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Health Inspection Summary
Fayette Health and Rehabilitation Center
1217 West Fayette Street
Baltimore, MD 21223
(410) 727-3947
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Deficiency Category
Inspection Date:
4/3/24
Complaint Reporting Period:
5/1/24 - 4/30/25
Inspection Date:
3/11/19
Complaint Reporting Period:
5/1/23 - 4/30/24
Inspection Date:
10/6/17
Complaint Reporting Period:
5/1/22 - 4/30/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies131
Quality of Life and Care Deficiencies471
Infection Control Deficiencies100
Resident Assessment and Care Planning Deficiencies533
Nursing and Physician Services Deficiencies120
Resident Rights Deficiencies752
Nutrition and Dietary Deficiencies030
Pharmacy Service Deficiencies241
Environmental Deficiencies210
Administration Deficiencies121

Detailed result for inspection on 4/3/24
Date of last standard health inspection:4/3/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 5/1/24 - 4/30/25
No complaint inspections
Date(s) of infection control inspection(s) between 5/1/24 - 4/30/25
No infection control inspections
Total number of Health Deficiencies for this nursing home:24
Average number of Health Deficiencies in Maryland:19.3
Average number of Health Deficiencies in the United States:9.6
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide activities to meet all resident's needs.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Some

Provide or obtain dental services for each resident.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide and implement an infection prevention and control program.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Some
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Some

Ensure each resident receives an accurate assessment.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Some

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Some

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Some

Give the resident's representative the ability to exercise the resident's rights.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Some

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Some
Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure medication error rates are not 5 percent or greater.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Employ staff that are licensed, certified, or registered in accordance with state laws.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few

Detailed result for inspection on 3/11/19
Date of last standard health inspection:3/11/19Read the full report (PDF)
Date(s) of complaint inspection(s) between 5/1/23 - 4/30/24
Date(s) of infection control inspection(s) between 5/1/23 - 4/30/24
No infection control inspections
Total number of Health Deficiencies for this nursing home:30
Average number of Health Deficiencies in Maryland:14.5
Average number of Health Deficiencies in the United States:9.5
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

10/2/2311/16/23
2 - Minimal harm or potential for actual harm
Few

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

10/2/2311/16/23
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

10/2/2311/16/23
2 - Minimal harm or potential for actual harm
Few

Provide enough food/fluids to maintain a resident's health.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Few

Provide safe, appropriate pain management for a resident who requires such services.

10/2/2310/17/22
3 - Actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

10/2/2311/16/23
4 - Immediate jeopardy to resident health or safety
Few

Provide safe, appropriate pain management for a resident who requires such services.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Few

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Some
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Post nurse staffing information every day.

3/11/195/8/19
1 - Potential for minimal harm
Many

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Few
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Keep residents' personal and medical records private and confidential.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Some

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Dispose of garbage and refuse properly.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Few

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Some

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Some
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Few

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

10/2/2311/16/23
2 - Minimal harm or potential for actual harm
Few

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

10/2/2311/16/23
2 - Minimal harm or potential for actual harm
Few

Ensure each resident’s drug regimen must be free from unnecessary drugs.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Some
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide timely, quality laboratory services/tests to meet the needs of residents.

3/11/195/8/19
2 - Minimal harm or potential for actual harm
Some

Hire a qualified full-time social worker in a facility with more than 120 beds.

10/2/2311/16/23
2 - Minimal harm or potential for actual harm
Few

Detailed result for inspection on 10/6/17
Date of last standard health inspection:10/6/17Read the full report (PDF)
Date(s) of complaint inspection(s) between 5/1/22 - 4/30/23
No complaint inspections
Date(s) of infection control inspection(s) between 5/1/22 - 4/30/23
No infection control inspections
Total number of Health Deficiencies for this nursing home:9
Average number of Health Deficiencies in Maryland:12.1
Average number of Health Deficiencies in the United States:8.8
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.

10/6/1711/19/17
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide necessary care and services to maintain or improve the highest well being of each resident .

10/6/1711/19/17
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Conduct initial and periodic assessments of each resident's functional capacity.

10/6/1711/19/17
2 - Minimal harm or potential for actual harm
Few

Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

10/6/1711/19/17
2 - Minimal harm or potential for actual harm
Few

Allow residents the right to participate in the planning or revision of care and treatment.

10/6/1711/19/17
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives.

10/6/179/1/17
3 - Actual harm
Few

Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.

10/6/1711/19/17
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure that residents are safe from serious medication errors.

10/6/179/10/17
3 - Actual harm
Some
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Keep accurate, complete and organized clinical records on each resident that meet professional standards.

10/6/1711/19/17
2 - Minimal harm or potential for actual harm
Few
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Some

Ensure each resident receives an accurate assessment.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Some

Give the resident's representative the ability to exercise the resident's rights.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Some

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

10/2/2311/16/23
2 - Minimal harm or potential for actual harm
Few

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

10/2/2311/16/23
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

10/2/2311/16/23
2 - Minimal harm or potential for actual harm
Few

Provide safe, appropriate pain management for a resident who requires such services.

10/2/2310/17/22
3 - Actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

10/2/2311/16/23
4 - Immediate jeopardy to resident health or safety
Few

Keep residents' personal and medical records private and confidential.

4/3/246/12/24
2 - Minimal harm or potential for actual harm
Few

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

10/2/2311/16/23
2 - Minimal harm or potential for actual harm
Few

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

10/2/2311/16/23
2 - Minimal harm or potential for actual harm
Few

Hire a qualified full-time social worker in a facility with more than 120 beds.

10/2/2311/16/23
2 - Minimal harm or potential for actual harm
Few
Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.
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