Roland Park Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Roland Park Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 24, 2026

  Based 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.The findings include:1. Review of the medical record for Resident #10 revealed diagnoses including unspecified dementia with unspecified severity with agitation. […]

• No harm, potential for more than minimal, patternF584Apr 20, 2026

  Based 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.The findings include: On 4/14/26 at 8:19AM during an initial tour of the facility, the surveyor observed dark patches all over the bedroom floor. The vinyl chair cover was also torn in 3 different places, measuring about 1x6, 1x8 and 1x3 inches respectively. In room [ROOM NUMBER] bathroom, the floor vinyl behind the toilet, extending all the way to the bathroom sink and measuring about 3 x1.5 feet was raised and coming/peeling off. […]

• No harm, potential for more than minimal, patternF628Apr 20, 2026

  Based 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.The findings include:1) On 04/14/2026 at 9:12 AM, review of Resident #3's medical record revealed he/she was sent to the hospital on 2/11/2026. […]

• No harm, potential for more than minimal, patternF803Apr 20, 2026

  Based 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.The findings include:In an interview with Resident #80 at 11:10 AM on 4/14/2026 the Resident stated that the food was awful, there were not enough portions, and the meal on the tray did not match the meal ticket. Resident further stated that he/she was supposed to get 2 juices and double portions of the meal, but he/she only received 1 juice and not enough portions of the meal. […]

• No harm, potential for more than minimal, patternF812Apr 20, 2026

  Based 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.The findings include:On tour of the facility's kitchen on 4/14/2026 at 7:10 AM with 3 dietary employees (#7, #8 and #11) in attendance the surveyor observed sanitation concerns: 1) employee's personal items - pink mug, foil wrapped food, and bottle of water on the small utility cart, 2) no running water in one of the hand sinks and standing water not draining in the other hand sink, 3) hole in the wall by the kitchen window where the telephone… […]