Towson Rehabilitation and Healthcare Center

Inspectors wroteBased on record review and interview and observation, it was determined that the facility failed to provide an environment that was free of accidents and hazards for residents. This deficient practice resulted in harm to Resident #7 and was evident for 1 (Resident #7) of 2 residents reviewed for quality of care complaints and 1 (Resident #4) of 3 residents reviewed for complaints of neglect. This was also evident during random observations on 3 of 3 nursing units.

Inspectors wroteBased on observations completed during tours of the facility on the second floor, it was determined that the facility failed to ensure the furniture provided in each resident room including dressers were functional and accessible to each resident. This was evident for 13 of 28 rooms observed on the second floor. During general observations and tour on 7/17/26 at 9:03 AM of the functionality and cleanliness of rooms, secondary to complaints 3047231 and 3029891 the following rooms were observed to have non-functioning dressers, determined by either; dresser drawers on observation hanging open off the tracks, observed from the doorway or drawers were unable to easily be opened, when tested after permission obtained from the resident. A follow-up tour with the facility NHA was completed on 7/22/26 at 10:26 AM. [...]

Inspectors wroteBased on multiple observations and interviews with staff, it was determined that the facility failed to keep a safe, sanitary and clean environment for the residents. This was noted on 2 of 3 floors throughout the course of the survey.

Inspectors wroteBased on medical record review and interview with facility staff and the review of a facility reported incident (FRI), the facility failed to implement appropriate interventions for the prevention of future occurrences of all types of abuse. This was evident during the review of 1 of 2 facility reported incidents. (Resident #2)

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 and to have the most accurate resident medical information in the physician notes. This was evident for 2 of 2 residents (Resident #9 and #1) reviewed during a complaint survey.

Inspectors wroteBased on observation, record review, and interview, it was determined that facility staff failed to ensure the resident had a medication error rate of less than 5%. This was evident for 2 (#10 and #11) of 3 residents' observed for medication administration.

Inspectors wroteBased on record review and interview, it was determined that facility staff failed to ensure that the resident's medication records were complete (Resident #4 and #7) and failed failed to provide residents with an updated bed hold policy when there was a change in Administration (Resident #1 and #5). This was evident for 4 of 9 medical records reviewed during the complaint survey.

Inspectors wroteBased on observation, record review, and interview, it was determined that facility staff failed to implement an effective infection prevention and control program. This was evident during a medication administration observation and evident during random observations on the nursing units conducted during the complaint survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, as evidenced by the failure to timely 1) implement physician orders pertaining to wound consultations or wound treatment, and 2) implement recommended wound care treatments following wound consultations. This was evident for 3 (Resident #14, #5, and #16) of 4 residents reviewed for wounds during the recertification/complaint survey.

Inspectors wroteBased on the kitchen tour and staff, it was determined that the facility failed to ensure that stored food items were labeled and were not expired. This was evident during the initial kitchen tour during the recertification/complaint survey. Findings Included:During the initial kitchen tour on 02/09/2026 at 7:44 AM, the following deficient practices were revealed:An initial observation of the kitchen staff revealed that one staff member, Staff #27 (the cook) was preparing breakfast; however, Staff #27 did not wear a hairnet as required. On 02/09/2026 at 7:54 AM, An observation of the refrigerators revealed the following conditions: Wholesome Farm Low-Fat Cottage Cheese (5 lbs): One open container was present. A second, un-opened container, both had a Best If Used By date of 1/30/2026; Prepared Cheese: A container was labeled with a prep date of 1/3/26 and a Used By date of 1/27/2026; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to appropriately assess and determine the clinical appropriateness of self-administration of medications. This was evident for 1 (Resident #14) of 1 resident reviewed for medication self-administration during the recertification/complaint survey.

Inspectors wroteBased on interviews with facility staff and review of medical records, it was determined that the facility failed to ensure that physicians and resident representatives (RPs) were notified of changes in resident conditions. This was evident for 1 (Resident #101) out of 3 residents reviewed for skin conditions (non-pressure related) during the facility's recertification/complaint survey.

Inspectors wroteBased on review of medical records and interviews with facility staff, it was determined that the facility failed to ensure a baseline care plan, including a current list of medications, was provided to the resident and/or resident representative (RP) and documented in the medical record. This was evident for 2 (Resident #51 and #3) out of 41 residents reviewed during the facility's recertification/complaint survey.

Inspectors wroteBased on record review and interviews with facility staff, it was determined that the facility failed to ensure that physician orders were carried out accurately to ensure patient safety and quality care. This was evident for 1 (Resident #3) out of 5 residents reviewed for unnecessary medications during the facility's recertification/complaint survey.

Inspectors wroteBased on a record review and interviews, it was determined that the facility failed to ensure that residents received appropriate treatment to maintain vision abilities. This was evident for 1 (Resident #64) of 2 residents reviewed for communication and sensory problems during the recertification/complaint survey process. Findings Included:On 02/09/2026 at 1:00 PM: During an interview, Resident #64 reported experiencing visual impairment, a need to see an ophthalmologist, and that this request had not been fulfilled. The resident reported that the glasses at bedside did not work and special glasses were needed. On 02/11/2026 at 9:56 AM: Staff #22 (unit manager) was interviewed regarding the ophthalmologist process. She explained the standard procedure: [...]

Inspectors wroteBased on observations, interviews, and medical record review, the facility failed to provide necessary respiratory care, specifically the care of the oxygen nasal cannula. This was evident for 1 (Resident #12) of 1 resident reviewed for oxygen during the recertification/complaint survey.

Inspectors wroteBased on interviews with facility staff, review of pertinent documentation and medical record reviews, it was determined that the facility failed to ensure providers responded to the monthly pharmacy review reports and took action to address the recommendations. This was evident for 2 (Resident #3 and # 8) of 6 residents reviewed for unnecessary medications during the facility's recertification/complaint survey.

Inspectors wroteBased on observations, record review, and interview with facility staff, it was determined that the facility failed to ensure the medication error rate was less than 5%. This was evident for 2 medication errors out of 37 opportunities which resulted in a medication error rate of 5.41%.

Inspectors wroteBased on interviews with facility staff and residents and review of the medical record, it was determined that the facility failed to ensure medications were stored properly. This was evident for 1 (Resident #51) out of 41 residents reviewed during the facility's recertification survey.

Inspectors wroteBased on record observation and interviews, it was determined that the facility failed to serve food at an appetizing temperature. This was evident during the completion of the kitchen facility task during the recertification/complaint survey. Findings Included:On 02/09/2026 at 9:12 AM: Resident #10 reported hot foods were not hot. Resident #12 reported that food was sometimes served hot and sometimes not, and the taste was poor. On 02/09/2026 at 12:46 PM, another resident, Resident #4, reported that food was being served cold and sometimes it is due to the wait for assistance with feeding. On 02/13/2026 at 08:50 AM, the Food Service Director was informed to provide a test tray (sample tray) on the last food cart for delivery to the unit during the lunch time. On 02/13/2026 at 12:30 PM, observation of the last food cart delivery to the Terrace unit began. [...]

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to maintain the medical records on each resident that was accurately documented. This was evident for 2 behavioral monitoring assessments reviewed in the January 2026 Medication Administration Record (MAR) during the recertification/complaint survey.

Inspectors wroteBased on observation, interview, and medical record review it was determined the facility failed to: 1) ensure staff donned appropriate personal protective equipment (PPE) during wound care for resident who was on Enhanced Barrier Precautions and entering residents' room who was on Droplet Precaution, 2) use appropriate infection control practice when performing wound care. This was evident for 1 (GNA #5 ) out of 1 employee observed entering the Droplet Precautions room and 1 (LPN #26) out of 1 employee conducting wound care during the recertification survey.

Inspectors wroteBased on medical record review, documentation review, and interview, it was determined the facility staff failed to notify the resident's responsible party of the addition of a medication and an increase in an anti-anxiety medication. This was evident for 1 (Resident #3) of 4 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview it was determined the physician progress notes were not in the resident medical records the day the resident was seen. This was evident for 1 (Resident #3) of 4 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to ensure a resident's drug regimen was free from an unnecessary drug as evidenced by a PRN (when necessary) medication that was given routinely and lack of documented behavior monitoring. This was evident for 1 (Resident #3) of 4 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (Resident #3) of 4 residents reviewed during a complaint survey.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to report an allegation of abuse to the state survey agency (SSA) for 1 (Resident #2) of 10 residents reviewed for abuse.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to ensure an investigation into an allegation of abuse was submitted to the state survey agency (SSA) and failed to ensure documentation of the facility's investigation reflected a thorough investigation for 1 (Resident #2) of 10 residents reviewed for abuse.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to 1.) complete wound care in a manner to prevent cross-contamination when they did not use proper barriers during wound care for three of three residents reviewed for wound care (Resident (R) 91, and R82, and R298), and 2.) ensure peripheral inserted central catheter (PICC) dressings were changed and/or remained intact for one of one resident (R298) reviewed for PICC lines out of total sample of 24. These failures had the potential to increase contamination and the spread of infection. Review of the facility policy titled, Wound Care, dated 10/01/23 revealed, . (5) use disposable cloth (paper towel is adequate) to establish a clean field. Place all items to be used during the procedure on a clean field. Arrange supplies so they can be easily reached . (7) Position resident. [...]

Inspectors wroteBased on record review and staff interview it was determined that the facility failed to ensure that all allegations of abuse were reported to the State Agency (SA) within the required timeframe. This was evident for 1 (MD00209677) of 2 facility reported incidents reviewed.

Inspectors wroteBased on observation, record review, and staff interview it was determined that the facility failed to turn and reposition a resident who was at risk for pressure injury. This was evident for 1 (#72) of 4 residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the cleanliness of the ice machine filter and drip pan for one of two ice machines at the facility. This failure had the potential to cause contamination of the ice which could have a negative impact on all 104 residents currently residing at the facility.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to prevent a known wandering resident from leaving the facility. This was evident for 1 of 6 ( #18) residents reviewed for elopements. This failure resulted in an Immediate Jeopardy for Resident #18. After the elopement incident the facility developed, initiated and completed a plan of correction to prevent further elopements. Therefore, this deficiency will be cited as a past non-compliance. The date of correction was 5/27/2023.

Inspectors wroteBased on interview and medical record review, it was determined the facility staff failed to provide a resident a copy of the resident's medical record in a timely manner (Resident #15). This was evident for 1 of 36 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to notify the resident representative and physician of a change in condition. This was evident during the review of a complaint for 1 of 3 residents (#4).

Inspectors wroteBased on record review and interview it was determined that the facility failed to have a process in place to ensure that allegations of abuse were reported to the State Agency within the required 2-hour time frame and to ensure that the final report was sent to the State Agency within 5 business days. This was evident for 3 of 3 allegations of abuse reviewed.

Inspectors wroteBased on record review and interview it was determined that the facility failed to conduct a thorough investigation of allegations of abuse. This was evident for 3 of 3 allegations of abuse reviewed.

Inspectors wroteBased on medical record review and interview the facility staff failed to 1.) follow physician orders for a resident in a timely manner (Resident #15); and 2.) failed to administer care to a resident when in distress (Resident #30). This was evident for 2 of 36 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview, the facility staff failed to provide siderails as ordered by the consulting physician (Resident #15). This was evident for 1 of 36 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility staff failed to appropriately order and administer a medication. This was evident for 1 of 36 (#4) residents reviewed during a complaint survey.

Inspectors wroteBased on review of pertinent facility documents and interview with facility staff, it was determined that the facility failed to have an updated annual facility assessment.

Inspectors wroteBased on medical record review and interview, the facility staff failed to follow up with outside resources for the care of residents (Resident #15 and #14). This was evident for 2 of 36 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to constantly document activities of daily living (ADL) care provided to a dependent resident. This was evident during the review of 1 of 36 residents (#32) related to complaints of lack of ADL care.

Inspectors wroteBased on medical record review, observation and interview, it was determined the facility staff failed to provide a Resident (#49) with foods of preference. This was evident for 1 of 3 residents selected for review of choices and 1 of 39 selected for review during the annual survey process.

Inspectors wroteBased on record review and staff interview, it was determined that the facility staff failed to determine a resident's wishes regarding life sustaining treatment upon admission to the facility. This was evident for 1 (Resident #416) of 8 residents reviewed for advance directives during an annual recertification survey.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure a safe, comfortable, clean homelike environment. This was evident in 3 resident rooms on the ground floor of the facility.

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 (#95 and #102) transfer to the hospital. This was evident for 2 of 5 resident reviewed for hospitalization during the annual recertification survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to initiate a care plan addressing dental for a Resident (#365) and bowel management for another (#46). This was evident for 2 of 39 residents selected for review during the annual survey.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined the facility staff failed to ensure that a resident with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 1 (Resident #91) of 6 residents reviewed for limited mobility during an annual recertification survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to provide an environment free from potential accidents by not checking the placement of Resident #16's alert bracelet. This was evident for 1 (#16) of 39 residents selected for review during the annual survey process.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to document the blood pressure for Resident #49 when the physician ordered parameters. This was evident for 1 of 6 residents selected for un-necessary medication review and 1 of 39 residents selected for review during the annual survey process.

Inspectors wroteBased on observation and interview, it was determined the facility staff failed to ensure that medications were accurately labeled with residents' name, dose of medication to be administered and date when the medication was open. This was evident for 1 of 3 medication carts observed during the annual survey process.