Dennett Rehab Center
DENNETT REHAB CENTER in OAKLAND, MD — inspection on March 5, 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
with Resident #39 secondary to his/her diagnosis of cerebral palsy was reviewed with the facility
215216 03/05/2025
Dennett Rehab Center 1113 Mary Drive Oakland, MD 21550
Observation of the narcotic logs with the ADON on the 100 unit on 3/3/25 at approximately 11:45 AM noted no concerns with the narcotic logs or the signatures.
There were no noted holes or discrepancies for March or February for this log.
On 3/4/25 at 8:35 AM Agency LPN #9 was interviewed regarding the process of completing the narcotic log, sign in and sign out with another nurse.
She stated that you count the cards and the pills in the card and sign with the nurse.
There was a new narcotic log implemented as per the ad hoc meeting and there were no concerns or holes or errors noted.
This surveyor asked the process for discrepancies, and LPN #9 stated that they recount, look for the medication then immediately report to the ADON or DON.
Interview with the DON on 3/5/25 at 10:37 AM regarding what initiated that concern with LPN #14 and the discrepancies.
She stated the same as the ADON, that around 2/12/25 something seemed off.
When they came in on 2/17/25 they did an audit and looked at the nurses' signatures and it appeared that one of the signatures was not that nurse's actual signature and that was the straw' then they realized paper was missing and others were remade by LPN #14.
LPN #14 was terminated from the facility on 2/21/25.
215216 03/05/2025
Dennett Rehab Center 1113 Mary Drive Oakland, MD 21550
During the tour of the facility and observation of resident and staff practices, on 3/3/25 at approximately 12:45 PM, this surveyor observed LPN #3 in the room of Resident #39, with Resident #39 and GNA #4. Resident #39 was due for nutrition to be administrated via the gastrostomy tube (medical device that provides a direct route to the stomach for nutrition and medication). At this time s/he was very active and not responsive to the requests from LPN #3 to sit and let her administer the fluid bolus. GNA #4 was attempting to hold Resident #39's right arm and they both hollered for assistance. GNA #5 then came to the room to assist with the feeding administration.
When LPN #3 saw this surveyor at the door observing the event in Resident #39's room, she yelled for the door to be closed.
This surveyor waited outside the door until all 3 staff members exited the room.
Upon exiting the room, this surveyor asked what PPE the 3 of the staff wore while providing care.
LPN #3 stated we had our gloves and masks on, did you see he was flailing trying to head butt me? It was reviewed at that time that there was an Enhanced Barrier Precaution sign on Resident #39's door and no one was wearing the appropriate PPE, which included according to the sign and the facility policy to the donning of gowns prior to the interaction with Resident #39s' gastrostomy tube, especially if they knew the potential of his/her behaviors and potential rejection of care that LPN #3 reported upon exiting the room.
The DON and NHA were notified of the observations during the survey and again during exit on 3/5/25.
According to facility reported incident #MD00213420 occurring on 1/9/25, a family brought medications from home to the facility for Resident #302, which included Ativan (sedative).
Unfortunately, about a week or so after they were discharged home, they alleged that the Ativan bottle they brought home no longer contained Ativan but metformin (diabetic medication).
They called the facility and complained.
The facility did an investigation and was unable to determine if there was a mix-up with the medication but did implement new policies for residents bringing in medications from home.
This also initiated the first round of education provided to the nurses regarding narcotic medications and the increase in audits of the narcotic logs by the Assistant Director of Nursing (ADON) and Director od Nursing (DON).
Interview on 3/3/35 at 11:21 AM with the facility ADON revealed that the administration started to notice a pattern with a specific nurse, so they started to watch her and the narcotic logbook closely. It was during this audit that the DON and ADON found a questionable signature on a narcotic log from 1/3/25 that LPN #14 forged.
'A pattern of incorrect documentation, missing forms, missing medication, and false documentation was identified by DON and ADON and later identified to only occur on the days when staff LPN #14 worked and completed the forms.
They realized that the pharmacy sheets that came in and out were not matching and they found a pattern only where this specific nurse worked.'
According to the facility investigation packet, reviewed on 3/3/25, LPN #14 was interviewed regarding the DON's findings and initially denied any wrongdoing but had confirmed that she signed another nurse's signature on one of the pharmacy narcotic forms.
The facility's investigation determined that there was Tramadol (narcotic for moderate-severe pain) taken from Resident #1 and Gabapentin (anticonvulsant/nerve pain medication) from Resident #17.
The facility implemented an ad hoc quality assurance and performance improvement meeting on 1/13/25 related to this concern of drug diversion with LPN #14.
The plan included:
215216
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 215216 B.
Wing 03/05/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Dennett Rehab Center 1113 Mary Drive Oakland, MD 21550
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.