Inspection Reports for Roland Park Place
830 West 40th Street, Baltimore, MD, 21211
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 1, 2025, identified deficiencies related to the facility’s failure to report allegations of abuse to law enforcement and to notify the ombudsman of a resident’s hospital transfer, as well as not providing the bed-hold policy to the resident or their representative. Earlier inspections showed multiple deficiencies involving resident dignity, staffing documentation, medication management, and food safety, with some issues related to verbal abuse and inaccurate reporting. Complaint investigations found substantiated failures in reporting abuse and notification procedures, but enforcement actions such as fines or license suspensions were not listed in the available reports. Prior reports noted issues with care plan updates, medication storage, and dietary needs, indicating ongoing challenges in regulatory compliance. The inspection history shows some recurring themes in resident rights and administrative reporting, with recent findings highlighting areas needing improved communication and procedural adherence.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
53% better than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 1, 2025
Visit Reason
The inspection was conducted as part of the facility's Medicare/Medicaid recertification survey and focused on reviewing facility reported investigations related to allegations of abuse involving residents.
Complaint Details
The investigation was triggered by allegations of abuse reported by Resident #11 and Resident #13. The allegations involved verbal and physical abuse by staff. The facility did not notify law enforcement as required. The Director of Nursing acknowledged the failure and agreed that law enforcement should have been notified.
Findings
The facility failed to report allegations of abuse involving two residents to the appropriate law enforcement agency. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that law enforcement was not notified despite policies requiring all allegations to be reported.
Deficiencies (1)
Failure to timely report suspected abuse to law enforcement authorities for two residents.
Report Facts
Residents reviewed for facility reported investigations: 3
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding failure to notify law enforcement about abuse allegations |
| Director of Nursing | Director of Nursing | Interviewed regarding failure to notify law enforcement about abuse allegations and acknowledged the deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 1, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to notify the ombudsman of a resident's hospital transfer and failure to provide the bed-hold policy to the resident or their representative prior to hospital transfer.
Complaint Details
The complaint investigation found that the facility failed to notify the ombudsman of Resident #8's hospital transfer and failed to provide the bed-hold policy to Resident #8 or their representative. The Nursing Home Administrator was unaware of these requirements until surveyor intervention.
Findings
The facility failed to notify the ombudsman of Resident #8's transfer to the hospital and did not provide the bed-hold policy to Resident #8 or their representative before the transfer. The Nursing Home Administrator was initially unaware of these requirements but implemented corrective actions after surveyor intervention.
Deficiencies (2)
Failure to notify the ombudsman of a resident's transfer to the hospital.
Failure to provide the bed-hold policy to a resident or resident representative before hospital transfer.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Interviewed regarding notification of ombudsman and bed-hold policy provision. |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Mar 17, 2021
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity, inadequate call bell accessibility, failure to update care plans, incomplete discharge summaries, improper nurse staffing postings, medication regimen review deficiencies, improper medication storage temperatures, failure to meet dietary needs, and incomplete medical records.
Deficiencies (10)
Facility failed to treat residents with dignity by labeling residents as feeders.
Facility staff failed to have a call bell within reach for a resident dependent on staff for activities of daily living.
Facility staff failed to evaluate and update a resident's plan of care after each assessment.
Facility staff failed to provide a resident with a completed discharge summary.
Facility failed to post total number and actual hours worked by nursing categories per shift and facility name on staffing records.
Pharmacist failed to identify medication order discrepancies and facility staff failed to ensure pharmacy recommendations were acted upon.
Facility failed to ensure medications requiring refrigeration were stored at proper temperatures.
Facility failed to provide meals that met residents' special dietary needs and preferences.
Facility failed to keep complete and accurate medical records, including unclear medication orders.
Facility failed to ensure psychotropic medication prescribed as needed was limited to 14 days.
Report Facts
Residents identified with dignity labeling issue: 7
Residents observed for call bell accessibility: 17
Residents reviewed for care plan evaluation: 2
Residents reviewed for discharge summary: 27
Survey days with missing nurse staffing info: 4
Residents reviewed for unnecessary medications: 5
Residents reviewed for pressure ulcers: 4
Medication storage refrigerator temperature: 52
Residents reviewed for dietary needs: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #17 | Geriatric Nursing Assistant (GNA) | Secured call bell cord to Resident #17's wheelchair |
| Staff #6 | Clinical Coordinator | Made aware of care plan evaluation concerns and medication irregularities |
| Director of Nurses | Made aware of call bell, medication, and discharge summary findings | |
| Dietary Manager | Interviewed about meal discrepancies and software issues | |
| Clinical Unit Coordinator | Confirmed medication refrigerator temperature issues | |
| Staff #10 | Nurse | Observed medication refrigerator temperature and unlocked refrigerator |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Aug 31, 2018
Visit Reason
The facility underwent an annual Medicare/Medicaid survey to assess compliance with regulatory requirements including resident rights, abuse prevention, accurate resident assessments, nurse staffing documentation, and food safety standards.
Findings
The survey identified multiple deficiencies including failure to honor resident dignity and respect, verbal abuse by staff, inaccurate coding of side rails as restraints, incomplete nurse staffing documentation, and improper food labeling and infection control practices in the kitchen.
Deficiencies (5)
Failed to honor the resident's right to be treated with respect and dignity, including an incident where an Activity Assistant verbally insulted a resident and was terminated.
Failed to protect residents from verbal abuse; the same Activity Assistant was involved in verbal abuse leading to termination.
Failed to accurately code side rails on the Minimum Data Set (MDS), incorrectly documenting side rails as restraints.
Failed to document daily nursing staffing forms reflecting total hours worked by licensed staff on assignment sheets for 2 of 3 units.
Failed to ensure foods were properly labeled with preparation dates and failed to maintain infection control by allowing food service vendors to enter kitchen without hair nets.
Report Facts
Residents identified with physical restraints on census form: 27
Residents identified with physical restraints on matrix form: 41
Residents reviewed for MDS side rail coding: 3
Units with incomplete nurse staffing documentation: 2
Date of incident involving verbal abuse by Activity Assistant: Mar 20, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Assistant (staff #35) | Involved in verbal abuse and disrespectful behavior toward Resident #31, resulting in termination | |
| Administrator | Interviewed regarding the verbal abuse incident and staff disciplinary actions | |
| Director of Nursing (DON) | Interviewed regarding inaccurate MDS coding and nurse staffing documentation | |
| Licensed Practical Nurse (LPN), Staff #1 | Interviewed about incomplete nurse staffing assignment sheets | |
| Food Service Manager | Interviewed about food labeling and infection control deficiencies | |
| MDS Coordinator | Interviewed about inaccurate coding of side rails on MDS | |
| Staff Development Coordinator | Interviewed about inaccurate coding of side rails on MDS | |
| Activity Director | Provided information about verbal abuse incidents and evidence supporting termination |
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