CARROLL PARK HEALTHCARE
3330 WILKENS AVENUE, BALTIMORE, MD, 21229 · 4105251544
Legal business name: GWYNNFALLS MD OPCO
What CMS has flagged
- CMS has flagged this facility for abuse citations.
- CMS status on record: SFF.
On the CMS record
- Certified beds
- 140
- Ownership type
- For profit - Limited Liability company
- Chain
- ENGAGE HEALTHCARE
Inspection findings on record (81)
Quoted exactly as CMS published them. We do not rewrite findings.
— Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
— Quality of Life and Care Deficiencies
Provide routine and 24-hour emergency dental care for each resident.
— Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
— Resident Rights Deficiencies
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
— Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
— Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
— Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
— Nursing and Physician Services Deficiencies
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
— Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
— Resident Assessment and Care Planning Deficiencies
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
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— Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Recorded as corrected on .
— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Recorded as corrected on .
— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
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— Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
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— Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Recorded as corrected on .
— Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
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— Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Recorded as corrected on .
— Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Recorded as corrected on .
— Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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— Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
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— Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Recorded as corrected on .
— Resident Rights Deficiencies
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
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— Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Recorded as corrected on .
— Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Recorded as corrected on .
— Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Recorded as corrected on .
— Administration Deficiencies
Hire a qualified full-time social worker in a facility with more than 120 beds.
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— Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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— Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
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— Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Recorded as corrected on .
— Resident Rights Deficiencies
The resident has the right to receive notices in a format and a language he or she understands.
Recorded as corrected on .
— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
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— Resident Rights Deficiencies
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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— Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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— Resident Rights Deficiencies
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Recorded as corrected on .
— Resident Assessment and Care Planning Deficiencies
Plan the resident's discharge to meet the resident's goals and needs.
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— Quality of Life and Care Deficiencies
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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— Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
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— Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
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— Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
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— Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
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— Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
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— Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Recorded as corrected on .
— Nutrition and Dietary Deficiencies
Dispose of garbage and refuse properly.
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— Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
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— Infection Control Deficiencies
Provide and implement an infection prevention and control program.
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— Environmental Deficiencies
Keep all essential equipment working safely.
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— Administration Deficiencies
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
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— Freedom from Abuse, Neglect, and Exploitation Deficiencies
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Recorded as corrected on .
Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 215085