Caroline Nursing And Rehab
CAROLINE NURSING AND REHAB in DENTON, MD — inspection on October 29, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined that the facility failed to ensure the discharge of a resident was documented in the medical record that included the resident's status at the time of discharge and the reason for the discharge.
This was identified for 1 (Resident #12) of 3 residents reviewed for discharge during the complaint survey.The findings include:On 10/27/2025 at 12:30 PM a review of Resident #12's medical record revealed: A Transfer/Discharge Report that include Resident #12's information of an admission date of 11/11/2023 and a discharge date of 09/23/2025 for transfer/discharge to an acute care hospital.
However, further review of Resident #12's medical record revealed no indication of Resident's status or the reason for the transfer/discharge to the hospital. On 10/27/2025 at 1:25 PM during an interview, Staff #4 Registered Nurse (RN) stated if a resident had a change in condition, an assessment would be completed. An EInteract Change in Condition form is completed, the physician is notified, and all actions are documented in the progress notes of the Electronic medical record.On 10/28/2025 at 8:35 AM during an interview, the Director of Nursing (DON) stated that when a resident is transferred to the hospital, the nurse completes an EInteract form, and a physician order would be obtained.On 10/28/2025 at 12:26 PM the DON verified there was no documentation or Physician order for Resident #12's change in condition that resulted in him/her being transferred to the hospital on [DATE]. At this time the DON was made aware of the concern.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Caroline Nursing and Rehab
520 Kerr Avenue Denton, MD 21629
SUMMARY STATEMENT OF DEFICIENCIES
September indicated that nurse's notes were documented for the Fish Oil as medication unavailable.
There was no evidence that indicated Pharmacy, or a Physician was notified about the unavailable medication.
On 10/27/2025 at 1:20 PM during an interview, Staff #3 Certified Medication Aide (CMA) stated that if a medication is unavailable, she documents in the electronic medical record the medication is unavailable and informs the nurse.
On 10/27/2025 at 1:25 PM during an interview, Staff # 4 Registered Nurse (RN) stated if a medication is unavailable, the Pharmacy must be contacted to ascertain the medication's delivery status.
The Physician should be notified for an alternative medication, and the Omnicell (a backup system for nurses to retrieve medication) should be checked.
Notification to both the Physician and Pharmacy is required on the first day of the medication's unavailability.
On 10/28/2025 at 8:35 AM, during an interview with the Director of Nursing (DON) stated that if a medication is unavailable, the pharmacy would be contacted for a refill, or the backup system would be used to obtain the medication.
Nurses would contact the Physician if a medication were on backorder.
The Director of Nursing (DON) was informed of concerns at this time.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Caroline Nursing and Rehab
520 Kerr Avenue Denton, MD 21629
SUMMARY STATEMENT OF DEFICIENCIES
During an interview with the Director of Nursing (DON) on 10/27/25 at 12:21 PM, the surveyor reviewed Resident #4's medical record with the DON.
The DON verified that Resident #4 did not have medical records supporting the administration of Oxycodone 5mg. He confirmed that, per the medical records, Resident #4 received Oxycodone 15mg on 7/29/25 instead of the ordered 5mg of Oxycodone.
The surveyor shared concern with the DON that Resident #4 received the wrong dose of Oxycodone on 7/29/25.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Caroline Nursing and Rehab
520 Kerr Avenue Denton, MD 21629
SUMMARY STATEMENT OF DEFICIENCIES
Based on the investigation of complaints, record review, and staff interviews, it was determined that the facility staff failed to document the administration of medication in a resident's Medication Administration Record (MAR).
This was evident for one (Resident #4) of the four residents reviewed for medication administration during the complaint survey.The findings include:A portion of the investigation for complaint #2575219, conducted on 10/27/25 at 10:12 AM, revealed that Resident #4 received Narcan (naloxone), a life-saving drug that can reverse an opioid overdose, on 7/29/25 due to a lethargic condition.A further review of Resident #4's progress note revealed that Staff #19 (Registered Nurse) documented on 7/29/25 at 1 PM: This nurse has made the clinical decision to Narcan resident once.
However, there was no documentation for the medication in the MAR.
During an interview with Staff #1 (Registered Nurse) on 10/27/25 at 1:03 PM, she stated that a resident who received Narcan should be documented in both the MAR and the progress note.In an interview with the Director of Nursing (DON) on 10/29/25 around 1 PM, the surveyor shared the concern that the facility staff did not document Resident #4's Narcan administration.
The DON validated the concern.
Facility ID: