who failed to attend the education regarding transfers.

The list consisted of 7 nurses and 4 GNA’s. Staff #9 was asked if staff on the list were written up for not attending and she answered, “No.”

A review of GNA #36’s employee record was conducted on 8/11/25 at 12:13 PM. The review revealed the last education regarding transfer was done on 1/13/21 and last performance evaluation was dated 9/5/22. There was no other documentation found to indicate a performance evaluation was conducted

in the last 2 years.

On 8/13/25 at 8:43 AM, the findings were reviewed with the Nursing Home Administrator (NHA) and the DON, and the concern was discussed that GNA #36 had failed to follow the appropriate transfer status of a resident resulting in harm as evidenced by Resident #104’s lower leg fracture. Also, there was no evidence to indicate that all clinical staff were educated on transfers after the 2/20/25 incident with Resident #104. Both staff acknowledged the concern.

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

Frostburg Rehab Center

1 Kaylor Circle Frostburg, MD 21532

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 0695

Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

Based on observations, record review and staff interviews, it was determined that the facility failed to administer oxygen as ordered by the physician. This was evident for 1 resident (Resident #5) reviewed as a complaint, #358479, during this survey.The findings include: Oxygen therapy is the administration of oxygen at concentrations greater than that in room air with the intent of treating or preventing hypoxia- low oxygen level in the blood.On 8/6/25 at 11:00 AM this surveyor observed Resident #5 lying in bed with oxygen (O2) via nasal canula (NC) at 4 liters (L). In an interview, Licensed Practical Nurse (LPN #10) confirmed O2 NC at 4L. On 8/7/25 5:49 AM a record review of Resident #5's Treatment Administration Record (TAR) revealed: Respiratory: Oxygen - Continuous at 5L NC every shift for Respiratory Failure. On 8/7/25 at 5:53 AM A record review of physician orders revealed 5Liters (L) oxygen (O2) continuous via nasal cannula (NC) every shift for Respiratory Failure.On 8/7/25 at 7:11 AM this surveyor observed Resident #5 asleep with 4L O2 NC. On 8/7/25 at 7:45 AM in an interview, LPN #12 confirmed Resident #5's oxygen was O2 NC at 4L.

LPN #12 acknowledged the oxygen order was 5L NC.On 8/7/25 at 8:07 AM a second surveyor confirmed O2 at 4L NC.

Residents Affected - Few

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

Event ID:

Facility ID:

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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

Frostburg Rehab Center

1 Kaylor Circle Frostburg, MD 21532

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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Based on review of medical records and other pertinent documentation, and interviews it was determined that the facility failed to ensure staff had adequate training. This was evident for one geriatric nursing assistant (GNA #25) out of two GNAs reviewed for mechanical lift training.The findings include: A review of Resident #45's clinical record revealed that they were admitted to the facility in 2022 and they required assistance to transfer from bed to wheelchair.A review of the facility's mechanical lift policy titled Lifting Machine, Using a Mechanical, revealed the statement that read, in part, that when lowering the resident, care should be taken ensure the sling bar did not hit the resident. On 8/06/2025 at 3:28 PM a record review of Resident #45's medical record revealed a progress note written on 7/10/25 by Licensed Practical Nurse (Staff #23) which described an incident when the resident developed a forehead hematoma (bruise) when

they were hit on the forehead by the mechanical lift while being transferred into the wheelchair. The note explained that 2 Geriatric Nursing Assistants (GNA) assisted the resident with the transfer.On 8/07/2025 at 11:10 AM an interview was conducted with the unit manager Staff #2 to review the incident. When asked about the incident she said that GNAs were trained to use the mechanical lift but that she herself did not provide the training. She was asked to provide evidence of training for the two GNAs (Staff #24, Staff #25) who assisted the resident during the incident,.On 8/07/2025 at 11:57 AM Staff #2 brought training documents for Staff #24 and Staff #25. A review of Staff #25's training competency checklist revealed that it was a self-evaluation. There was no evidence that Staff #25 had received training in the use of a mechanical lift or that she had been deemed competent to perform a transfer with a mechanical lift.On 8/07/2025 at 12:03 PM an interview with Human Resources Director, Staff #9 was conducted to review the GNA training records for Staff #25. Staff #9 reviewed the document and concurred that the documents did not show evidence of training or competency. When asked for further evidence, Staff #9 replied that Staff #25 was an agency GNA and that there were no other training documents available.On 8/07/2025 at 12:43 PM the Director of Nursing confirmed that documentation in the resident's medical record confirmed that

the mechanical lift bar hit the resident in the head and resulted in a bruise, and he also confirmed that there was no evidence that Staff #25 was competent to use the mechanical lift.

Event ID:

Facility ID:

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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

Frostburg Rehab Center

1 Kaylor Circle Frostburg, MD 21532

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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis.

Based on review of pertinent documentation and interviews it was determined that the facility failed to ensure a registered nurse was working for at least 8 consecutive hours every day. This was found to be evident for 3 out of 16 weekends of staffing reviewed during the survey but has the potential to affect all residents.The findings include: On 8/11/25 surveyor reviewed the staffing sheets for the weekends during January, February and March of 2025, as well as the staffing sheets for 7/15 -7/30/25 for the presence of a registered nurse (RN). These schedules reflected 24 hour periods that started and ended at 7:00 AM. The nurses usually worked 12 hour shifts, either day shift 7:00 AM to 7:00 PM or night 7:00 PM to 7:00 AM.Review of the Friday 1/10/25 staffing sheet failed to reveal an RN on duty for the night shift.Review of

the Saturday 1/11/25 staffing sheet failed to reveal an RN on duty for the day or night shift.Review of the Sunday 1/12/25 staffing sheet failed to reveal an RN on duty for the day or night shift.This represents a continuous 60 hours without an RN working in the building.Review of the 7/25/25 staffing sheet failed to reveal an RN on duty for the day or night shift.Review of the 7/26/25 staffing sheet failed to reveal an RN on duty for the day or the night shift. A separate report provided by the facility for hours worked per patient day (PPD) included documentation to indicate the Director of Nursing (DON) had worked for 4 hours on 7/26/25. An interview with the DON on 8/11/25 at 3:01 PM revealed that he has worked on the floor a couple of times and indicated that he recently had worked from 11:00 AM to 3:00 PM to cover the medication cart. When DON was told this was in regard to Saturday 7/26, the DON responded that he probably came in to help out on the weekend. On 8/11/25 at 3:32 PM surveyor reviewed with the Nursing Home Administrator the above findings for July 25 and 26, and January 11 and 12. On 8/12/25 surveyor requested the staffing sheets for 8/9 and 8/10/25.Review of the Saturday 8/9/25 staffing sheet failed to reveal an RN on duty for the day or night shift.Review of the Saturday 8/10/25 staffing sheet failed to reveal

an RN on duty for the day shift.On 8/12/25 at 11:28 AM the Human Resources Director confirmed that this past weekend there was no RN coverage from Saturday 8/9 at 7 AM until Sunday 8/10 at 7:00 PM.This represents a 36 hour period with no RN in the facility.On 8/13/25 at 8:40 AM surveyor informed the NHA of

the concern regarding multiple days when the facility failed to ensure an RN was working for 8 consecutive hours, including this past weekend.

Event ID:

Facility ID:

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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

Frostburg Rehab Center

1 Kaylor Circle Frostburg, MD 21532

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 0730

Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or potential for actual harm

Based on review of pertinent documentation and interviews it was determinted that the facility failed to ensure annual evaluations were being completed for geriatric nursing assistants (GNA). This was found to be evident for three (GNA #48, #18 and #49) out of three GNAs who were selected for review of annual training.The findings include: Review of a list of employees with their hire dates revealed GNA #48 was hired in March of 2023; GNA #18 was hired in June of 2004; and GNA #49 was hired in March of 2021. On 8/7/25 surveyor requested from the Human Resource Director documentation of the the annual evaluations for these three GNAs.On 8/11/25 review of the documentation provided failed to reveal documentation to indicate an annual review had been completed for GNA #48. The most recent Annual Performance Appraisal for GNA #18 was dated 8/13/22. The most recent Annual Performance Appraisal for GNA #49 was dated May 2023.On 8/11/25 at 11:55 AM the Human Resource Director reported she generates a list of who suppose to get an evaluation and sends it to nursing and then it is nursing's responsibility to complete them. She confirmed that GNA #48 has not had an evaluation; and that the most recent evaluations for GNA #18 and #49 were completed prior to 2024.On 8/13/25 at approximately 8:45 AM surveyor review the concern with the Nursing Home Administrator and the Director of Nursing regarding the failure to ensure evaluations are being completed annually for GNAs.Cross reference to F 689

Residents Affected - Many

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

Frostburg Rehab Center

1 Kaylor Circle Frostburg, MD 21532

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 FROSTBURG VILLAGE REHAB CENTER in FROSTBURG, 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 C: pattern, no actual harm with potential for minimal harm.

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

This was one of 26 deficiencies cited during this inspection of FROSTBURG VILLAGE REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-30.

Federal health inspectors cited FROSTBURG VILLAGE REHAB CENTER in FROSTBURG, 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 26 deficiencies cited during this inspection of FROSTBURG VILLAGE REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-30.

Federal health inspectors cited FROSTBURG VILLAGE REHAB CENTER in FROSTBURG, 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 26 deficiencies cited during this inspection of FROSTBURG VILLAGE REHAB CENTER.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2025-09-30.

F 0760

Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or potential for actual harm

Based on medical record review and interview it was determined that the facility failed to ensure residents were free from significant medication errors. This was found to be evident for one (Resident #114) of 15 residents reviewed for potential abuse.The findings include: Review of Resident #114's medical record revealed the resident was admitted to the facility in 2023 with diagnosis that included, but not limited to, dementia and high blood pressure. The resident had an order for Metoprolol extended release 25 mg give one tablet one time a day related to hypertension (high blood pressure) and to Hold if the pulse (heart rate) was less than 60 or if the SBP(systolic blood pressure - the top number of a blood pressure reading) was less than 130. This order was in effect from 9/26/24 until it was discontinued on 3/28/25.Review of the March 2025 Medication Administration Record (MAR) revealed the metoprolol was administered on the following dates when the blood pressure and or heart rate were within the parameters to hold the medication:3/1 SBP was 1263/6 SBP was 121; HR: 553/10 SBP was1263/15 SBP was 1263/16: SBP 1263/22: SBP was 124 On 8/8/25 at 2:16 PM the Director of Nursing reported that he expects staff to follow

the parameters that are included in orders for a medication. Surveyor reviewed the concern the metoprolol was administered on 6 occasions in March when, based on the ordered parameters, the medication should of been held. On 8/13/25 at 8:40 AM surveyor reviewed the concern regarding the failure to keep the resident free from a significant medication error with the Nursing Home Administrator.

Residents Affected - Few

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

Frostburg Rehab Center

1 Kaylor Circle Frostburg, MD 21532

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 FROSTBURG VILLAGE REHAB CENTER in FROSTBURG, 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 26 deficiencies cited during this inspection of FROSTBURG VILLAGE REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-30.

F 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Based on a review of pertinent documents, observations and interviews, the facility failed to have a place to ensure residents were provided with water and other fluids to support their hydration and preferences. This was evident in two out of three units reviewed for dining during the survey.The Findings include:On 8/06/25 at 2:30 PM, a review of resident council minutes revealed that residents reported they were not receiving ice or water between the hours of 11:00 PM and 7:00 AM In addition review of complaint #358470 8/11/25 revealed a concern that the residents were not provided water. On 8/07/25 at 5:32 AM, a nighttime

observation was conducted from 4:00 AM to 5:15 AM. The observation revealed that GNA Staff #19 and Hospitality Aide (Staff #21) were in the process of delivering water to residents. Staff #19 reported typically beginning water delivery around 5:00 AM.On 8/07/25 at 4:28 AM, an observation in Resident #92's room revealed an empty cup of water with the date 8/6 written on the top rim.On 8/07/25 at 4:29 AM, an

observation in Resident #73's room revealed a cup with a small amount of water remaining and no date written on the top.On 8/07/25 at 4:38 AM, the above observations were confirmed by GNA Staff #4.On 8/07/25 at 4:49 AM, an observation in Resident #129's room revealed an empty cup on the bedside table.

Continued observation failed to reveal any additional water containers in the room.On 8/07/25 at 4:52 AM,

an observation in Resident #49's room revealed a cup on the bedside table containing a small amount of brown liquid.At 4:52 AM, a brief interview was conducted with Resident #49, who was noted to have no documented cognitive decline. The resident reported that the cup had contained Pepsi from the previous day and that no water had been provided on 8/06/25.On 8/07/25 at 4:54 AM, an observation in Resident #83's room revealed a single cup with a very small amount of water and the date 8/5 written on the top.On 8/07/25 at 4:56 AM, the observations for Residents #49 and #83 were confirmed by GNA Staff #3.On 8/07/25 at 7:44 AM, an interview was conducted with the Administrator and the Director of Nursing (DON).

Both reported recent experience working the night shift and familiarity with the 11:00 PM - 7:00 AM water distribution process. The DON stated an understanding that new water cups were dated and distributed around 5:00 AM to ensure residents had water for the morning pass. The Administrator stated an understanding that new cups were distributed at the beginning of the night shift to ensure residents had access to water throughout the night. Both confirmed there was no consistent procedure in place to ensure residents received water to support hydration.

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

Frostburg Rehab Center

1 Kaylor Circle Frostburg, MD 21532

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 FROSTBURG VILLAGE REHAB CENTER in FROSTBURG, MD for a deficiency under regulatory tag F-F0809 during a complaint investigation conducted on 2025-08-13.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Scope/Severity Level E: pattern, 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 26 deficiencies cited during this inspection of FROSTBURG VILLAGE REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-30.

Federal health inspectors cited FROSTBURG VILLAGE REHAB CENTER in FROSTBURG, MD for a deficiency under regulatory tag F-F0838 during a standard health inspection conducted on 2025-08-13.

Category: Administration Deficiencies

The facility was found deficient in the following area: Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

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 26 deficiencies cited during this inspection of FROSTBURG VILLAGE REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-30.

Federal health inspectors cited FROSTBURG VILLAGE REHAB CENTER in FROSTBURG, 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 26 deficiencies cited during this inspection of FROSTBURG VILLAGE REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-30.

Federal health inspectors cited FROSTBURG VILLAGE REHAB CENTER in FROSTBURG, MD for a deficiency under regulatory tag F-F0868 during a standard health inspection conducted on 2025-08-13.

Category: Administration Deficiencies

The facility was found deficient in the following area: Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

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 26 deficiencies cited during this inspection of FROSTBURG VILLAGE REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-30.

Federal health inspectors cited FROSTBURG VILLAGE REHAB CENTER in FROSTBURG, 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 26 deficiencies cited during this inspection of FROSTBURG VILLAGE REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-13.

Federal health inspectors cited FROSTBURG VILLAGE REHAB CENTER in FROSTBURG, MD for a deficiency under regulatory tag F-F0919 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 a working call system is available in each resident's bathroom and bathing area.

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 26 deficiencies cited during this inspection of FROSTBURG VILLAGE REHAB CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-30.