Caroline Nursing and Rehab: Discharge Records Missing - MD
The resident, identified in the inspection report only as Resident 12, had lived at Caroline Nursing and Rehab on Kerr Avenue since November 2023. On September 23, 2025, something happened, and the facility sent them to an acute care hospital. What that something was, the medical record did not say.
Inspectors conducting a complaint survey at the facility on October 27 pulled the chart and found the Transfer/Discharge Report listed the admission date, the discharge date, and the destination. The rest of the fields that would explain the transfer, the resident's status, the reason for the move, were blank. There was no EInteract Change in Condition form. No physician order authorizing the transfer. No progress note describing what a nurse observed before calling for help.
A registered nurse interviewed that afternoon explained how the process was supposed to work. If a resident had a change in condition, she said, staff would complete an assessment, fill out an EInteract form, notify the physician, and document all of it in the electronic medical record. The Director of Nursing said the same thing the next morning. When a resident goes to the hospital, a nurse completes the EInteract form and a physician order is obtained.
Neither of those things happened for Resident 12.
On October 28, at 12:26 in the afternoon, the Director of Nursing sat with inspectors and confirmed it directly. There was no documentation. There was no physician order. Whatever prompted the transfer of a long-term resident to an acute care hospital on September 23 existed nowhere in the medical record. The Director of Nursing acknowledged the gap only after inspectors raised it.
The finding was cited at a level of minimal harm or potential for actual harm, the lowest tier on the federal scale. It affected one of three residents whose discharge records inspectors reviewed during the complaint survey.
What the citation captures is narrow: a documentation failure, a missing form, a physician order that was never obtained or never recorded. What it does not capture is what Resident 12's family, if they had one, would have been told about why their relative was transferred. Or whether a physician was actually consulted before the move, and the record simply wasn't made. Or whether the absence of documentation reflects a gap in paperwork alone, or something more.
The inspection report does not say. It records what inspectors found in the chart, what two staff members said the process should look like, and what the Director of Nursing confirmed was missing. It does not describe Resident 12's condition on the day of the transfer, or what happened to them afterward.
Caroline Nursing and Rehab has operated at the Kerr Avenue address in Denton, a small county seat on Maryland's Eastern Shore, for years. The October 29 survey was a complaint inspection, meaning someone, a resident, a family member, a staff member, had raised a concern that triggered the visit. The inspection report does not identify the nature of the original complaint or whether it was related to Resident 12's transfer.
What the record shows is a resident who spent nearly two years at a facility, was transferred to a hospital in September, and left behind a chart that could not answer the most basic questions about why.
The Director of Nursing was made aware of the concern at 12:26 PM on October 28, 2025, more than a month after Resident 12 had already gone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Caroline Nursing and Rehab from 2025-10-29 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 23, 2026 · Our methodology
CAROLINE NURSING AND REHAB in DENTON, MD was cited for violations during a health inspection on October 29, 2025.
The resident, identified in the inspection report only as Resident 12, had lived at Caroline Nursing and Rehab on Kerr Avenue since November 2023.
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.