Roland Park Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 4669 Falls Road, Baltimore, Maryland 21209
- CMS Provider Number
- 215301
- Inspections on file
- 16
- Latest survey
- February 24, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Roland Park Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia, agitation, and a history of wandering and aggression repeatedly entered other residents’ rooms, physically assaulting a resident in bed, striking a GNA in the face, exposing themselves at another resident’s bedside, and frequently intruding despite STOP signs and verbal redirection. Several cognitively intact, wheelchair-dependent and bedbound residents reported ongoing fear, distress, and repeated room entries, stating they had informed staff multiple times. Psychiatric notes documented persistent confusion, disorientation, noncompliance with staying out of others’ rooms, and unpredictable agitation, yet no new interventions beyond monitoring were implemented, and staff primarily relied on informal redirection while the resident continued to wander the halls and stop at doorways without staff intervention. The state agency determined this lack of effective supervision and absence of documented interventions after an earlier assault met the federal definition of Immediate Jeopardy.
A resident’s room and bathroom were found in an unsanitary and uncomfortable condition during a survey. The surveyor observed curtains with red and brown spots, floors with paper trash and food that appeared dirty, and a bedside commode over the toilet with brown material in the crevices and on the seat. The bathroom had a strong odor of urine and feces, demonstrating that staff did not maintain a safe, clean, and homelike environment for the resident.
A complaint investigation found that the facility failed to provide a receiving facility with a comprehensive discharge summary and complete medications for a resident being discharged. The discharging LPN reported not being familiar with the discharge process, did not send narcotic medications, and only sent non-narcotic medications. Documentation showed that a neurology team from the receiving facility later picked up some narcotics and signed for them. The DON stated that narcotics are only sent with a physician’s order and produced printed prescriptions, but record review did not show any physician order to send narcotics with the resident or any documented discharge note summarizing the resident’s stay and courses of treatment and care.
A resident with a documented intellectual disability had a PASARR Level I screening indicating that a Level II evaluation was required, but the facility did not complete or document the necessary Level II PASARR referral. During surveyor review, no Level II PASARR documentation was found in the record, and the Director of Social Work acknowledged that the resident’s diagnosis had been overlooked at admission despite the Level I form showing that a Level II referral was needed.
The facility failed to complete a trauma-informed assessment and care plan for a resident following an alleged physical assault by another resident. A complaint indicated that a resident reported another resident entered the room, grabbed both hands, and punched the resident in the face multiple times. Record review showed no evidence that a trauma-informed assessment or trauma-focused care plan was completed after this incident. In an interview, the resident was tearful and reported ongoing fear, difficulty sleeping, and feeling scared when the alleged perpetrator entered the dining room. Facility leadership acknowledged that trauma-informed assessments were expected at admission and after a change in condition, but this was not done in this case.
A resident’s medical record contained psychiatric NP evaluations and consultations that were completed but not uploaded in a timely manner, with delays of up to a month between completion and upload. During a complaint survey, surveyors found that several psychiatric visit notes following an incident were missing from the record on the day of review, despite the visits having already occurred. Interviews with the NHA and DON revealed that the facility uploads NP documentation promptly upon receipt, but there is a delay in the process by which the NP’s notes are transmitted to the facility. This delay affected both general progress notes and notes with medication changes, including an example of a Trazodone dose increase documented several days before the note was uploaded, resulting in physician/NP notes not being readily available in the medical record after resident visits.
Surveyors found that the facility’s written assessment did not function as a true facility-wide assessment of the current resident population, but instead listed services the facility can offer. A resident with a tracheostomy and gastrostomy tube was identified on the resident matrix and in records, yet the assessment did not document any residents needing trach or G-tube support. The assessment also referenced behavioral/mental health "supportive care" without identifying the type of providers or their qualifications, and it failed to describe the actual mix of residents, including those dependent for ADLs and those independently mobile in wheelchairs or walking.
The facility failed to ensure that a nurse employed in a supervisory RN role held an active, recognized RN license consistent with state requirements. A nurse with a Virginia compact RN license, later suspended, was working while the Maryland Board of Nursing did not recognize the license due to graduation from a non-approved program. The nurse also held a Maryland LPN license and was reportedly changed from an RN to an LPN supervisor, but facility HR could not provide documentation of when this change occurred or when the RN license was forfeited. Review of the nurse’s education and licensure history showed the school attended was removed from the state’s approved list for LPN programs before the LPN license was issued.
A resident’s room was found to be in disrepair, with surveyors observing that the bathroom grab bar next to the toilet was loose, bathroom floor tiles were missing and cracked making wheelchair or walker use difficult, a cable cover plate was detached from the wall, the ceiling showed brown water-damage stains, the nightstand had a broken handle, and the walls had peeling paint and scrapes, especially at the head of the beds. These conditions demonstrated the facility’s failure to maintain a safe, clean, comfortable, and functional environment in that room.
A resident reported receiving a threatening text message from a GNA, alleging intent to cause harm. The facility did not immediately report this abuse allegation to the Office of Health Care Quality; instead, the incident was disclosed to a surveyor, who then informed the DON. No further information was provided by the Administrator during interviews.
A resident alleged that a GNA sent a threatening text message about poisoning. The facility did not maintain documentation to show that this abuse allegation was thoroughly investigated, and staff confirmed the absence of related records in the investigation file.
A resident reported receiving threatening text messages after alleging a staff member attempted to poison them. Despite being informed, the facility staff did not report the threat to authorities until after surveyor intervention. The Social Services Director's attempts to identify the sender were unsuccessful, and the facility's Administrator and DON were initially unaware of the threat's severity.
The facility failed to suspend a GNA accused of taking a resident's wallet during an investigation and could not provide evidence of a thorough investigation. Additionally, the facility was unable to locate records for another abuse allegation, as the documentation was retained by the prior owner. Despite efforts to retrieve the missing records, the facility acknowledged that they should have retained all resident records for at least five years.
A facility failed to adequately prepare a resident for discharge, as the resident did not sign any discharge paperwork, including discharge instructions and a property list. The discharge paperwork also lacked wound care instructions. The DON confirmed that the facility's process for discharge planning and documentation was not followed, leading to concerns about discharge preparations and a lack of documentation.
A resident reported being unable to see with new glasses provided by a contracted vision vendor. Despite the ombudsman notifying the DON via email, the issue was not addressed until a survey in January revealed the oversight. The resident had an optometry exam and received glasses in August, but the DON was unaware of the problem until the surveyor's inquiry.
Facility staff failed to prevent an accident by not removing low-hanging extension cords from the 3rd floor ceiling, posing a hazard to residents and visitors. This occurred after a water leak caused lighting issues, leading to the installation of temporary lights with extension cords that were not properly secured.
A facility failed to implement physician care orders for a resident admitted with a colostomy. The resident's medical records lacked orders for ostomy care from late May to mid-July during their intermittent stay. This deficiency was confirmed with the facility's DON and Regional DON, who could not provide evidence of care during this period.
Failure to Supervise Aggressive Wanderer Leading to Repeated Resident Distress and Assaults
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accident hazards related to a resident with dementia, wandering, and aggressive behaviors. Resident #10 had documented diagnoses of unspecified dementia with agitation and vascular dementia with behavioral disturbances, including wandering, physical aggression, noncompliance with treatment, irritability, and poor insight. Psychiatric evaluations in December and January documented ongoing confusion, disorientation, unpredictable agitation, noncompliance with rules about staying out of other residents’ rooms, disorganized speech, and poor insight, yet no new interventions were recommended beyond continued monitoring. Despite multiple resident complaints about ongoing room entries and inappropriate behaviors since an assault on 12/6/25, there were no documented changes in the plan of care or additional interventions implemented after 12/10/25. On 2/18/26, GNA staff #2 reported being struck in the face by Resident #10 while cleaning the resident’s room after a messy bowel movement. She stated that the resident had been notably agitated when brought back and left in the room by the DON, and that while she was focused on cleaning, Resident #10 got up, was agitated, and she ended up with a black eye. GNA #2 indicated that similar incidents with Resident #10 occurred about once a month and reported that the resident had punched Resident #5 in December. However, a change in condition note entered by the DON documented that the black eye occurred when the GNA attempted to catch the resident from falling, which did not match GNA #2’s account of being hit. The DON stated that staff were familiar with the resident and redirected him/her as needed, and that referrals had been sent out, but did not identify additional specific interventions in response to the repeated incidents and grievances involving other residents. Multiple cognitively intact residents on the same floor reported ongoing fear and distress due to Resident #10’s behaviors and repeated entry into their rooms. Resident #5, with a BIMS score of 15 and wheelchair dependence, reported that on 12/6/25 Resident #10 entered the room, grabbed both hands, then punched the resident in the face about five times, leading to police being called and a brief two-day one-to-one. Resident #5 stated that in the week of 2/9/26 the same resident continued to walk in and out of the room, causing fear and difficulty sleeping, and reported never being offered another room or having a STOP sign banner placed; a surveyor confirmed on 2/19/26 that no STOP banner was in use. Resident #8, also cognitively intact with depression, anxiety, and wheelchair use, reported that Resident #10 frequently entered the room despite a STOP banner, grabbed items, and on one occasion went to the roommate’s side of the bed, pulled pants down, and was about to pull down a pull-up, prompting both roommates to yell and one to hit Resident #10 with a grabber. Resident #7, with a BIMS of 15 and reliance on a power wheelchair, reported that Resident #10 entered the room when the roommate was absent, causing stress and fear due to limited ability to defend against an intruder, and stated that staff had been repeatedly informed of these concerns. Resident #1, bedbound and cognitively intact with a BIMS score of 15, reported that Resident #10 would come into the room at night, pull pants off, and stand at the bedside, and expressed fear of being hit, noting that the resident had already hit a friend and staff. During a surveyor observation on 2/19/26, Resident #10 was seen walking up and down the hallway, stopping at each doorway while residents inside their rooms, many eating, yelled for the resident to stay out or leave. Staff were present at the nurses’ station or walking around the unit, but no staff intervened to redirect Resident #10 during this observation. The Maryland Office of Health Care Quality determined that these concerns met the federal definition of Immediate Jeopardy related to lack of supervision, with a resident inappropriately wandering into multiple rooms and verbally or physically assaulting residents, and noted there were no documented interventions in place after 12/10/25 to address these ongoing behaviors. The facility’s initial and revised plans of removal were submitted and reviewed on 2/19/26, and the Immediate Jeopardy was not removed until 2/24/26 after verification that the accepted plan of correction had been implemented.
Removal Plan
- Have the identified resident evaluated by the medical director
- Prescribe antianxiety medication for the identified resident
- Place the identified resident on a 1:1 assignment until further notice
- Assess the residents with the identified concerns by the social worker
- Hold an ad hoc quality assurance meeting with the interdisciplinary team
- Complete education with facility staff on the Dementia protocol and Unmanageable Residents
Failure to Maintain Clean and Sanitary Resident Room and Bathroom
Penalty
Summary
Facility staff failed to honor a resident’s right to a safe, clean, comfortable, and homelike environment in one resident room (Room 209) during a review for safe/clean/comfortable/homelike environment. During an interview with Resident #2 in that room related to a complaint, the surveyor observed that the room’s curtains had red and brown spots scattered throughout, the floors contained paper trash and food and appeared dirty throughout, and the bedside commode placed over the toilet had brown material in all the crevices and on the seat. The bathroom also had a strong smell of urine and feces. These conditions demonstrated that staff did not ensure a sanitary and safe interior environment for the resident in that room. The deficiency was identified based on surveyor observation and interview with the resident, showing that the facility did not maintain the resident’s room and bathroom in a clean and sanitary condition, including visibly soiled curtains, dirty floors with debris and food, and an unclean bedside commode, along with strong odors of urine and feces in the bathroom.
Failure to Provide Comprehensive Discharge Summary and Proper Medication Transfer
Penalty
Summary
The facility failed to provide the receiving facility with a comprehensive discharge summary and appropriate handling of medications for a resident transferred out of the facility. A complaint investigation revealed that the receiving facility reported not receiving a discharge summary of the resident’s stay and not receiving all of the resident’s medications as discussed during pre-discharge planning. During interview, the discharging LPN stated she was not familiar with the discharge process, was unsure how to handle narcotics, and therefore did not send any narcotic medications with the resident, although she reported sending non-narcotic medications. Review of documentation showed a miscellaneous note indicating that a neurology team from the receiving facility later came to pick up some narcotics and signed a paper with a nurse from the discharging facility. When interviewed, the DON stated that narcotics are only sent with a physician’s order and produced printed prescriptions for the resident; however, record review did not show any physician order for narcotics to be sent with the resident, nor any documentation that a discharge note summarizing the resident’s stay, including all courses of treatment and care, was provided to the receiving facility. The deficiency centers on the lack of a documented discharge summary and the absence of documented orders and procedures for sending the resident’s narcotic medications at the time of discharge, as identified through interviews with staff and review of the resident’s records and the complaint file.
Failure to Complete Required PASARR Level II Referral for Resident With Intellectual Disability
Penalty
Summary
The facility failed to complete the required Level II Preadmission Screening and Resident Review (PASARR) referral for a resident with an intellectual disability. Record review on 2/20/26 at 11:00 AM showed a PASARR Level I screening form dated 10/12/23 that indicated the resident should have been referred for a Level II evaluation, but no Level II PASARR documentation was found in the resident’s record. During an interview at 11:15 AM on the same day, the Director of Social Work acknowledged that the resident’s diagnosis of intellectual disabilities had been overlooked at admission, despite the Level I form indicating that a Level II referral was required. On 2/24/26 at 2:15 PM, the Nursing Home Administrator was informed that the resident did not have the required PASARR Level II referral. The deficiency centers on the omission of the mandated Level II PASARR referral and associated documentation for a resident whose Level I screening and documented diagnosis of intellectual disabilities required such an evaluation, with the oversight confirmed by the Director of Social Work during the surveyor interview.
Failure to Complete Trauma-Informed Assessment After Alleged Resident-to-Resident Assault
Penalty
Summary
Surveyors found that the facility failed to provide trauma-informed care by not completing a trauma-informed assessment or care plan for a resident who experienced an alleged physical assault by another resident. A complaint reported that Resident #5 alleged another resident entered the room in the evening, grabbed both of the resident’s hands, and punched the resident in the face approximately five times. Record review showed that after this incident there was no documentation that a trauma-informed assessment had been conducted or that a trauma-informed care plan had been developed to address the resident’s trauma history or needs following the event. During an interview, Resident #5 was tearful and reported being in fear, afraid to go to sleep at night, and scared when the alleged perpetrator walked into the dining room. Interviews with facility leadership confirmed that trauma-informed assessments were expected to be completed at admission and after a change in condition, but this had not been done for Resident #5 following the reported assault.
Delayed Upload of Psychiatric NP Notes to Medical Record
Penalty
Summary
Surveyors identified a deficiency related to the timeliness of physician and NP documentation being available in the medical record following resident visits. For one resident reviewed during a complaint survey, the medical record showed multiple psychiatric evaluations and consultations by a psychiatric NP, but the completion dates of these assessments did not match the dates they were uploaded into the resident’s electronic record. In some instances, there was up to a month delay between the date the NP completed the evaluation and the date the note was uploaded into the miscellaneous section of the record. During review on one survey date, several psychiatric visit notes following an incident were not yet present in the resident’s record, despite the visits having already occurred. Further review and interviews with the NHA and DON confirmed that the process for handling the psychiatric NP’s documentation involved a delay between completion of the notes and their receipt and upload by facility staff. The DON reported that the staff member responsible for medical records uploads the NP’s documents as soon as they are received, indicating that the lag occurs before the notes reach the facility. Surveyors noted that this delay affected not only general progress notes but also notes containing medication changes, including an example where a note documenting an increase in Trazodone was completed on one date and not uploaded until several days later. The deficiency centered on the lack of timely availability of physician/NP notes in the resident’s medical record after visits and assessments had been completed.
Incomplete Facility Assessment of Current Resident Population and Service Needs
Penalty
Summary
Facility staff failed to complete a comprehensive facility-wide assessment that included all information required to determine necessary resources to care for residents competently during routine operations and emergencies. During an extended survey, reviewers found that the existing facility assessment primarily described services the facility offers, rather than functioning as an assessment of the current resident population. The assessment indicated that the facility offers tracheostomy and gastrostomy services, but did not document that any current residents actually required these services. At survey entrance, a resident matrix identified a resident with a tracheostomy, and subsequent record review showed that this same resident also had a gastrostomy tube for nutritional support. Despite this, the facility assessment did not reflect that any current residents needed tracheostomy or gastrostomy support. The assessment also referenced "supportive care" for behavioral/mental health providers but did not specify who provided this care or their qualifications (e.g., NP, physician, social worker), nor did it describe what support was provided or the type of clientele served. Multiple tours revealed residents in bed requiring staff assistance with ADLs and others independently mobilizing in wheelchairs or walking, yet the assessment did not include an actual evaluation of the current resident population for the assessed year. These concerns were discussed with the NHA during the survey.
Failure to Verify and Maintain Appropriate Nursing Licensure for Supervisory Role
Penalty
Summary
The deficiency involves the facility’s failure to ensure that employed nursing staff held active professional licenses consistent with state law and their job descriptions. A complaint alleged that a registered nurse was employed as an RN supervisor without an active license over a defined period. Review of this staff member’s personnel file showed that the individual held an RN license issued in Virginia with compact designation, but that license was suspended several months after issuance. The personnel file also listed Maryland as the staff member’s primary address. The Maryland Board of Nursing did not recognize this nurse’s license because the nurse graduated from a program that was not approved by the Board. Further review and interviews revealed that the nurse had an active Maryland LPN license and that her role at the facility was changed from RN to LPN supervisor, but the human resources representative could not recall or provide documentation of when this role change occurred. The HR representative stated that all RNs licensed from Florida had to either sit for the Maryland Board of Nursing exam or forfeit their license, and that this nurse forfeited the RN license, but HR could not provide documentation of when this occurred. In an interview, the nurse reported graduating from VMT Education Center and later sitting for the Maryland LPN boards, stating that she delayed testing because the school would not release her transcript due to unpaid tuition. Review of the Maryland Board of Nursing and VMT Education Center information showed that VMT was not recognized by the Board and had been removed from the approved list because it did not meet LPN qualifications, and that the nurse’s LPN license was issued months after the school’s removal from the approved list.
Failure to Maintain Safe and Functional Resident Room Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, comfortable, and functional environment in a specified resident room, resulting in multiple unresolved maintenance issues. During an interview in that room related to a complaint, a resident reported that staff had not ensured a safe interior environment. A subsequent tour of the room with the Maintenance Director identified that the bathroom grab bar next to the toilet was not firmly attached to the wall, and the bathroom floor tile was missing and cracked, making it difficult for residents to roll in and out of the bathroom using a wheelchair or walker. Additional observations included a cable cover plate that was not attached to the wall, a ceiling with visible water damage and marked brown areas, a nightstand with a broken handle, and damaged walls throughout the room with peeling paint and scrapes, particularly at the head of the beds. These conditions were directly observed by surveyors and were cited under F584 for failure to ensure a safe, easy to use, clean, and comfortable environment for residents, staff, and the public in that room.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to immediately report an incident of alleged abuse to the Office of Health Care Quality as required. Specifically, a resident alleged that a Geriatric Nursing Assistant sent a threatening text message indicating an intent to poison the resident. This allegation was not reported by the facility to the appropriate authorities; instead, the resident disclosed the incident to a surveyor during a previous survey, who then relayed the information to the Director of Nursing. Interviews with the Administrator did not yield any additional information regarding the incident or the reporting process.
Failure to Document Investigation of Abuse Allegation
Penalty
Summary
The facility failed to maintain documentation showing that an alleged abuse incident was thoroughly investigated. Specifically, a resident reported that a Geriatric Nursing Assistant sent a threatening text message, alleging intent to poison the resident. Upon review, the investigation file contained no evidence or documentation related to this abuse allegation. The Director of Social Services, who participated in the investigation, confirmed the absence of relevant documentation in the file. Further interview with the Nursing Home Administrator did not yield any additional information regarding the investigation.
Failure to Report Threatening Messages to Authorities
Penalty
Summary
The facility staff failed to report a threat of physical violence against a resident as required. A complaint was investigated regarding a staff member allegedly attempting to poison a resident. The resident's medical record indicated a history of behavioral problems, including verbal aggression and fabrication of care issues. Despite the facility addressing the resident's concerns and offering a room change, the resident received derogatory and threatening text messages, including one that expressed a wish to inflict physical harm. The resident shared these messages with the Unit Manager, who forwarded them to the Social Services Director. However, the facility did not report the threatening message to the proper authorities. Interviews with staff revealed that the Social Services Director attempted to identify the sender of the messages but was unsuccessful. The Administrator and Director of Nursing were unaware of the threatening nature of the messages until informed by the surveyor. The facility did not report the incident to the State Agency or the police until after surveyor intervention. The Administrator later confirmed that a report was sent to the State Agency and the police were contacted, but this was done only after the surveyor's involvement.
Failure to Suspend Staff and Missing Investigation Records
Penalty
Summary
The facility staff failed to prevent potential exploitation and did not provide evidence of a thorough investigation into alleged violations. In one incident, a resident alleged that a Geriatric Nursing Assistant (GNA) took their wallet containing $15 while making their bed. The facility conducted an investigation but was unable to substantiate the allegation. However, the investigation documentation did not show that the staff member in question was suspended pending the investigation's outcome. The staff schedules confirmed that the GNA continued to work during the investigation period. The Administrator was unable to provide evidence of the suspension and had not received any information from former staff before the exit conference. Additionally, the facility was unable to locate the investigation records for another facility-reported incident involving an abuse allegation. The Administrator indicated that the incident occurred under the facility's prior ownership, and the investigation records were retained by the previous owner. Despite reaching out to the prior owner and former administrators, the current Administrator was unable to retrieve the missing documentation. The facility acknowledged that they should have retained all resident records for at least five years, but the investigation documentation could not be found within the facility.
Failure in Discharge Preparation and Documentation
Penalty
Summary
The facility failed to adequately prepare a resident for discharge, as evidenced by a complaint review and staff interview. A complaint revealed concerns about the discharge planning and preparation for a resident, who was not provided with their personal belongings prior to discharge. Upon reviewing the discharge that occurred, it was found that the resident had not signed any discharge paperwork, including the discharge instructions and post-discharge plan review, as well as the resident property list. Additionally, the discharge paperwork lacked instructions for wound care. The Director of Nursing (DON) confirmed that the facility's process requires staff to review discharge planning with the resident, have them sign it, and scan it into the computer, which was not completed for this resident. The DON identified concerns regarding discharge preparations and a lack of documentation, as well as staff's failure to follow the facility's discharge planning and preparation process.
Failure to Address Resident's Vision Concerns
Penalty
Summary
The facility staff failed to address a resident's concerns regarding their inability to see with glasses provided by a contracted vision vendor. The issue was identified during a complaint survey involving one of 53 residents reviewed. The resident had an optometry exam in August 2024 and received new glasses shortly after. However, the resident reported to an ombudsman that they were unable to see with the new glasses. The ombudsman communicated this concern to the Director of Nursing (DON) via email in November 2024. Despite this communication, the DON was unaware of the issue until it was brought up during the survey in January 2025. Upon further inquiry, the DON acknowledged receiving the email but had not addressed the resident's concerns.
Inadequate Supervision Due to Low-Hanging Extension Cords
Penalty
Summary
The facility staff failed to provide adequate supervision to prevent an accident by not removing low-hanging extension cords from the 3rd floor ceiling. This issue was identified during a surveyor's observation on 1/24/25 at approximately 10:30 am, where extension cords connected to temporary lights were seen hanging from the ceiling tiles at the back of the 3rd floor unit. These cords were low enough to potentially hinder residents or visitors walking in the area adjacent to certain rooms. The deficiency arose after a water leak on 1/10/25 at approximately 5:00 pm, which affected the lighting on the 3rd floor. Contractors installed temporary lighting that required extension cords, which were not properly secured, creating a hazard. Interviews with the DON, Administrator, and Maintenance Director confirmed the circumstances leading to the installation of these temporary lights and the resulting hazard.
Failure to Implement Colostomy Care Orders
Penalty
Summary
The facility failed to implement physician care orders for a resident who was admitted with a colostomy. The resident was admitted to the facility following a colostomy procedure, which involves creating a stoma in the abdomen for waste discharge. Upon review of the medical records, it was found that there were no orders in place for the care and treatment of the resident's ostomy from late May to mid-July during the resident's intermittent stay at the facility. This lack of documentation and care was confirmed during a review with the facility's Director of Nursing (DON) and the Regional DON, who were unable to provide evidence that the resident received the necessary ostomy care during this period.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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