Dennett Rehab: Nurse Stole Narcotics from Patients - MD
The drug diversion scheme began unraveling in January when a family brought their relative's medications home after discharge, only to discover the Ativan bottle no longer contained the prescribed sedative. Instead, they found metformin, a diabetes medication.
The family called the facility to complain. Administrators investigated but couldn't determine if medications had been switched, according to the March 5 inspection report. They implemented new policies for residents bringing medications from home and increased audits of narcotic logs.
Those audits revealed a pattern.
"A pattern of incorrect documentation, missing forms, missing medication, and false documentation was identified by DON and ADON and later identified to only occur on the days when staff LPN #14 worked and completed the forms," the Assistant Director of Nursing told inspectors. "They realized that the pharmacy sheets that came in and out were not matching and they found a pattern only where this specific nurse worked."
The investigation found LPN #14 had taken Tramadol from one resident and Gabapentin from another. Tramadol treats moderate to severe pain. Gabapentin treats nerve pain and seizures.
When questioned, the nurse initially denied wrongdoing but admitted to forging another nurse's signature on pharmacy narcotic forms, inspection records show.
The Director of Nursing told inspectors that around February 12, "something seemed off." When administrators audited records on February 17, they discovered what appeared to be a forged signature. "That was the straw," the DON said. They realized papers were missing and others had been remade by LPN #14.
The facility terminated LPN #14 on February 21.
Administrators held an emergency quality meeting on January 13 to address the drug diversion. New protocols required two nurses to sign for all narcotics entering the building from the pharmacy. Only management could destroy controlled medications. Staff had to complete shift-to-shift count sheets every time narcotic keys changed hands, even for lunch breaks.
The facility also mandated black ink only for narcotic logs. Staff could no longer scratch out or write over mistakes. Instead, they had to cross out errors with one line, initial them, write "error," and record the correct information.
All nurses received education on the new protocols by February 28, according to facility records.
But drug diversion wasn't the only violation inspectors found.
On March 3, an inspector observed three staff members providing care to a resident without proper protective equipment, despite an "Enhanced Barrier Precaution" sign on the room door.
Resident #39 was receiving nutrition through a gastrostomy tube when the inspector arrived. The resident was "very active and not responsive to requests" from LPN #3 to sit still for the feeding. A nursing assistant held the resident's right arm while both staff members called for help.
A second nursing assistant entered to assist. When LPN #3 noticed the inspector at the door, she yelled for it to be closed.
After the three staff members left the room, the inspector asked what protective equipment they had worn. LPN #3 said they had gloves and masks on, adding, "Did you see he was flailing trying to head butt me?"
None of the staff wore gowns, which facility policy required for interactions with the resident's gastrostomy tube, especially given the resident's behavioral history that LPN #3 described.
The facility's infection control policy mandated full protective equipment for residents under Enhanced Barrier Precautions. The violation put other residents at risk of infection spread.
Federal inspectors found the facility's new narcotic protocols were working by March. Logs showed no discrepancies or errors for February and March. An agency nurse interviewed during the inspection correctly described the two-person counting process and knew to immediately report discrepancies to nursing leadership.
The facility received minimal harm citations for both the drug diversion and infection control violations. But for residents like those whose medications were stolen, the harm was already done.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 13, 2026 · Our methodology
DENNETT REHAB CENTER in OAKLAND, MD was cited for violations during a health inspection on March 5, 2025.
Instead, they found metformin, a diabetes medication.
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.
Frequently Asked Questions
- What happened at DENNETT REHAB CENTER?
- Instead, they found metformin, a diabetes medication.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in OAKLAND, MD, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from DENNETT REHAB CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 215216.
- Has this facility had violations before?
- To check DENNETT REHAB CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.