Dennett Rehab Center: PPE Violations During Tube Feeding - MD
The inspection took place on March 3, 2025, just before 1 in the afternoon. LPN #3 was attempting to administer a fluid bolus through Resident 39's gastrostomy tube, a device that delivers nutrition and medication directly into the stomach. Resident 39 was not cooperating. According to the inspection report, the resident was "very active and not responsive" to the nurse's requests to sit still. A nursing aide, GNA #4, was trying to hold the resident's right arm. Both of them were calling for help.
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See the Derila PillowA second aide, GNA #5, came to assist. Three staff members were now in the room, working to administer a feeding through a direct line into a resident's stomach. None of them were wearing gowns.
There was a sign on the door that said they should be.
The sign designated Resident 39's room as requiring Enhanced Barrier Precautions, a protocol that calls for gowns, in addition to gloves and masks, before any hands-on contact. The precautions exist because certain residents carry bacteria or infections that can spread to other patients, to staff, and back again, and a gastrostomy tube site represents exactly the kind of direct opening where that risk is highest.
When the inspector appeared at the doorway, LPN #3 called for the door to be shut. The inspector waited outside until all three staff members came out.
Asked what protective equipment they had worn, LPN #3 said: "We had our gloves and masks on, did you see he was flailing trying to head butt me?"
She was right that the resident had been difficult. She was not right about the PPE. Gloves and masks were not enough. The sign on the door the staff walked through to reach the resident required gowns. The facility's own policy required gowns. Nobody had one on.
The nurse's explanation captured something real about how infection control breaks down in practice. A resident is combative. Staff are scrambling. A second aide gets pulled in to help. In that moment, the gown requirement, the sign on the door, the reason any of it exists, gets left behind. The focus narrows to getting the feeding done.
That narrowing is precisely what the Enhanced Barrier Precaution protocol is designed to prevent. A gastrostomy tube site is not a routine contact point. It is a direct route into the body, and the resident's resistance during the procedure, the movement, the physical contact from multiple staff members, is the kind of interaction the gown requirement anticipates.
The inspector noted the discrepancy between what LPN #3 claimed and what had been observed. The director of nursing and the nursing home administrator were both informed of the findings during the survey and again at the exit conference on March 5.
The inspection report classified the violation as minimal harm or potential for actual harm, affecting few residents. Resident 39 was the only resident identified in the finding.
What the report does not resolve is how many times the same door was opened before an inspector happened to be standing there. The sign was already posted. The policy was already in place. On this afternoon, with a resident resisting care and three staff members in the room trying to manage the situation, none of that translated into a gown.
LPN #3's first instinct, when she saw someone watching, was to get the door closed.
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.
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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.
The inspection took place on March 3, 2025, just before 1 in the afternoon.
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.