Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Roland Park Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Poorly Maintained Resident Areas and Broken Fixtures: Surveyors observed multiple environmental issues in resident rooms and common areas, including torn chair vinyl, dark patches on a bedroom floor, peeling bathroom flooring, hanging cove base, marred and chipped bathroom doors, a hole in a resident room wall, black substance near a ceiling vent, a stopped-up toilet, and missing wall tiles. The Maintenance Director said he does scheduled maintenance and would address the areas needing repair.
Failure to provide written transfer and bed hold notices and timely Ombudsman notification. A resident transferred to the hospital did not have documented written notice to the representative about the bed hold policy or the transfer, and two other residents’ hospital transfers had no record of timely Ombudsman notification. The DON confirmed representatives were notified by phone rather than in writing, and the SSD stated Ombudsman notices were being sent in monthly email batches instead of at the time of transfer.
Posted menu meals were not consistently provided as planned, and meal tickets did not match what was served. A resident reported receiving the wrong items and too little food, while another resident said the food was not good and portions were insufficient. During lunch tray line observation, dietary staff ran out of meatloaf and green peas, so 8 residents received a substitute meal instead of the posted menu. The FSD and District FSD were present when the shortage occurred, and the LNHA was later notified.
Food Storage and Service Sanitation Deficiencies: Surveyors observed multiple kitchen sanitation issues, including personal items on a utility cart, nonfunctioning hand sinks, missing temp logs, and several opened food items in the freezer that were not dated. On a nursing unit, a food delivery cart with meal trays was left at the elevator undelivered, and items in the nourishment refrigerator were not labeled with the resident's name and date as required by policy.
Failure to Care Plan for Anticoagulant Use: A resident receiving Xarelto for DVT had an active order for anticoagulant side effect monitoring and an MDS coded for anticoagulant use, but the comprehensive care plan did not address anticoagulant medication usage. The DON acknowledged the missing care plan during survey review.
A resident did not receive documented quarterly care plan meetings as expected. The resident said it had been a while since the last meeting, and record review showed the last care plan meeting note was from 7/30/2025. The SS Director stated meetings were done quarterly after each quarterly comprehensive assessment, but the facility had no additional documentation showing another meeting had occurred, and the DON reviewed the concern.
Missing Communication Board for Resident with Trach: A resident with a trach stoma and oxygen humidifier attached to the trach site could only mouth words, and staff relied on lip reading to communicate. The surveyor could not understand everything the resident was trying to say, and no communication board was present at the bedside. An LPN confirmed there was no alternate communication method available, and the DON acknowledged the resident did not have a communication board.
A resident with dementia and a history of falls was lowered to the floor during morning care when a GNA working alone could not control the resident while turning them. The resident was later found to have left hip pain and was hospitalized with a left femur subacute fracture; MDSs showed the resident had been dependent for rolling and was not designated as a 2-person assist until after the fall.
Missing Oxygen Use Signage for Residents on Ordered Oxygen: Two residents with physician orders for O2 at 2 L via NC were observed in bed with oxygen concentrators in use, but no no smoking/oxygen in use signage was posted on their room doors or door frames. The DON was informed of the observations and stated she was surprised, and the facility policy required an Oxygen in Use sign on the outside of the room entrance door.
A resident’s MAR audit showed repeated late administration of multiple ordered meds, including pain meds, anticoagulants, anticonvulsants, steroids, and supplements. The doses were often given more than an hour after the scheduled time, with some evening meds not administered until after midnight or the next morning. The DON stated staff were expected to give meds within one hour before or after the ordered time.
Improper disposal of garbage and refuse was observed at the outside dumpster area during survey. Surveyors found trash on the ground, a bag of trash behind the dumpster, and the trash dumpster left open, and on follow-up the next morning they again observed scattered trash including an empty can of beans, empty juice cups, plastic gloves, and paper towels.
A resident’s record included an active order for anticoagulant side effect monitoring every shift, but there was no active physician order for an anticoagulant medication. The MDS assessments were not coded to show anticoagulant use, and the care plan did not include anticoagulant medication usage. The DON confirmed the resident did not have an anticoagulant medication order.
Missing Physician Order for Hospice Services: A resident receiving hospice had a hospice-coded MDS, a care plan for hospice services, and hospice agency notes in the chart, but the record initially lacked a physician order from the attending MD for hospice care. The DON acknowledged the missing order during survey review.
Incomplete QAPI Tracking and Missing PIP Documentation: The DON and ADON stated they jointly managed QAPI and that departments submitted monthly data, but they could not show documentation that data were regularly reviewed, analyzed, and acted upon. QAPI minutes showed blank action and PIP sections for multiple problem areas, including antipsychotic use, falls, wounds, infections, weights, and call light response time, and a later request for a PIP was met with an audit and an in-service instead of PIP documentation.
An unwrapped roll of toilet tissue was observed sitting on top of a red sharps bio-hazard container in a resident’s bathroom. An LPN and the DON were informed, and the DON acknowledged it was an infection control issue. The finding involved 1 of 64 residents reviewed during the annual survey.
A resident who was alert and oriented, non-verbal except for mouthing words, and had right-sided weakness and a trach stoma with O2 humidification was observed in a wheelchair with the call bell tucked inside the nightstand drawer and out of reach. An LPN confirmed the call bell had been placed there and acknowledged the resident would not be able to call for help if unable to reach it; the DON stated staff are expected to keep call bells within reach.
A facility failed to maintain a safe and comfortable laundry room environment. Surveyors observed a dryer with an exterior piece leaning against it, exposing parts of the dryer below the drying area, and a horizontal hole in the wall near the doorway between the clean and dirty laundry rooms. An LNA stated the conditions had been present since she started working there about a month earlier.
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.
Poorly Maintained Resident Areas and Broken Fixtures
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents based on multiple observations of poor physical plant conditions during the survey tour. Surveyors observed dark patches all over a bedroom floor, a vinyl chair cover torn in three places, raised and peeling vinyl flooring in a bathroom behind the toilet extending to the sink, and a section of cove base hanging off the wall behind an entrance door. These conditions were observed in resident areas during the initial tour of the facility. Additional observations on the Mount [NAME] Nursing Unit showed several resident rooms and common areas not in good repair, including marred bathroom doors, a marred wall behind a resident's bed, chipped wood on bathroom doors, a hole in a resident room wall, black substance on the ceiling and wall near a ceiling vent, a toilet that was stopped up and would not flush, and missing wall tiles in the nourishment room. During a later tour with the Maintenance Director, the surveyor again observed the hole in the wall, the marred and chipped bathroom doors, and the missing wall tiles. The Maintenance Director stated he performs scheduled maintenance and would get right on the areas needing repair and order the necessary items.
Failure to Provide Written Transfer and Bed Hold Notices and Timely Ombudsman Notification
Penalty
Summary
The facility failed to ensure that written information about the bed hold policy was provided to a resident’s representative when the resident was sent to the hospital. For Resident #3, the medical record showed a Bed Hold Agreement dated 2/11/2026 with handwritten wording indicating consent over the phone and a signature on the document. During interview, the DON stated that if a resident could acknowledge and sign the document, staff would provide it to them, but otherwise staff would call the resident representative, note the communication on the document, and sign. The facility also failed to provide written notice of transfer to a resident’s representative when Resident #3 was transferred to the hospital. The SNF/NF to Hospital Transfer Form dated 2/11/2026 indicated the representative was notified by telephone and aware of the clinical situation, but the record did not show that written notice was provided. In addition, the facility failed to timely notify the Ombudsman of hospital transfers for Resident #13 and Resident #73. Record review showed Resident #13 transferred to the hospital for critical abnormal lab values, and Resident #73 transferred to the hospital on 2/18/2026 and 3/8/2026, with no indication in the records that the Ombudsman was notified of these transfers. The DON identified Social Services as responsible for Ombudsman notification, and the SSD stated he had been sending monthly email lists of transfers and discharges rather than notifying the Ombudsman at the time of the hospital transfers.
Posted Menu Meals Not Provided as Ordered
Penalty
Summary
The facility failed to ensure that residents received the posted menu meal on time and that meal tickets matched the meals provided on resident trays. Resident #80 stated during interview that the food was awful, portions were not enough, and the meal on the tray did not match the meal ticket. The resident also stated that he or she was supposed to receive 2 juices and double portions of the meal, but only received 1 juice and not enough food. The meal ticket reviewed for breakfast on 4/14/2026 indicated 2 juices and entree x2 portions. Resident #123 also stated that the food was not good and that there was not enough food provided. Record review showed Resident #80 had physician orders for a Heart Healthy, Controlled Carbohydrate, regular consistency diet, and Resident #123 had orders for a Regular diet, Regular texture, and Regular (thin) liquid consistency. During observation of the lunch tray line on 4/16/2026, the tray line began at 11:27 AM and was completed at 1:15 PM. The posted lunch menu was Farmer's Meatloaf, mashed garlic potatoes, green peas, brown gravy, and strawberry shortcake parfait. During service, the dietary department ran out of meatloaf and green peas and did not have enough food to prepare the posted meal for 8 residents on the Cross Keys Nursing Unit. Those residents received a substitute lunch of beef slices, corn, mashed garlic potatoes, brown gravy, and strawberry shortcake parfait. The Food Services Director and District Food Services Director were present when the food ran out, the Food Services Director prepared the substitute beef slices, and the District Director went to another facility to obtain meatloaf. The Licensed Nursing Home Administrator was notified later that afternoon that the kitchen had run out of the posted menu meal.
Food Storage and Service Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and served in accordance with professional standards for sanitation and food service safety. During a kitchen tour, surveyors observed multiple sanitation concerns, including employee personal items on a utility cart, one hand sink with no running water and another with standing water that would not drain, a hole in the wall by the kitchen window, missing temperature documentation for a reach-in refrigerator on two dates, several food items in the walk-in freezer that were opened but not dated, ice buildup on the freezer ceiling and door, and a black substance near the baseboard in the dry storage room. The Licensed Nursing Home Administrator and the Food Services Director were notified of these concerns during the survey. On the Mount [NAME] Nursing Unit, surveyors observed a food delivery cart sitting at the elevator with meal trays still inside the cart and two meal trays on top of it that had not been delivered to residents. The Unit Manager stated she thought the trays had already been delivered. Later, the nourishment refrigerator on the unit was observed with resident food items that were not labeled with the resident's name and date, including a Pepsi bottle, cranberry juice bottle, plastic bag of grapes, and a gray lunch bag with orange trim. The Unit Manager confirmed that food items in the nourishment refrigerator were expected to be labeled with the resident's name and date, and the facility policy for foods brought by family and visitors stated that foods stored in the refrigerator are labeled with the resident's name and dated.
Failure to Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was receiving anticoagulant therapy. The resident stated during interview that he/she takes a blood thinner. Record review showed an active physician order for Rivaroxaban (Xarelto) 10 mg by mouth at bedtime for DVT, with an order date of 2/12/2026, and an active order for Anticoagulant Side Effect Monitoring every shift for anticoagulant use. The resident’s MDS 5-Day assessment dated 2/19/2026 was coded to indicate anticoagulant medication use. However, review of the comprehensive care plan showed no plan of care addressing anticoagulant medication usage. During interview, the DON stated that anticoagulant medication should be addressed on the resident’s care plan. After the surveyor reviewed the physician orders, MDS assessment, and care plan with the DON, the DON acknowledged that the resident did not have a comprehensive care plan for anticoagulant medication usage.
Missed Quarterly Care Plan Meeting
Penalty
Summary
The facility failed to ensure that Resident #6 received quarterly care plan meetings. During interview, the resident stated they were unaware of the last care plan meeting and said it had been a while. Review of the medical record showed the last documented care plan meeting was on 7/30/2025. The Social Services Director stated that care plan meetings were done quarterly after each quarterly comprehensive assessment, but when asked for documentation of the most recent meeting for Resident #6, the facility could only provide the 7/30/2025 note and had no further documentation showing that a care plan meeting had been held since that date. The Director of Nursing reviewed the concern and indicated understanding.
Missing Communication Board for Resident with Trach
Penalty
Summary
The facility failed to provide communication tools for a resident who was unable to communicate appropriately. Resident #12 was observed sitting in a wheelchair beside the bed in the room with a trach stoma in the neck and an oxygen humidifier attached to the trach site. The resident could only mouth words, and the surveyor was unable to understand everything the resident was trying to say. There was no communication board in sight or at the bedside during the observation. During interview, the resident's LPN stated that she reads lips to communicate with the resident and that the resident takes time to communicate, but confirmed there was no current communication board at the bedside. She also stated there was no alternate means of communication for people who could not read lips or understand the resident. Review of the care plan documented that the resident has a trach and that means of communication should be provided, but none was at the bedside. The DON stated that residents who have trouble communicating should have a communication board at the bedside and acknowledged that Resident #12 did not have one.
Failure to Provide Adequate Supervision During Bed Mobility
Penalty
Summary
Facility staff failed to provide adequate supervision to prevent a vulnerable resident with cognitive impairment and a history of falls from being lowered to the floor during morning care. On 6/24/25, a nurses' aide reported that while providing care and turning the resident on their side for cleanup, the aide could not control the resident and lowered them to the floor. The resident was assisted back to bed, assessed, and no injuries were noted at that time; the physician was notified. The resident later complained of left hip pain, pain medication was given, and an X-ray was ordered. Further review showed the X-ray results led to transfer to the hospital, where the resident was admitted with diagnoses including left femur subacute fracture, COPD, pneumonia, hypoxia, and dementia. MDS assessments dated 11/10/24, 2/10/25, and 5/13/25 documented the resident as dependent for rolling left and right, and the DON provided documentation showing the resident was not designated as a two-person assist until 7/2/25, after the fall and hospital return. The GNA who witnessed the incident confirmed they were doing morning care alone and could not control the resident while turning them, resulting in the resident being guided to the floor between the bed and cabinet.
Missing Oxygen Use Signage for Residents on Ordered Oxygen
Penalty
Summary
Appropriate respiratory care and services were not maintained for two residents who had physician orders for oxygen at 2 liters via nasal cannula. On 4/14/2026, the surveyor observed Resident #27 and Resident #66 in bed, both in no distress, with oxygen concentrators at the bedside and oxygen in use. During these observations, there was no no smoking/oxygen in use signage on either resident’s door or door frame to indicate that oxygen was being used. A record review on 4/15/2026 confirmed that both residents had physician orders for oxygen 2 liters via nasal cannula. In an interview the same day, the DON was informed that both residents had oxygen concentrators in their rooms with oxygen in use but no oxygen signage was posted on the room doors or door frames. The DON stated she was surprised as the facility used a lot of oxygen. The facility’s Oxygen Therapy Policy dated 12/25 stated that an Oxygen in Use sign should be placed on the outside of the room entrance door.
Late Medication Administration
Penalty
Summary
The facility failed to ensure that Resident #136 received pharmaceutical services to meet the resident’s needs regarding timely medication administration. The report states that medications were ordered by the physician for specific times and that medications should be administered within an hour before or after the ordered time. During review of Complaint #2968846, the surveyor identified multiple instances in January and February 2026 in which Resident #136’s medications were administered late compared with the scheduled times on the MAR. Resident #136 was admitted to the facility on an unspecified date and was discharged on 2/14/2026. The MAR audit showed repeated late administration of several medications, including Atovaquone, Tramadol, Vitamin D-3, Dexamethasone, Flomax, Levetiracetam, Apixaban, Temozolomide, Amlodipine Besylate, Oxycontin, Gabapentin, Pantoprazole, and Ondansetron. Some doses were given more than an hour late, and several scheduled evening doses were documented as being administered after midnight or the following morning. On 4/17/26, the DON stated that staff expectations were to administer medications between one hour before and one hour after the scheduled time, and that the MAR audit times reflected when the nurse administered the medications. The surveyor reviewed the late medication list with the DON, and she indicated that she understood the concern.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Improper disposal of garbage and refuse was identified during the annual recertification survey at the outside dumpster area. During the initial tour, surveyors observed multiple pieces of trash on the ground outside the trash dumpster, a bag of trash behind the dumpster, and the trash dumpster left open with the attached lid not closed. On follow-up the next morning, surveyors again observed multiple pieces of trash on the ground outside the dumpster area, including an empty large can of beans, empty juice cups, plastic gloves, and paper towels.
Inaccurate record for anticoagulant monitoring
Penalty
Summary
Resident #27’s medical record contained an active physician order for anticoagulant side effect monitoring every shift, including observation for signs and symptoms of bleeding or bruising, documentation of unusual findings in a progress note, and notification of the provider. However, the record did not contain an active physician order for any anticoagulant medication. The surveyor reviewed the record on 4/15/2026 and found that the monitoring order remained in place despite the absence of a corresponding anticoagulant medication order. Further review showed that Resident #27’s MDS assessments dated 1/30/2026 for Quarterly and 8/8/2025 for Medicare 5 Day were not coded to indicate that the resident was taking an anticoagulant medication. The current care plan also did not include a care plan for anticoagulant medication usage. During interview, the DON confirmed that Resident #27 did not have a physician order for an anticoagulant medication.
Missing Physician Order for Hospice Services
Penalty
Summary
The facility failed to have a physician order for hospice care and services for one resident who was documented as receiving hospice. Resident #73’s electronic record showed Hospice Medicaid MD as the primary payer as of 3/12/2026, a significant change MDS assessment coded for hospice, and a comprehensive care plan initiated on 3/13/2026 for hospice services with [NAME] Hospice Care, INC. Surveyor review also found hospice progress notes, evaluations, and a plan of care from the hospice agency in the resident’s record, but no physician order from the attending nursing home physician for hospice care and services. During the survey, the DON was informed that the resident was under hospice services and that the record contained a hospice-coded MDS and hospice care plan, but no physician order for hospice. The DON acknowledged that the resident should have a physician order for hospice care. On follow-up record review, the resident’s chart then contained a physician order from the attending physician for admit to hospice, entered by phone with the current primary physician.
Incomplete QAPI Tracking and Missing PIP Documentation
Penalty
Summary
The facility failed to track QAPI performance to determine whether improvements were realized and sustained, and it failed to conduct at least one annual Performance Improvement Plan/Project focused on problem-prone areas identified through data collection and analysis. During review of the facility’s QAPI process, the DON and ADON stated they were jointly responsible for QAPI and that departments submitted monthly data for the QAPI meeting. However, when asked how the collected data were regularly reviewed, analyzed, and acted upon, the ADON described examples such as staff in-services and weekly wound team meetings, but no documentation was provided to show ongoing review and follow-through. Surveyors reviewed QAPI meeting minutes that showed incomplete documentation. The 10/22/25 minutes listed an antipsychotic benchmark with 23 residents receiving antipsychotics and 19 with a qualifying diagnosis; the goal met column was marked no, but the action and PIP columns were blank. The same minutes listed call light response time, MOLST, UTI, wounds, and residents with significant weight loss greater than 5% in 30 days, but no goal status, action plan, or PIP was documented for those areas. The 11/26/25 minutes documented 5 resident falls with actions such as PT/OT, fall mats, toileting schedule, and purposeful rounding, while the 12/11/25 minutes documented 24 falls, 3 residents with multiple falls, and 2 residents with fall-related injuries, but no action plan or PIP was documented. The 1/29/26 minutes did not address falls, wounds, weights, or infections, and no goals or actions were documented. When asked to explain the increase in falls from November to December, no response was given, and the ADON later stated the facility was lacking documentation. When asked to provide a PIP addressing a high-risk issue identified during QAPI, the DON instead provided an audit for residents requiring assistance with bed mobility and then an in-service related to medication administration, with no PIP documentation provided.
Unwrapped Tissue Placed on Sharps Container
Penalty
Summary
The facility failed to maintain the resident care environment in a manner that minimized the potential spread of infection when an unwrapped roll of white toilet tissue was observed sitting on top of the red sharps bio-hazard container in Resident #8's bathroom. During the initial observation, the tissue was noted on top of the sharps container, and later the unwrapped tissue was shown to an LPN, who stated housekeeping would be called to dispose of it. The DON was also informed and acknowledged that unwrapped tissues on the sharps container was an infection control issue. The deficiency involved 1 of 64 residents reviewed during the annual survey.
Call Bell Not Within Reach of Dependent Resident
Penalty
Summary
The facility failed to have a call bell within reach of a dependent resident. During observation, the resident was found sitting in a wheelchair to the right side of the bed, with the bed positioned between the wheelchair and the nightstand. The call bell was tucked away on the top drawer of the nightstand to the left and out of the resident’s reach. The resident was alert and oriented, had a trach stoma in the neck with an oxygen humidifier attached to the trach site, could only mouth words, and had weakness on the right side. During interview, the resident’s nurse, an LPN, stated the resident could use the call bell but then found it inside the top drawer of the nightstand. The LPN said whoever made the bed that morning must have placed it there and acknowledged that the resident, who was non-verbal and wheelchair bound, would not be able to call for help if unable to reach it. The DON stated staff are expected to answer call bells within 5 minutes and make sure they are always within reach of residents, and she acknowledged the concern.
Laundry Room Environmental Deficiencies
Penalty
Summary
The facility failed to ensure residents and staff had a safe and comfortable environment, as observed in the laundry room. During an observation, the dryer closest to the wall had an exterior piece at the bottom leaning against it, and when the surveyor moved that piece, parts of the dryer below the drying area were exposed. The surveyor also observed a horizontal hole in the wall to the right of the door leading from the clean laundry room into the dirty laundry room, measuring approximately 8 inches long and 2 inches wide. A Laundry Aide stated she had started at the facility about a month earlier and that the hole in the wall and the lower part of the dryer had been like that since she began working there.
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.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Keswick Multi-care Center | 0.9 mi | ★★★★★ | 23 | 0 |
| Autumn Lake Healthcare At Alice Manor | 1 mi | ★★★★★ | 1 | 0 |
| Northwest Healthcare Center | 1.3 mi | ★★★★★ | 18 | 0 |
| Levindale Hebrew Ger Ctr & Hsp | 1.4 mi | ★★★★★ | 11 | 1 |
| Blue Point Healthcare Center | 1.5 mi | ★★★★★ | 27 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.