Dennett Rehab Center
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
diagnosis of diabetes. 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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DENNETT REHAB CENTER in OAKLAND, MD inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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 OAKLAND, 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 DENNETT REHAB CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.