Dennett Rehab Center
DENNETT REHAB CENTER in OAKLAND, MD — inspection on October 10, 2025.
Found 1 citation. 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
During an interview on 10/09/2025 at 12:50 PM, the NP stated that prior to going to see Resident #8 she documented to discontinue the medication, on a pharmacy recommendation, and used the diagnosis of chronic kidney disease.
The NP said she had a conversation with the resident about the medication.
Per the NP, Resident #8 was very alert and able to make their own medical decisions without any issue.
According to the NP, the resident told her they had been on glipizide for a long time and wanted to take it again.
The NP stated to comply with the resident's wishes, she ordered the medication at the smallest dose and ordered blood sugar checks for seven days.
The NP stated she spoke with Resident #8 every day, and the resident did not mention at any point that the staff were not checking their blood sugar.
She stated she was not aware Resident #8 had low blood sugar at the time of their transfer to the ER.
She said her expectation of the nurses would be for them to check a blood sugar and obtain a set of vitals on any resident they found unresponsive.
During an interview on 10/09/2025 at 7:15 AM, the Medical Director stated he had been made aware of the incident with Resident #8 having a low blood sugar of 29 mg/dL, and that the NP placed the resident back on glipizide with an order to do blood sugar checks for seven days. He stated he had a set parameter for blood sugars over 400 mg/dL and how to proceed; however, for blood sugars lower than 60 mg/dL, the nurses knew to call him for an order for glucose. He stated his expectation of the nurses was for them to follow physician's orders and to obtain vital signs and a blood sugar on all unresponsive residents, regardless of a diagnosis of diabetes.
During an interview on 10/09/2025 at 7:03 PM, Corporate Nurse (CN) #28 stated she was the Director of Nursing on record at the time of the incident in May 2025 with Resident #8.
She stated if a resident had a blood sugar less than 60 mg/dL, nurses were to call the doctor for orders. CN #28 stated she expected the nurses to follow physician's orders as they were written, to make sure they were put into the computer correctly for the staff to be able to see the orders, and for a blood sugar and vital signs to be completed on all unresponsive residents, whether staff knew the residents were diabetic or not. CN #28 said if the blood sugar was lower than 60 mg/dL, she expected the nurse to call the doctor for an order for glucagon.
During an interview on 10/09/2025 at 12:45 PM, the Administrator stated she was not notified of the issue of low blood sugar for Resident #8.
She stated the facility addressed the family member's concern and investigated the blood sugars not being done as ordered.
She stated her expectation of the nurses would be for them to follow the doctor's orders, to ensure orders entered in the computer were coded correctly to show up on the MAR and TAR, and that the nurses do vital signs and a blood sugar on any unresponsive resident to find the reason for their current state.
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