Federal inspectors found that Fairfield Nursing & Rehabilitation Center failed to follow medication safety protocols for Resident #8, who was taking three different blood pressure medications with strict monitoring requirements.
The resident had been admitted from an acute care hospital for rehabilitation following a stroke that left them with paralytic syndrome. Their medical conditions included hypertension, dementia, restless leg syndrome, and a sacral ulcer.
In June 2025, physicians ordered three blood pressure medications for the resident. Two medications — Isosorbide Monotrate 30 mg and Lisinopril 20 mg — were prescribed once daily at 9 AM. The third medication, hydralazine 25 mg, was ordered three times daily at 9 AM, 2 PM, and 9 PM.
All three medications carried the same critical safety parameter: hold the dose if the resident's blood pressure reading dropped below 100 systolic.
Nurses properly monitored blood pressure before the 9 AM doses. The medication administration record showed blood pressure readings and nurse initials next to both the Lisinopril and the morning dose of hydralazine.
But the afternoon and evening doses of hydralazine told a different story.
No blood pressure readings appeared next to the 2 PM dose on the medication record. No readings appeared next to the 9 PM dose either. The electronic medical record showed inconsistent vital sign monitoring at those times when the additional hydralazine doses were given.
This meant nurses were administering a blood pressure medication without knowing whether the resident's blood pressure had already dropped to dangerous levels.
Hydralazine works by relaxing blood vessels to lower blood pressure. Given to someone whose blood pressure is already too low, it can cause dizziness, falls, or more serious cardiovascular complications.
On September 17, inspectors interviewed the RN unit manager and Assistant Director of Nursing about the missing blood pressure checks. Both staff members reviewed the medication administration record with inspectors.
The Assistant Director of Nursing and unit manager acknowledged the problem immediately. They told inspectors that whoever entered the physician's order into the system should have created spaces for blood pressure recordings next to all three medications that required monitoring.
They confirmed the inspectors' findings about the missing blood pressure checks.
The facility's failure affected medication safety protocols designed to protect residents from potentially harmful drug interactions and side effects. Federal regulations require nursing homes to ensure each resident's drug regimen remains free from unnecessary medications and dangerous dosing practices.
For Resident #8, this meant receiving medication twice daily without the safety checks their physician had specifically ordered. The stroke patient's complex medical conditions — including hypertension and dementia — made proper medication monitoring especially critical.
The inspection occurred in response to a complaint about the facility. Inspectors reviewed 25 residents' medication records and found this blood pressure monitoring failure affected one resident.
Fairfield Nursing & Rehabilitation Center is located on Fairfield Loop Road in Crownsville, serving residents who require skilled nursing care and rehabilitation services.
The missing blood pressure checks represent a breakdown in the facility's medication administration system. When physicians write specific parameters for medication safety, those requirements become part of the resident's treatment plan that nursing staff must follow.
Without proper monitoring, residents face unnecessary risks from medications that should help rather than harm them.
The resident continued receiving the improperly monitored hydralazine doses while nurses failed to document the required safety checks that could have prevented potential complications from blood pressure medications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fairfield Nursing & Rehabilitation Center from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
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