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Complaint Investigation

Fayette Health And Rehabilitation Center

Inspection Date: August 14, 2025
Total Violations 2
Facility ID 215183
Location BALTIMORE, MD
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Inspection Findings

F-Tag F0684

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

provider would also order any medications needed for the resident at that time. Surveyor interview of RN #46 on 8/13/25 at 3:55pm revealed that RN #46 also did not remember resident #17 even after the surveyor reminded RN #46 that he/she wrote the admission note on 10/3/24. The surveyor asked RN#46 why would an admitting resident be using an oxygen tank instead of an oxygen concentrator. RN#46 stated that the oxygen tank would be used during the initial assessment of the resident and eventually switched to

an oxygen concentrator after the assessment by the provider. During an interview of the Executive Director (ED), Director of Nursing (DON), and Regional Clinical Director #44 on 8/13/25 at 4:15pm, the surveyor stated that a review of resident #17's medical record revealed that the resident did not have an oxygen administration order and the local hospital's discharge summary was missing pages in the scanned version of the discharge summary. The ED stated that the resident's paper records would be searched for the complete discharge summary and the oxygen order. The surveyor asked the group if nursing staff were responsible for ensuring that any discharge summaries were complete. Regional Clinical Director #44 confirmed that it is a shared responsibility for nursing staff and providers to ensure that a resident's discharge summaries are complete. Regional Clinical Director #44 also stated that every resident that required oxygen must have an order for oxygen administration. On 8/14/25 at 9:00am, interview of the ED, DON and Regional Clinical Director #44 confirmed that resident #17's medical records failed to contain an order for oxygen administration and a complete discharge statement from the local hospital. The ED also confirmed that the nursing staff and the provider failed to confirm that the discharge summary from the hospital was complete. The ED also confirmed that the telehealth provider failed to issue an oxygen administrator order for the resident after chart evaluation. The ED then stated that after surveyor intervention, the facility completed an audit of residents that were admitted in the last 30 days with oxygen to ensure that all of these residents had oxygen administration orders. Nurses were re-educated on the importance of ensuring that residents that are admitted with oxygen have a oxygen administration order as needed.

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Fayette Health and Rehabilitation Center

1217 West Fayette Street Baltimore, MD 21223

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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F-Tag F0695

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

records would be searched for the complete discharge summary and the oxygen order. The surveyor asked

the group if nursing staff were responsible for ensuring that any discharge summaries were complete.

Regional Clinical Director #44 confirmed that it is a shared responsibility for nursing staff and providers to ensure that a resident's discharge summaries are complete. Regional Clinical Director #44 also stated that every resident that required oxygen must have an order for oxygen administration. On 8/14/25 at 9:00am,

interview of the ED, DON and Regional Clinical Director #44 confirmed that resident #17's medical records failed to contain an order for oxygen administration and a complete discharge statement from the local hospital. The ED also confirmed that the nursing staff and the provider failed to confirm that the discharge summary from the hospital was complete. The ED also confirmed that the telehealth provider failed to issue

an oxygen administrator order for the resident after chart evaluation. The ED then stated that after surveyor intervention, the facility completed an audit of residents that were admitted in the last 30 days with oxygen to ensure that all of these residents had oxygen administration orders. Nurses were re-educated on the importance of ensuring that residents that are admitted with oxygen have a oxygen administration order as needed.

Event ID:

Facility ID:

If continuation sheet

📋 Inspection Summary

FAYETTE HEALTH AND REHABILITATION CENTER in BALTIMORE, MD inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BALTIMORE, MD, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FAYETTE HEALTH AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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