Fairfield Nursing & Rehabilitation: Care Plan Failure - MD
That finding came out of a complaint inspection completed September 17, 2025, when a state surveyor reviewed the case of Resident 13, a patient who had been transferred to an acute care hospital on August 10, 2024, after a change in condition. The resident spent roughly six weeks there before returning to Fairfield on September 25, 2024.
After a hospitalization that long, a care plan meeting is how a nursing home takes stock. It is where staff, and often the resident and family, go over what changed, what the treatment goals are, and how care should be adjusted going forward. A formal assessment, called an MDS, was completed for Resident 13 with a reference date of October 1, 2024. That assessment is supposed to trigger exactly that kind of meeting.
It never happened.
When the surveyor reviewed Resident 13's medical record, there was nothing in it to show a care plan meeting had been held. No documentation. No notes. No record of anyone gathering to discuss this person's treatment or prognosis after a six-week absence from the facility.
At 12:49 in the afternoon on September 11, 2025, the surveyor sat down with the Social Work Director. The director looked through her own notes. She confirmed the meeting had not been held. A care plan meeting, she said, should have been scheduled for October 2024.
"It fell through the cracks," the Social Work Director told the surveyor.
That phrase, offered plainly and without apparent dispute, is the whole story. A resident came back from the hospital having gone through enough to warrant six weeks of acute care. The facility completed its formal paperwork. And then the thing the paperwork was supposed to set in motion, the conversation about what this person needed now, simply did not occur.
The inspection was triggered by a complaint, logged as complaint 323367, which alleged that Resident 13 had been sent back from the hospital with no care plan meeting and no discussion of treatment and prognosis going forward. The surveyor found the allegation substantiated.
CMS rated the harm level as minimal harm or potential for actual harm. One resident out of the fourteen reviewed was affected.
That framing, minimal harm, is the regulatory language. What it describes is a resident who returned from a significant hospitalization and spent months at the facility without the documented, coordinated review of their care that the assessment process is designed to produce. Whether any harm resulted from that gap, whether Resident 13's needs were fully understood and met in the weeks and months that followed, is not something the inspection report resolves.
Fairfield Nursing & Rehabilitation Center is located at 1454 Fairfield Loop Road in Crownsville. The inspection was completed September 17, 2025, and printed August 8, 2026.
The Social Work Director did not dispute the finding. She knew when the meeting should have been held. She knew it had not happened. Nearly a year had passed between the missed October 2024 meeting and the day she sat across from a surveyor and confirmed it out loud.
Resident 13's family had filed the complaint. Someone close to that resident had noticed the absence of a meeting and decided it was worth reporting. The inspection confirmed what they said was true.
What the record does not show is what Resident 13 was told, if anything, about their own care in the months after coming home from the hospital.
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.
Download the official CMS inspection PDF from Medicare.gov
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 18, 2026 · Our methodology
FAIRFIELD NURSING & REHABILITATION CENTER in CROWNSVILLE, MD was cited for violations during a health inspection on September 17, 2025.
The resident spent roughly six weeks there before returning to Fairfield on September 25, 2024.
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.