Caroline Nursing and Rehab: Narcan Record Gap - MD
The resident, identified in inspection records only as Resident 4, received Narcan on July 29, 2025. The nurse's own progress note, written that afternoon at 1 p.m., stated: "This nurse has made the clinical decision to Narcan resident once." The resident had been lethargic. Narcan, the brand name for naloxone, reverses opioid overdose and is not a drug administered routinely or lightly.
The Medication Administration Record, the document nurses use to log every drug given to every resident, contained no entry for it. Nobody added one.
The gap sat undiscovered for three months.
Federal inspectors arrived on October 27, 2025, responding to a complaint. Reviewing Resident 4's records, they found the progress note describing the Narcan decision and then found nothing in the MAR to match it. A registered nurse on staff, identified as Staff 1, told the surveyor that a resident who receives Narcan should be documented in both places. That is what the facility's own nursing staff understood the standard to be. The MAR entry did not exist.
The Director of Nursing was interviewed two days later, on October 29. The surveyor laid out the finding. The DON, according to inspection records, validated the concern.
That word, validated, is doing a lot of work in an inspection report. It means the person responsible for nursing practice at the facility agreed, when confronted with the evidence, that something had gone wrong. It does not mean anyone had caught it before inspectors arrived.
The MAR is not a bureaucratic formality. It is the primary tool a nurse uses when taking over a shift to understand what a resident has received, what is due, and what reactions to watch for. When a resident receives Narcan, the clinical picture that follows matters: why was the drug needed, what opioid was involved, what is the resident's current status, has the opioid's effect returned. Narcan wears off. Opioids sometimes do not. A nurse reading an incomplete MAR has an incomplete picture.
Inspectors classified the violation as causing minimal harm or potential for actual harm, and noted it affected few residents. The complaint survey covered four residents total for medication administration review. The gap was found in one of them.
Caroline Nursing and Rehab is a skilled nursing facility in Denton, the county seat of Caroline County on Maryland's Eastern Shore. The inspection was a complaint survey, meaning someone had raised a concern before inspectors walked in. The full scope of that complaint is not reflected in the publicly available findings from this visit.
What the record does show is narrow but specific: one resident, one drug, one nurse's note that acknowledged the administration, and a medication record that showed nothing. The nurse who gave the Narcan documented the clinical decision in a progress note and stopped there. The MAR went unsigned.
The registered nurse interviewed by inspectors said both records should have been completed. The Director of Nursing agreed the documentation was missing. No explanation for why the MAR entry was never made appears in the inspection findings.
Resident 4's condition on July 29, what happened after the Narcan was given, whether the resident recovered without further incident, none of that is contained in the publicly released inspection narrative. What remains in the record is the note a nurse wrote to explain a decision, and the blank space where the proof of that decision should have been.
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.
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 6, 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 inspection records only as Resident 4, received Narcan on July 29, 2025.
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.