Dennett Rehab Center: Narcotic Log Falsification - MD
That was when managers at Dennett Rehab Center, a nursing home on Mary Drive in this small western Maryland city, first noticed the controlled substance records on one of their units weren't adding up. They didn't act immediately. They came back five days later, on February 17, and started pulling signatures.
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See the Derila PillowWhat they found was that one of the signatures on the narcotic logs didn't belong to the nurse whose name it carried. Someone had signed for her. Then they looked closer and found pages missing, and then they found that those missing pages had been remade, reconstructed after the fact by the same nurse, LPN #14.
She was fired on February 21.
The Director of Nursing described the sequence to a federal inspector on March 5 at 10:37 in the morning. The forged signature, she said, was "the straw." Once they saw it, everything else followed: the gaps in the paper trail, the recreated documents, a record that had been altered to hide whatever had happened to the medications themselves.
The inspection report does not say what happened to the controlled substances. It does not say how many pills were unaccounted for, which residents had been prescribed them, or whether anyone was harmed. The level of harm is listed as minimal harm or potential for actual harm, and the number of residents affected is listed as few.
What the report does describe is a facility that moved quickly once it understood what it was looking at, and a paper trail that had been carefully manipulated before anyone thought to look.
Controlled substance logs at nursing facilities exist for exactly this reason. Every pill is supposed to be counted at every shift change, with two nurses signing off together. The count sheets are supposed to stay in their binders until management collects them. Mistakes get a single line through them, initials, the word "error," and the correct number written beside it. You do not write over numbers. You do not scratch anything out.
LPN #14 did not follow that process. She remade pages entirely.
The facility held an all-staff education session on February 28, three days before federal inspectors arrived. Every nurse signed the log. A new narcotic tracking system had already been put in place.
When inspectors reviewed the narcotic logs on the 100 unit on March 3 with the Assistant Director of Nursing, they found no holes, no discrepancies, nothing missing for February or March. An agency nurse, LPN #9, explained the counting process the following morning: you count the cards, count the pills in the card, and sign with another nurse. If something doesn't match, you recount, you search for the medication, and you report immediately to the ADON or DON.
That is the process as it is supposed to work. For some stretch of time before February 12, it did not.
The inspection report does not name the residents whose medications were logged during the period in question. It does not say whether the discrepancies covered days or weeks. It does not say whether law enforcement was notified, whether a pharmacy audit was conducted, or whether the residents involved were told anything had gone wrong with their controlled substance records.
What it says is that a nurse forged a colleague's signature, that pages disappeared and then reappeared in altered form, and that managers terminated her nine days after they started looking.
The facility's plan of correction was not included in the inspection materials reviewed. For information on how Dennett Rehab Center intends to address this deficiency, the Centers for Medicare and Medicaid Services directs the public to contact the nursing home or the state survey agency directly.
The residents on that unit, the ones whose narcotic records were falsified and remade, are still there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dennett Rehab Center from 2025-03-05 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 13, 2026 · Our methodology
DENNETT REHAB CENTER in OAKLAND, MD was cited for violations during a health inspection on March 5, 2025.
They came back five days later, on February 17, and started pulling signatures.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.