The resident, identified as Resident #4 in the inspection report, weighed 213 pounds in September 2024. By August 2025, their weight had dropped to 178 pounds — a loss that went unreported to physicians for nearly five months.
Resident #4 has dysphagia, a medical condition that makes swallowing food or liquids difficult. The resident has lived at Fairfield Nursing & Rehabilitation Center since 2015.
The weight loss began accelerating in early 2025. By February 4, the resident had dropped to 200.8 pounds, prompting the facility's former dietitian to order Med Pass nutritional shakes twice daily for 30 days. Med Pass is a fortified supplement designed to boost calories and protein.
Six days later, a nurse practitioner documented that nursing staff reported the patient had lost 12 pounds in a single month. The practitioner's February 10 note outlined a plan: nutrition consultation, supplements, dental follow-up to refit dentures, and weight monitoring.
But the dietitian didn't see the resident again for three and a half weeks.
When the dietitian returned on March 6, the resident's weight had plummeted to 190.9 pounds. The dietitian documented "unplanned weight loss" and recommended increasing Med Pass to three times daily. The dietitian also requested that the medical doctor consider ordering medication with appetite-stimulating side effects.
The appetite stimulant wasn't ordered until March 26 — 20 days later.
After that intervention, the resident's physician and nurse practitioner received no further updates about the continuing weight loss. The facility's current dietitian saw the resident monthly but put no additional interventions in place and failed to notify the resident's physician about the ongoing decline.
By August 9, when the current dietitian last weighed the resident, their weight had dropped to 178 pounds.
Federal inspectors reviewed all physician and nurse practitioner notes through August 18 and found no documentation that medical providers knew about the resident's continued weight loss since the March appetite stimulant order.
When inspectors interviewed the resident's nurse practitioner on September 17, the practitioner was unaware of the 35-pound weight loss since September 2024. The nurse practitioner told inspectors that nursing staff usually alerts her to residents' weight loss.
The Assistant Director of Nursing confirmed to inspectors that facility staff had failed to order the appetite stimulant in a timely manner and failed to notify the resident's physician or nurse practitioner about the continued weight loss.
The violation represents a breakdown in the facility's nutritional monitoring system for a vulnerable resident whose medical condition already made eating difficult. Federal regulations require nursing homes to provide adequate nutrition and hydration to maintain residents' health.
The inspection was conducted as part of a complaint survey, indicating someone reported concerns about care at the facility to state health officials.
Fairfield Nursing & Rehabilitation Center is located on Fairfield Loop Road in Crownsville, Maryland. The facility must submit a plan of correction to address the nutritional monitoring deficiency identified by federal inspectors.
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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