The resident's phenytoin, an anti-seizure medication prescribed for 9 PM administration, was signed off by staff at 1:54 AM on September 10. On September 7, the same 9 PM dose was documented as given at 12:42 PM the following day.
Blood pressure medication arrived even later for another resident. Amlodipine prescribed for 9 AM was administered at 4:13 PM on September 10 — more than seven hours behind schedule. The same resident's blood thinner Eliquis, also scheduled for 9 AM, was given nearly seven hours late that day.
Staff #11, a licensed practical nurse, told inspectors that late medication administration happened for two reasons: nurses signing off documentation hours after actually giving medications, or medications genuinely administered past the required one-hour window.
"It depends on the workload," Staff #11 said during the September 15 interview. "There are times you come on the floor and don't have a medicine aide working with you; therefore, you have to make sure the medications are given out timely and then you sign off later."
Without a medication aide, the nurse explained, a single staff member becomes responsible for administering drugs to more than 18 patients. "Some of the patients will get medications when they should and other times they won't."
The inspection revealed a pattern of delayed medication across multiple residents and drug types. One resident's morning insulin, prescribed for 6:30 AM, was consistently given hours late throughout September. On September 1, the 4:30 PM insulin dose was signed off at 7:53 PM. Three days later, the same afternoon insulin was documented at 7:52 PM.
Critical medications suffered the same delays. A resident's gabapentin for nerve pain, scheduled three times daily at 9 AM, 2 PM, and 9 PM, was routinely administered hours late. The September 1 morning dose was given at 12:18 PM, while the afternoon dose arrived at 7:52 PM — nearly six hours behind schedule.
Prescription mouthwash became another casualty of the facility's medication timing problems. Chlorhexidine gluconate, ordered three times daily for one resident, was consistently delayed. The September 1 evening dose, scheduled for 9 PM, was administered at 7:51 PM the following day — nearly 23 hours late.
The phenytoin delays affected the same resident multiple times. The anti-seizure medication, prescribed at precise 8-hour intervals of 6 AM, 2 PM, and 9 PM, was routinely off schedule. On September 1, the 2 PM dose was given at 6:05 PM. The 6 AM dose on another day was administered at 7:50 AM, while the 2 PM dose arrived at 6:34 PM.
Inspectors documented these medication delays as just "a sampling" of the timing problems at Fairfield Nursing. The assistant director of nursing and Staff #26, a unit manager, both acknowledged the medication administration concerns during their September 15 interview with federal surveyors.
The inspection found that Fairfield Nursing's medication delays created minimal harm or potential for actual harm, affecting some residents. Federal regulations require nursing homes to administer medications within a one-hour window of scheduled times to maintain therapeutic effectiveness and prevent adverse outcomes.
Late administration of anti-seizure medications can lead to breakthrough seizures, while delayed blood pressure medications may result in dangerous spikes. Blood thinners given off schedule can affect clotting times and increase stroke or bleeding risks.
Staff #11's explanation revealed the facility's underlying staffing challenge: nurses working alone without medication aides must choose between giving medications on time to some residents while others wait, or attempting to serve all 18-plus patients with inevitable delays across the board.
The September inspection occurred after a complaint prompted federal surveyors to examine medication practices at the Crownsville facility. Fairfield Nursing & Rehabilitation Center, located on Fairfield Loop Road, serves residents requiring both nursing care and rehabilitation services.
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.
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