Roland Park Rehabilitation and Healthcare Center

Inspectors wroteBased on observations and interviews it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment for Residents. This finding was found to be evident during the tour of the facility for review of the physical environment.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure 1) written information was provided to a resident's representative regarding the facility's bed hold policy, and 2) written notice of the transfer was provided to a resident's representative upon transfer to the hospital and 3) failed to provide timely notification to the facility's Ombudsman when Residents transferred to the hospital. This was evident for 3 (Resident #3, #13, and #73) out of 6 residents reviewed for hospitalization and discharge process.

Inspectors wroteBased on observations, interviews and record reviews it was determined that the facility failed to ensure that the Residents received the posted menu meal timely and the meal ticket matched the provided meal on Resident trays. This finding was found to be evident in 10 (Resident #80, #123, 6, 31, 60, 77, 91, 92, 100 and 111) out of 10 Residents reviewed for food and nutrition services.

Inspectors wroteBased on observations, interviews and record reviews, it was determined that the facility failed to ensure that food was stored and served in accordance with professional standards for sanitation and food service safety. This finding was found to be evident in the kitchen and on the Mount [NAME] Nursing Unit during the annual recertification survey.

Inspectors wroteBased on interviews and surveyor record reviews it was determined that the facility failed to develop and implement a comprehensive care plan for a Resident. This finding was found to be evident in 1 (Resident #119) out of 1 Resident reviewed for anticoagulant medication usage.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that a resident received quarterly care plan meetings. This was evident for 1 (Resident #6) of 4 residents reviewed for care planning.

Inspectors wroteBased on observation, interviews and record reviews, it was determined that the facility failed to provide communication tools for a resident who is unable to communicate appropriately. This was evident for 1 (Resident #12) of 1 resident reviewed for language and communication during the annual survey.

Inspectors wroteBased on observation, medical record review, and staff interviews, facility staff failed to provide adequate supervision to prevent Resident #1, a vulnerable, cognitively impaired resident with a history of falls, from experiencing a fall that resulted in a major injury. This was evident for 1(Resident #1) of 64 residents reviewed during the annual survey.

Inspectors wroteBased on observations, interviews and surveyor record reviews it was determined that the facility failed to maintain appropriate respiratory care and services. This finding was found to be evident in 2 (Resident #27 and #66) out of 2 Residents reviewed for oxygen usage.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure a resident received pharmaceutical services to meet their needs regarding timely medication administration. This was evident for 1 (Complaint #2968846) of 5 complaints reviewed during the annual survey.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to dispose of garbage and refuse properly. This finding was found to be evident in review of the outside dumpster area during the annual recertification survey.

Inspectors wroteBased on interview and surveyor record review it was determined that the facility failed to maintain an accurate medical record for a Resident. This finding was found to be evident in 1 (Resident #27) out of 1 Resident reviewed for Resident records.

Inspectors wroteBased on interviews and surveyor record reviews it was determined that the facility failed to have a physician order for a Resident to receive Hospice care. This finding was found to be evident in 1 (Resident #73) out of 2 Residents reviewed for Hospice Services.

Inspectors wroteBased on staff interviews, review of pertinent documentation including the facilities Quality Assurance and Performance Improvement (QAPI) policy, and survey findings, it was determined the facility staff failed to 1.) track performance to ensure improvements are realized and sustained and 2.) failed to conduct at least one Performance Improvement Plan/Project (PIP) annually that focuses on problem prone areas identified by the facility through data collection and analysis. This was evident during review of the facilities Quality Assurance program.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to ensure that the environment of resident care was maintained in a manner that minimized the potential spread of infection as evidenced by an unwrapped toilet tissue roll placed on top of the red sharps bio-hazard container. This was evident for 1 (Resident #8) of 64 residents investigated during the annual survey.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to have call bells within reach of a dependent resident. This was evident for 1 (Resident #12) of 1 resident reviewed for language and communication during the annual survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure residents and staff had a safe and comfortable environment. This was evident for 1 of 1 observation made in the facility laundry room.

Inspectors wroteBased on medical record review and interview with facility staff and residents, it was determined that the facility failed to provide adequate supervision of Resident #10 with known wandering, aggressive, and inappropriate behaviors to ensure the safety of Resident #10 and other residents. This finding was evident during the review of multiple complaints for 4 of 4 residents(#5, # 8, #7, and #1 ) on the 3rd floor. The Maryland Office of Health Care Quality (OHCQ) determined that concerns met the Federal definition of Immediate Jeopardy and the facility was notified in writing of this determination at 3:10 PM on 2/19/26.

Inspectors wroteBased on surveyor observation and interview with staff it was determined the facility staff failed to provide a safe, clean, comfortable, and homelike environment for residents. This was evident for 1 (Room # 209) of 3 resident rooms observed during review for Safe/Clean/Comfortable/Homelike Environment.

Inspectors wroteBased on the review of a complaint 2748952 regarding a planned discharge, it was determined that the facility failed to provide the receiving facility with a comprehensive discharge summary of the residents stay in the facility. This was evident for 1 of 1 resident (11) reviewed for discharge.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to refer residents to the appropriate state-designated authority for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination. This was evident for 1 resident (Resident #2) of 1 residents reviewed for PASSAR during the complaint survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to develop and implement a process to determine if residents with a history of trauma received the appropriate trauma informed care. This was evident for 1 (#5) of 2 residents reviewed for trauma informed care.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the physicians failed to have their notes in the medical record timely after seeing the resident. This was evident for 1 of 1 (#10) Residents reviewed during a complaint survey.

Inspectors wroteBased on record review and staff interview, it was determined that facility staff failed to complete a facility assessment with all the information as required. This was evident during the extended survey review.

Inspectors wroteBased on review of employee files and interviews with facility staff it was determined that the facility failed to employee staff with active professional licenses relevant to their hired job descriptions. This was evident during the review of 1 of 2 employee files, (Staff #7)

Inspectors wroteBased on observations it was determined that the facility failed to maintain a safe, sanitary, comfortable, and functional environment for the residents in room [ROOM NUMBER].

Inspectors wroteBased on surveyor review of a facility reported incident and facility staff interview, it was determined that the facility failed to immediately report an incident of alleged abuse by a resident to the Office of Health Care Quality. This finding was evident for 1 (Resident #62) of 4 residents selected for an abuse investigation. This finding is related to facility reported incident # MD00214230.

Inspectors wroteBased on review of a facility reported abuse allegation and interview it was determined that the facility failed to maintain documentation that alleged abuse was thoroughly investigated. This was evident for 1 of 3 facility reported incidents reviewed during the survey. This finding is related to facility reported incident # MD00214230.

Inspectors wroteBased on record review and resident and staff interviews, it was determined that the facility staff failed to report a threat of physical violence against a resident as required. This was evident for 1 (#39) of 53 residents reviewed during the survey.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility staff 1) failed to prevent further potential exploitation while an investigation was in progress, and 2) failed to have evidence that all alleged violations are thoroughly investigated. This was evident for 2 facility reported incidents reviewed for 1 (#11) of 53 residents reviewed during the survey.

Inspectors wroteBased on the review of a complaint, staff interview and medical record review, it was determined that the facility failed to adequately prepare a resident for discharge. This was evident for one resident during the review of 1 of 3 complaints regarding discharges. (Resident #23)

Inspectors wroteBased on medical record review and staff interview, the facility staff failed to address a resident's concerns (resident # 49) of not being able to see from glasses received from a contracted provider in 8/2024. This was evident for 1 of 53 residents reviewed during a complaint survey.

Inspectors wroteBased on surveyor observation and staff interview, the facility staff failed to provide supervision to prevent an accident when the facility staff failed to remove low-hanging extension cords from the 3rd floor ceiling. This would affect all residents and visitors on the back of the 3rd floor unit.

Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to implement physician care orders for a resident admitted with a colostomy. This was evident for 1 (#41) of 3 residents reviewed related to a complaint about colostomy care.

Inspectors wroteBased on resident interview, it was determined that the facility failed to ensure residents have a choice in recreational activities. This was true for 5 (#4, #9, #26, #50, and #64) out of the 7 residents representing the resident council.

Inspectors wroteBased on staff interview and observation, it was determined the facility staff failed to promote care for residents in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality by labeling residents as feeders on a posted staffing board. This occurred on 1 of 2 nursing unit staffing boards.

Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to notify the residents or responsible party in writing of the reason for Residents (#87, and #102) transfer to the hospital. This was evident for 2 of 6 resident reviewed for hospitalization during the annual recertification survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to notify the resident or the resident's responsible party in writing of the facilities bed-hold policy before transferring them to the hospital. This was evident for 2 (Residents #87 and #102) of 6 residents sampled for investigations.

Inspectors wroteBased on medical record review, resident and staff interviews, it was determined that the facility staff failed to accurately transcribe a written physician order (Resident #1). This is evident for 1 of 3 resident's selected for infections review during the annual survey.

Inspectors wroteBased on record review, observation and interview, it was determined the facility staff failed to have the appropriate interdisciplinary team members attend a Resident's care plan meeting (#304) and failed to maintain a fluid restriction as ordered by the physician for Resident #35. This was evident for 2 of 4 residents reviewed for nutrition during the annual survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed ensure a resident was free from un-necessary medication by failing to discontinue the medication Lorazepam as ordered by the Physician for Resident (#77). This was evident for 1 of 53 residents selected for review during the annual survey.

Inspectors wroteBased on observations and staff interview during facility environmental observations, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed on both resident care areas 2nd and 3rd floors of the facility.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to develop comprehensive person-centered care plans with goals that were measurable. This was evident for 3 (#3, #51, and #54) of 27 residents investigated.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to evaluate resident care plans. This was evident for 4 (#3, #51, #54, and #89) of 54 residents investigated during the annual survey.

Inspectors wroteBased on observation, staff interview and facility documentation review, it was determined the facility failed to discard medications/biologicals after the expiration date. This was evident for 3 of 5 medication carts observed on 1 of 2 nursing units.

Inspectors wroteBased on review of facility Quality Assurance & Assessment (QA&A) activities, previous survey results, and interview with facility staff, it was determined that the facility failed to remain free of repeat citations from previous surveys. This failure to remain free of repeat citations is evidence that the facility's efforts to correct citations have not been effective. This was true for 5 of 18 (F584, F609, F641, F656, & F812) citations assessed on this annual recertification survey.

Inspectors wroteBased on record review, interviews,and facility investigation it was determined that the facility failed to keep a resident free from verbal abuse as evidenced by reports of a resident being verbally abused by a staff member. This was evident during the review of facility reported incident MD00127467.

Inspectors wroteBased on record review and interviews and review of the facility investigation, it was determined that the facility staff failed to report an allegation of verbal abuse immediately. This was evident during the review of facility reported incident MD00127467.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility staff failed to initiate a significant change MDS assessment for (Residents #112). This was evident for 1 out of the 7 residents reviewed. A significant change in status assessment is a comprehensive assessment that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either a major improvement or decline. When a resident is enrolled is a hospice program a significant change in status assessment.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#107) of 5 residents reviewed for accidents and 1 (#65) of 3 residents review for dental services.

Inspectors wroteBased on medical record review and interviews with staff, it was determined that the facility staff failed to provide a resident with a copy of his/her baseline care plan. This was evident for 1 (#207) of 1 residents reviewed for care plan. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.

Inspectors wroteBased on medical record review, observation and staff interview, it was determined the facility failed to follow physician's orders and the care plan for potential for altered skin integrity for a resident who was totally dependent on staff for all mobility needs and by failing to administer routine medication for pain and anticogulation as per the resident's plan of care and physicians orders. This was evident for 1 (#54) of 5 residents reviewed for positioning and for 1 (#207) of 4 residents reviewed for pain management.

Inspectors wroteBased on surveyor observation, it was determined that the facility staff failed to serve food in a sanitary manner. This was observed during 1 of 3 dining observations.

Inspectors wroteBased on medical record review, observation and staff interview it was determined the facility failed to accurately document in resident medical records as evidenced by licensed nursing staff signing off that treatments were implemented when the treatments were observed not implemented. This was evident for 1 (#54) of 5 residents reviewed for positioning, 1 (#207) of 7 residents reviewed for medication review, 1 (#58) of 8 residents reviewed based on facility complaints, and for 1 of 1 resident reviewed for hospice care.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 3 (#109, #3, #94) of 6 residents reviewed that were transferred to an acute care facility.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy when the resident was transferred to an acute care facility. This was evident for 3 (#109, #3, #94) of 6 residents reviewed that were transferred to an acute care facility.