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
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
