Frostburg Rehab Center
1 Kaylor Circle, Frostburg, MD 21532 · Allegany County · 122 certified beds · avg 107 residents/day · certified since Dec 4, 1978
1/5
Health inspection rating (on-site)
1
Serious findings on record
$16,559
Fines, last 3 years
3.47
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Aug 13, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 30, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (51)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Aug 13, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 13, 2025 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| Aug 13, 2025 | F · Potential for harm, facility-wide | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint |
| Aug 13, 2025 | F · Potential for harm, facility-wide | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. |
| Aug 13, 2025 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Aug 13, 2025 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Aug 13, 2025 | E · Potential for harm, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Aug 13, 2025 | E · Potential for harm, repeated | The facility did not provide residents with enough to drink, or with drinks matching their needs and preferences, to keep them properly hydrated. · from a complaint |
| Aug 13, 2025 | E · Potential for harm, repeated | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. · from a complaint |
| Aug 13, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Aug 13, 2025 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Aug 13, 2025 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Aug 13, 2025 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Aug 13, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Aug 13, 2025 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Aug 13, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 13, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Aug 13, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Aug 13, 2025 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Aug 13, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Aug 13, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Aug 13, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Aug 13, 2025 | D · Potential for harm, one-off | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Aug 13, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 13, 2025 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Aug 13, 2025 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Sep 27, 2022 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Sep 27, 2022 | E · Potential for harm, repeated | The facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit. |
| Sep 27, 2022 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility admitted a resident without a doctor's order, or did not make sure each resident stayed under a doctor's ongoing care. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Sep 27, 2022 | D · Potential for harm, one-off | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (25 → 26).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 25 | 0 | E |
| 2025 | 26 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $16,559.
| Date | Type | Amount / length |
|---|---|---|
| Aug 13, 2025 | Fine | $16,559 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Maryland avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.47 | 3.83 | 3.95 | bottom 47% in Maryland; bottom 35% in the U.S. |
| Registered Nurse hours | 0.45 | 0.83 | 0.69 | bottom 10% in Maryland; bottom 30% in the U.S. |
| Weekend total nurse staffing | 3.10 | 3.43 | 3.50 | bottom 44% in Maryland; bottom 36% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.37 | 0.63 | 0.48 | bottom 22% in Maryland; bottom 47% in the U.S. |
| Total nursing staff turnover (%) | 63.7 | 40.2 | 45.8 | bottom 4% in Maryland; bottom 11% in the U.S. |
| RN turnover (%) | 41.7 | 38.7 | 42.9 | bottom 39% in Maryland; top 50% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.37, RN 0.44, weekend 3.01. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 2/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Glen Echo Holdings LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| MD Sans Holdings LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| MD Sans Mars 2024 Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| MD Sans Venus 2024 Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| Oberon Core Holdings | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| Zambry Holdings LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| Zambry Mars 2024 Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| Zambry Venus 2024 Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 03/01/2025 |
| Accord Consultants | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| Brand Sonnenschine LLP | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| Cibc Bank USA | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 03/01/2025 |
| Cibc Bank USA | Organization | Operational/Managerial Control | NOT APPLICABLE | 03/01/2025 |
| Cibc Bank USA | Organization | ADP of the SNF | NOT APPLICABLE | 04/02/2025 |
| Cline, Carrie | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2025 |
| Cline, Carrie | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| Collins, Elizabeth | Individual | Managing Control - Governing Body | NOT APPLICABLE | 03/01/2025 |
| Collins, Elizabeth | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2025 |
| Collins, Elizabeth | Individual | ADP of the SNF | NOT APPLICABLE | 05/14/2025 |
| Donald, Michael | Individual | Managing Control - Governing Body | NOT APPLICABLE | 03/01/2025 |
| Donald, Michael | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How many hours a day is a registered nurse physically in the building, including weekends?"
- "How often do you evaluate your nurse aides and what ongoing training do they receive?"
- "How do you decide you have enough staff and resources for your resident population, including nights and weekends?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "How do you make sure residents — especially those who can't ask — get enough fluids throughout the day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Mountain City Rehab Center | 1.5 mi | Frostburg, MD | ★☆☆☆☆ | 1/5 | abuse |
| Lions Rehab Center | 5.9 mi | Cumberland, MD | ★★☆☆☆ | 2/5 | |
| Devlin Manor Nursing and Rehabilitation Center | 6.7 mi | Cumberland, MD | ★★★☆☆ | 3/5 | |
| Egle Nursing Home | 6.8 mi | Lonaconing, MD | ★☆☆☆☆ | 3/5 | |
| Allegany Health Nursing and Rehab | 7.8 mi | Cumberland, MD | ★★★★☆ | 4/5 | |
| Cumberland Healthcare Center | 8.7 mi | Cumberland, MD | ★★☆☆☆ | 2/5 | |
| Complete Care at Dawnview LLC | 11.6 mi | Fort Ashby, WV | ★★★★☆ | 3/5 | |
| Moran Nursing and Rehabilitation Center | 12.5 mi | Westernport, MD | ★★☆☆☆ | 2/5 | abuse |
| Casselman Healthcare and Rehabilitation Center | 12.9 mi | Meyersdale, PA | ★★☆☆☆ | 2/5 | |
| Goodwill Mennonite Home, INC. | 13.7 mi | Grantsville, MD | ★★★★☆ | 3/5 | |
| Keyser Healthcare Center | 15.6 mi | Keyser, WV | ★★☆☆☆ | 2/5 | |
| Meadow View Nursing Center | 18.9 mi | Berlin, PA | ★★★☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 215115.