Fayette Health: Resident on Oxygen Without Orders - MD
The violation at Fayette Health and Rehabilitation Center emerged during a complaint investigation in August, when inspectors discovered that resident #17 had been using oxygen since his October 2024 admission without proper medical authorization.
RN #46, who wrote the resident's admission note on October 3, 2024, told inspectors during an August 13 interview that she didn't remember the resident at all. Even after inspectors reminded her that she had documented his admission, the nurse still couldn't recall him.
When asked why an incoming resident would be using an oxygen tank instead of an oxygen concentrator, RN #46 explained that oxygen tanks were used during initial assessments and would eventually be switched to concentrators after provider evaluation. But no such evaluation or order ever materialized.
The resident's medical records revealed multiple problems. The hospital discharge summary was incomplete, with missing pages in the scanned version. No oxygen administration order existed anywhere in his file.
During interviews on August 13 with the Executive Director, Director of Nursing, and Regional Clinical Director #44, inspectors laid out the violations. The Executive Director promised to search paper records for the complete discharge summary and missing oxygen order.
Regional Clinical Director #44 confirmed that nursing staff and providers share responsibility for ensuring discharge summaries are complete. She also stated unequivocally that every resident requiring oxygen must have an order for oxygen administration.
The next morning, facility leadership confirmed what inspectors had found. The resident's medical records contained no oxygen administration order and no complete discharge summary from the hospital. Nursing staff and the provider had failed to verify that discharge paperwork was complete.
The Executive Director acknowledged that the telehealth provider never issued an oxygen administration order after reviewing the resident's chart. This meant the resident had been receiving medical treatment for nearly ten months without proper authorization.
Only after inspectors intervened did the facility take action. The Executive Director ordered an audit of all residents admitted in the previous 30 days who required oxygen, checking whether they had proper administration orders.
The facility also re-educated nurses on ensuring that residents admitted with oxygen have appropriate medical orders. But this training came only after federal oversight exposed the violation.
The case highlights fundamental breakdowns in admission procedures. A nurse couldn't remember a resident she had admitted. Critical hospital discharge documents were incomplete. Medical orders for ongoing treatment were missing entirely.
For resident #17, the oversight meant months of oxygen therapy without medical supervision or proper documentation. The treatment continued despite multiple opportunities for staff to identify and correct the missing authorization.
The violation occurred under the facility's medication administration standards, which require proper physician orders for all treatments. Federal regulations mandate that nursing homes ensure residents receive medications and treatments only as ordered by their physicians.
The inspection found that few residents were affected by the violation, with minimal harm or potential for actual harm. But the case demonstrates how admission oversights can persist for months without detection.
Fayette Health and Rehabilitation Center, located at 1217 West Fayette Street, serves residents requiring skilled nursing and rehabilitation services. The facility must now demonstrate that its corrective measures prevent similar violations.
The oxygen order violation represents a basic failure in medical oversight. Residents depend on nursing homes to ensure all treatments are properly authorized and documented. When facilities skip these fundamental steps, they put residents at risk and violate federal care standards.
For resident #17, the missing oxygen order meant nearly a year of treatment without proper medical supervision. The incomplete discharge summary compounded the problem, leaving staff without complete information about his hospital care and ongoing needs.
The facility's response came only after federal intervention exposed the violations. Without the complaint investigation, resident #17 might have continued receiving unauthorized oxygen therapy indefinitely.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fayette Health and Rehabilitation Center from 2025-08-14 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 20, 2026 · Our methodology
Fayette Health and Rehabilitation Center in BALTIMORE, MD was cited for violations during a health inspection on August 14, 2025.
RN #46, who wrote the resident's admission note on October 3, 2024, told inspectors during an August 13 interview that she didn't remember the resident at all.
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.