Roland Park Place

Based on observation, interview, and record review, it was determined that the facility failed to store food in a sanitary manner by ensuring opened food items were properly labeled with the date opened. This is evident for 1 of 1 kitchen areas reviewed.The findings include:On 06/15/2026 at 7:47 AM, an inspection of the spice shelf in the kitchen revealed containers of Montreal chicken spice, ground white pepper, Hungarian style paprika, and ground turmeric without dates indicating when the containers had been opened. Only one spice container was observed on the shelf to have had the opening date correctly labeled on the side of the container.During interview at the time of the observation, Staff #6 stated that opened spice containers should be marked with the date they were opened and confirmed that the dates were missing from the identified spices. On 06/15/2026 at 8:40 AM, the Director of Food and Beverage was informed of the concern regarding the undated spices.

Based on review of a facility reported investigation and staff interviews, it was determined that the facility failed to report an allegation of abuse to the law enforcement agency. This was evident for 2 (Resident #11 and #13) out of 3 residents reviewed for facility reported investigations during the facility's Medicare/Medicaid recertification survey. The findings include: 1. On 04/30/2025 at 12:11 PM, the surveyor reviewed intake MD#00181652 and found that during Resident #11's care plan meeting on 03/14/2022, the resident described the behavior of a Geriatric Nursing Assistant (GNA) #17 as abusive. Resident #11 further characterized GNA #17 as intimidating, abrupt, and dismissive. On 04/30/2025 at 2:24 PM, during an interview with the Nursing Home Administrator (NHA), when she was asked who was notified about the allegations of verbal abuse, she stated that the ombudsman was informed. When she was asked whether a law enforcement agency was notified regarding the incident, she stated that law enforcement was not contacted because the incident involved verbal abuse. When asked to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on resident interview, record review, and staff interview, it was determined that the facility failed to notify the ombudsman of a resident's transfer to the hospital. This was evident for 1 (Resident #8) out of 1 resident reviewed for hospitalizations. The findings include: On 4/29/25 at 9:44 AM, an interview was conducted with Resident #8. When asked whether they were hospitalized recently, Resident #8 stated that they had just returned from the hospital a few days ago. On 4/29/25 at 1:02 PM, a review of Resident #8's progress notes was conducted. In the note from 4/18/25 at 2:44 pm, it was documented that the resident was transferred to the hospital for further evaluation of shortness of breath. On 4/29/25 at 2:20 PM, an interview with the Nursing Home Administrator (NHA) was conducted. When asked to provide evidence that the ombudsman was notified of Resident #8's transfer on 4/18/25, the NHA stated that they were unaware that the ombudsman needed to be notified of resident transfers to hospital. This surveyor made the NHA aware that notifying the ombudsman of transfers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on resident interview, record review, and staff interview, it was determined that the facility failed to provide the bed-hold policy to a resident or resident representative before the resident was transferred to the hospital. This was evident for 1 (Resident #8) out of 1 resident reviewed for hospitalizations. A bed-hold policy addresses holding a resident's bed during periods of absence, such as during hospitalization or therapeutic leave. The findings include: On 4/29/25 at 9:44 AM, an interview was conducted with Resident #8. When asked whether they were hospitalized recently, Resident #8 stated that they had just returned from the hospital a few days ago. On 4/29/25 at 1:02 PM, a review of Resident #8's progress notes was conducted. In the note from 4/18/25 at 2:44 pm, it was documented that the resident was transferred to the hospital for further evaluation of shortness of breath. On 4/29/25 at 2:20 PM, an interview with the Nursing Home Administrator (NHA) was conducted. The NHA stated that they would check if a bed-hold policy was provided to Resident #8. On 4/30/25 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, review of daily staffing records, and staff interview it was determined that the facility failed to post the total number and actual hours worked by categories of Registered Nurses (RN), Licensed Practical Nurses(LPN), and Certified Geriatric Nurse Aides (GNA) per shift. Additionally, the facility name was not on the form. This was observed for at least 4 of the 7 survey days. The findings include. On the Health Care Center 2 unit, review of the day shift staff assignment sheet on 3/9, 3/10, 3/11, and 3/12/21 did not reveal the name of the facility or the total number and actual hours worked by categories of Registered Nurses (RN), Licensed Practical Nurses(LPN), and Certified Geriatric Nurse Aides (GNA) per shift. The staff assignment posting did have individual hours for each staff person but did not include a total number of hours. There were staff assigned to the other nursing home unit and the staff hours worked posting on one unit did not reflect the totals for the entire facility. The posting is to be in a clear and readable format. The total amount of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview it was determined: 1) the pharmacist failed to identify a medication order discrepancy during a monthly pharmacy medication review and 2) facility staff failed to have a process to ensure that pharmacy recommendations were acted upon by the physician. This was evident for 2 (#3, #8) of 5 residents reviewed for unnecessary medications and 1 of 4 residents reviewed for pressure ulcers (Resident #14). The findings include: 1) On 3/11/21 at 1:53 PM, review of Resident #8's March 2021 MAR (medication administration record) revealed an 8/12/16 order for Acetaminophen (Tylenol) (analgesic) by mouth that documented 2 different times to administer the medication. The order read to give Acetaminophen 2 tablets by mouth every 6 hours PRN (as needed) for pain and 2 tablets by mouth every 8 hours. There was no clear indication in the order as to whether the Acetaminophen should be given every 6 hours as needed or if it should be given every 8 hours. The DON (Director of Nurses) was made aware of this finding on 3/16/21 at 11:15 AM and stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on resident interview, staff interview and record review it was determined that the facility failed to provide a meal that met a resident's special dietary needs and preferences. This was evident for 3 of 27 residents reviewed during the annual survey (Residents #7, #12 and #31). The findings include: On 3/11/2021 at approximately 12:45 PM, during lunch service, Resident #7, #12 and #21's meal tickets were compared to their meal trays for accuracy. Residents #7 and #12 both had P/PU4 Dilled Baby Carrots on their meal tickets indicating that their meal should contain pureed dilled baby carrot, however, observation revealed that their meals did not include carrots. Further observation of lunch service revealed that Resident #21's meal ticket included Assorted Rolls but no rolls or bread were included in their meal. During an interview on 3/11/2021 at 1:29 PM the Dietary Manager was asked if the kitchen had run out of carrots and responded that the facility had not run out and they were not sure why the residents did not receive the missing carrots and rolls. At 1:46 PM the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview it was determined that the facility failed to keep complete and accurate medical records. This was evident for 1 of 5 residents reviewed for unnecessary medication (Resident #8). The findings include: On 3/11/21 at 1:53 PM, review of Resident #8's March 2021 MAR (medication administration record) revealed an 8/12/16 order for Acetaminophen (Tylenol) (analgesic) by mouth that documented 2 different times to administer the medication. The order read to give Acetaminophen 2 tablets by mouth every 6 hours PRN (as needed) for pain and 2 tablets by mouth every 8 hours. There was no clear indication in the order as to whether the Acetaminophen should be given every 6 hours as needed or if it should be given every 8 hours. The DON (Director of Nurses) was made aware of this finding on 3/16/21 at 11:15 AM and stated the order needed to be clarified. Cross reference F 756

Based on observation, and staff interview, it was determined that the facility failed to treat resident with dignity and respect by labeling and identifying resident's as feeders. This was identified for 7 of 24 residents in the facility at the initiation of the survey (Residents #6, #11, #13, #15, #23, #29 #74) . The findings include. Observations of the daily staff assignments posting on 3/10/2021, 3/11/2021, and 3/12/2021 revealed that residents were labeled feeder(s) with a corresponding room number. Labeling residents by the type of assistance they require, rather than a human being who needs assistance may be deemed as derogatory. The posting of staff assignments was discussed with the facility administrator on 3/12/2021 at 1:46 PM. The administrator revealed that the staff posting was on an older form that should not have been used.

Based on observation, resident and staff interview it was determined that facility staff failed to have a call bell in reach for a resident who was dependent on staff for activities of daily living. This was evident for 1 of 17 residents observed in the initial resident pool (Resodemt #17) . The findings include: On 3/10/21 at 9:54 AM, an observation was made of Resident #17, sitting in a wheelchair, on the right side of the bed, with a round side table in between the resident and the bed. On the left side of the bed, the call bell cord was observed hanging on the top of the call bell prong attached to the wall, and was not within reach of the resident. The surveyor asked Resident #17 how he/she called for the nurse, and the resident stated that he/she would push the call bell. At that time, the resident looked around, pointed to the side table and stated, it's usually right here. When aware the call bell was hanging on the wall, Resident #17 stated he/she could not reach the call bell. On 3/10/21, at approximately 10:00 AM, Staff # 17, geriatric nursing assistant (GNA), entered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview it was determined that the facility staff failed to evaluate and update a resident's plan of care after each assessment. This was evident for 1 of 2 residents reviewed for accidents (Resident #17). The findings include: 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. On 3/1621 at 2:53 PM, Resident #17's medical record was reviewed and revealed the resident's most recent quarterly assessment had a reference date of 1/8/21 and the prior quarterly assessment had a reference date of 10/15/20. 1. A review of Resident #17's care plans revealed the resident had multiple care plans, including a cardiovascular care plan: Resident #17 has potential for complications from HTN (hypertension) and CAD (coronary artery disease), stent placement 6/7/18 with the goal, Resident #17 will have no complications for cardiovascular disease and will no require outside medical intervention x 90 days that included the interventions 1) provide blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of a closed medical record and staff interview, it was determined that the facility staff failed to provide a resident with a completed discharge summary. This was evident for 1 of 27 residents reviewed during an annual refortification survey (Resident #24) . The findings include: On 3/16/2021 on review of Resident #24's closed medical record revealed that Resident #24 was discharged from the facility on 12/16/2020. Resident #24's electronic medical record and paper record failed to reveal a completed discharge summary from Resident #24's attending physician that included: a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of all pre-discharge medications with the post discharge medications, and a post discharge plan of care. In an interview on 3/16/2021 at 11:22 AM the Director of Nursing confirmed that Resident #24's record did not include a completed discharge summary. The Administrator and Director of Nursing were made aware of these findings during the exit conference on 3/16/2021.

Based on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by failing to ensure that a psychotropic medication prescribed as needed was limited to 14 days. This was evident for 1 of 4 residents reviewed for pressure ulcers (Resident #14). The findings include: On 3/16/21 at 10:00 AM, a review of Resident #14's March 2021 TAR (treatment administration record) revealed a 5/21/20 order for Lorazepam (Ativan) (antianxiety medication) 1 mg (milligram) sublingual every 6 hour as needed for anxiety and agitation. The order had no discontinuation/end date, was not limited to 14 days duration. Further review of the medical record fail to reveal physician documented rational for continuing the order beyond 14 days. The Director of Nurses confirmed the findings on 3/16/21 at 11:15 AM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, it was determined that the facility failed to ensure that medications requiring refrigeration were stored safely. This was found to be evident in 1 out of 1 medication storage rooms and had the potential to affect all residents. The findings include: On [DATE] at 10:02 am, the refrigerator temperature log located in a binder in the locked medication storage room revealed the refrigerator inside temperature was last checked on [DATE] with a temperature logged at 36 degrees Fahrenheit. The facility's refrigerator temperature log stated 11-7 must check and record temperatures and check and discard expired medication and ensure that all medications are labelled and dated. On [DATE] at 10:03 am, at the time of the observation, a nurse (staff #10) unlocked refrigerator located in locked medication storage room. The surveyor identified the following medications stored in the refrigerator: Tuberculin Acetaminophen suppositories 650 mg, Purified Protein Derivative Diluted Aplisol 5…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.