Roland Park Rehabilitation And Healthcare Center
ROLAND PARK REHABILITATION AND HEALTHCARE CENTER in BALTIMORE, MD — inspection on February 24, 2026.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
limited to receiving treatment and supports for daily living safely.
surveyor observation and interview with staff it was determined the facility staff failed to provide a
209) of 3 resident rooms observed during review for Safe/Clean/Comfortable/Homelike Environment.
The findings include:An interview on 2/20/26 at 11:00 AM, with Resident #2 in room [ROOM NUMBER] for complaint #2682305 revealed the facility's staff failed to ensure a sanitary and safe interior environment.The following was observed by the surveyor.
The curtains had red and brown spots scattered throughout the curtains.The floors had paper trash, food and were dirty in appearance throughout.The bedside commode that was over the toilet had brown materials in all the crevices and on the seat of the commode.
The bathroom had a strong smell of urine and Feces.On 2/20/26 at 11:30 AM, Administrator was made aware of the findings.On 2/20/26 at 1 PM another observation of the room revealed that the curtains had been replaced, and housekeeping staff were cleaning the bathroom.Cross reference F 921.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
215301 02/24/2026
Roland Park Rehabilitation and Healthcare Center 4669 Falls Road Baltimore, MD 21209
During an interview on 2/24/26 with the discharging nurse, LPN #3 revealed that she was not familiar with what to do with discharges, she wasn't sure of the process with narcotics and didn't send any with the resident to the receiving facility.
She stated that she sent all the non-narcotic medication with [resident], but she wasn't clear on how to discharge a resident.
The DON and ADON were then interviewed regarding the discharge with Resident # 11. In the miscellaneous section there was a note where the neurology team from the receiving facility came and picked up a few narcotics and signed a paper with a nurse from this facility.
The DON was asked what the process was for discharging a resident with narcotics.
She stated that they do so only with a physician's order and showed the surveyor that there were prescriptions printed out for the resident within the copies that were requested prior for the investigation. A review on 2/24/26 at 12:50 PM failed to reveal any order for the narcotics to be sent with the resident or documentation that a discharge note summarizing the residents stay, to include all courses of treatment and care in the facility, was provided to the receiving facility.
215301 02/24/2026
Roland Park Rehabilitation and Healthcare Center 4669 Falls Road Baltimore, MD 21209
(PASARR) evaluation and determination.
This was evident for 1 resident (Resident #2) of 1 residents
Resident Review (PASARR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings.On 2/20/26 at 11:00 AM, a review of Resident #2's records revealed a PASSAR Level I screening form dated 10/12/23 which indicated that the resident should have been referred for a Level II evaluation. No Level II PASSAR documentation found in the residents' records.On 2/20/26 at 11:15 AM, an interview with the Director of Social work was conducted.
The Level I PASSAR was reviewed which indicated that a Level II referral was required.
The Director of Social Work stated that the Resident's diagnosis of intellectual disabilities was overlooked on admission and that a new PASSAR will be completed to reflect Level II is needed for Resident #2.The Social Worker was asked to provide evidence that a PASSAR II referral was done for Resident #2.On 2/24/26 2:15 PM, the Nursing Home Administrator (NHA) was informed that Resident #2 did not have the required referral for PASSAR Level II.
215301 02/24/2026
Roland Park Rehabilitation and Healthcare Center 4669 Falls Road Baltimore, MD 21209
S/he stated that secondary to his/her medical condition s/he is not able to fend off an intruder in the
jeopardy to resident health or reporting that Resident #10 comes into this room when the roommate is not present and it is very safety scary. Resident #7 is observed in the ?b' bed by the window and the roommate's bed is by the door, so it would be visible walking by the doorway when the roommate is not in the room. Resident #7
staff was aware of his/her concerns of Resident #10 coming into the room and Resident #7 stated ?yes, I have told them and keep telling them.' S/he further stated that ?it's a lot of stress when you try to sleep in a room alone and here [resident] comes in.' Medical record review on 2/19/26 at 9:30 AM of Resident #7 revealed an assessed BIMS score of 15 from a 10/19/25 minimum data set. S/he has a dependence on staff for some activities of daily living including meal setup and bathing and the reliance on a power wheelchair to mobilize around the facility. 1d. Resident #1 was interviewed on 2/19/26 at 12:32 PM. S/he was interviewed secondary to a complaint submitted by a family member who had considerable concerns about Resident #1 as they are bedbound, and Resident #1 called them about Resident #10 coming into the room and exposing themselves on repeated occasions. Resident #1 stated to this surveyor that Resident # 10 ?will come in at night and pull his/her pants off and stand at my bed. S/he has hit my friend and staff, what makes me think that s/he won't hit me? Next time s/he comes in here and invades my privacy I'm going to fight [resident] back.' Medical record review for Resident #1 on 2/19/26 at 12:50 PM revealed a 1/16/26 BIMS revealed a score of 15, showing s/he is cognitively intact. Resident #10 was observed on the unit on 2/19/26 at approximately 12:40 PM walking up and down the halls. Resident #10 was observed walking up the hallway and stopping at each doorway.
Residents, male and female, could be heard from inside of their rooms yelling for Resident #10 to ?stay out/stay away/get out.' Resident #10 would then proceed and continue walking to the next room, during this observation, staff were observed at the nurses station or walking around the unit. At no time did any staff intercede and direct Resident #10 elsewhere as most of the residents in their rooms were observed eating and this was an interruption and potential intrusion. On 2/19/36, at 3:10 PM an Immediate Jeopardy was called related to a lack of supervision which resulted in a resident inappropriately wandering into multiple resident rooms and verbally or physically assaulting residents with no documented interventions in place after 12/10/25.The facility submitted an initial plan of action to the surveyor and the Office of Health Care Quality for review at 5:10 PM on 2/19/26.
This initial plan was not accepted. A revised plan was submitted at 5:18 PM on 2/19/26, which was not accepted.
Another revised plan was submitted at 5:50 PM on 2/19/26, which was not accepted.
The facility submitted a subsequent revised plan of action at 6:32 PM on 2/19/26, which was reviewed by the surveyor and the Office of Health Care Quality.
The plan was accepted at 6:35 PM on 2/19/26 but the Immediate Jeopardy was not removed until 2/24/26 at 1:58 PM after the plan of correction was verified to have been implemented.The facility plans of removal included the following: The identified resident was evaluated by the medical director and prescribed antianxiety medication 3 times a day and put on a 1:1 assignment starting at 3:00 PM until further notice.
Additionally, the residents with the identified concerns are to be assessed by the social worker. An ad hoc quality assurance meeting was held with the interdisciplinary team and education will be completed with the facility staff on the Dementia protocol and Unmanageable Residents.
The plans were presented on 2/19/26 at 5:10 PM, with adjustments made and resubmitted at 5:18 PM, again at 5:50 PM and a final plan submitted and accepted at 6:32 PM on 2/19/26.
215301 02/24/2026
Roland Park Rehabilitation and Healthcare Center 4669 Falls Road Baltimore, MD 21209
process to determine if residents with a history of trauma received the appropriate trauma informed
include:On 2/19/26 at 8am, a review of complaint 2689128 which reported that resident #5 alleged that Resident #10 enter the room around 7 pm and grabbed both of resident's hands and was punched in the face about five time.A medical record review for Resident #5 on 2/19/26 at 8:30AM, revealed the resident was admitted to the facility on [DATE].
Further review revealed no evidence that a trauma informed assessment or care plan had been completed to ensure the resident received trauma informed care after the incident.On 2/19/26 at 9 AM, an interview with Resident #5 revealed that Resident #5 was tearful and stated that I'm in fear, and afraid to go to sleep at night. I'm scared when the perpetrator walks in the dining room.On 2/20/25 at 10am, an interview with the Director of Social Work confirmed that Resident #5 trauma informed assessments should be done after a change in condition and will be completed for the resident.On 2/25/26 at 2:15 PM, the Administrator confirmed resident trauma informed assessments should be done at admission and after a change in condition and the Director of Social Work is addressing the issue.
Cross reference F 689.
215301 02/24/2026
Roland Park Rehabilitation and Healthcare Center 4669 Falls Road Baltimore, MD 21209
During exit the concerns were reviewed again.
The regional nurse staff #4 asked for some clarification, if the content of the notes mattered with the timing of the upload. It was reviewed at that time that there were notes completed with medication changes that had a delay in uploading as well.
Specifically, there was a note completed 8/18/25 that was uploaded 8/21/25 regarding an increase in Trazadone.
However, it was reviewed again that it is not just about notes with medication changes, the concern was about the availability of physician notes on the medical record after visiting a resident and completing an assessment.
215301 02/24/2026
Roland Park Rehabilitation and Healthcare Center 4669 Falls Road Baltimore, MD 21209
Based on record review and staff interview, it was determined that facility staff failed to complete a
review.
The findings include:During review of the facility assessment, secondary to completing the extended survey, it was determined that the facility assessment provided revealed what the facility offers, however it is not based on a ?facility assessment.'At entrance to the facility on 2/19/26 a resident matrix was requested and provided. On this matrix it notes a resident with a tracheostomy.
Record review on 2/20/26 at 1:00 PM revealed that this Resident #12, also has a gastrostomy tube in place for nutritional support.
However, review of the facility assessment failed to show that any current residents are in need of tracheostomy or gastrostomy support, only that the facility ?offers' those services.
Additionally, it notes that they have ?supportive care' for behavioral/mental health providers. It does not say who, therefore the qualifications are not there-i.e. NP, Dr, SW, what support is provided and what type of clientele is served at the facility.
The assessment does say what type of clientele they ?can' serve, however, not an assessment of what the current population for the assessed year was.
During multiple tours of the facility from 2/19/26 through 2/24/26, multiple residents were observed in bed requiring the support of staff for activities of daily living, additionally there were multiple residents observed independently mobilizing wheelchairs or walking around the facility.
The actual assessment of the current population was not available in the assessment.
This concern was reviewed with the NHA on 2/20/26 at 1:40 PM and again with the NHA during exit on 2/24/26.
215301 02/24/2026
Roland Park Rehabilitation and Healthcare Center 4669 Falls Road Baltimore, MD 21209
The surveyor requested when staff #7 role was changed from RN to LPN.
The HR staff did not remember the date or provide documentation as requested. On 2/24/26 at 12 PM interview with Staff #7 Revealed that she went to VMT Education Center, located in [NAME], D.C and graduated in 2001.
Staff #7 stated that she sat for the Maryland boards for her LPN license in 3/2003.
The Surveyor asked why she/he waited so long to sit for the boards? and the reply was I still own the school money, and they would not release my transcript. Resident #7 denied going to any other schools to obtain his/her LPN license.On 2/24/26 at 12:20 PM, a review of VMT Education Center and the Maryland Board of Nursing Revealed that VMT is not recognized by the MBON and was removed on 2/25/2003 because it did not meet qualification for LPN. A review on the MBON revealed that staff #7 Received the LPN license on 10/6/2003.
Eight months later.
After the interview with Staff #7 the information was discussed with the Regional Nurse.
Staff #7 was suspended until further investigation by the facility staff.
215301 02/24/2026
Roland Park Rehabilitation and Healthcare Center 4669 Falls Road Baltimore, MD 21209
and the public.
observations it was determined that the facility failed to maintain a safe, sanitary, comfortable, and
on 2/20/26 at 11:00 AM, with Resident #2 in room [ROOM NUMBER] for complaint #2682305 revealed the facility's staff failed to ensure a safe interior environment.On 2/20/26 at 1Pm, a tour of room [ROOM NUMBER] with the Maintenance Director revealed unattended maintenance needs: The grab bar in the bathroom next to the toilet was not firmly attached to the wall.The floor tile to the bathroom was missing and cracked.
This made it difficult for the residents to roll in and out of the bathroom using a wheelchair or walker.The cable cover plate was not attached to the wall.The ceiling had evidence of water damage with marked brown areas.The nightstand had a broken handle.room [ROOM NUMBER] has damaged walls with peeling paint and scrapes throughout greater at the head of the beds.
Cross reference F 584.