CMS · Maryland Office of Health Care Quality publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F557
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F558
F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F559
F584Honor 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F584
F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F604
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F641
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F656
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F658
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F677
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F684
F693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F693
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F697
F732Post nurse staffing information every day.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F732
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F755
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F812
F814Dispose of garbage and refuse properly.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F814
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F842
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F880
F908Keep all essential equipment working safely.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F908
F919Make sure that a working call system is available in each resident's bathroom and bathing area.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F919
F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F921
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-10-22Record 215097-20250818-F925
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F550
F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F553
F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F561
F572Give residents a notice of rights, rules, services and charges.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F572
F584Honor 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F584
F610Respond appropriately to all alleged violations.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F610
F625Notify 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F625
F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F636
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity FStandard
Care planningRecords
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F655
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity FStandard
Care planningRecords
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity FStandard
Care planningRecords
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F657
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F677
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F689
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F690
F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F691
F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F711
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F755
F759Ensure medication error rates are not 5 percent or greater.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F759
F761Ensure 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.Scope/severity FStandard
Medication
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F761
F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F803
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F804
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F842
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F883
F920Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.Scope/severity FStandard
Environment
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F920
F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-08Record 215097-20230324-F921
F732Post nurse staffing information every day.Scope/severity CPaperwork
Staffing
Widespread; potential for minimal harm.Corrected 2023-05-08Record 215097-20230324-F732
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F550
F558Reasonably accommodate the needs and preferences of each resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F558
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F584
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F609
F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F622
F624Prepare residents for a safe transfer or discharge from the nursing home.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F624
F641Ensure each resident receives an accurate assessment.Scope/severity FStandard
Care planningRecords
Widespread; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F641
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F655
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F656
F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F657
F675Honor each resident's preferences, choices, values and beliefs.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F675
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F677
F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F688
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F689
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F690
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F697
F730Observe each nurse aide's job performance and give regular training.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F730
F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F758
F760Ensure that residents are free from significant medication errors.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F760
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F761
F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F801
F809Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F809
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F812
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F842
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity FStandard
Records
Widespread; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F867
F880Provide and implement an infection prevention and control program.Scope/severity FStandard
Infection control
Widespread; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F880
F908Keep all essential equipment working safely.Scope/severity FStandard
Environment
Widespread; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F908
F922Have enough backup water supply for essential areas of the nursing home.Scope/severity FStandard
Environment
Widespread; no actual harm, potential for more than minimal harm.Corrected 2019-01-31Record 215097-20181221-F922
F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Scope/severity CPaperwork
Abuse & neglect
Widespread; potential for minimal harm.Corrected 2019-01-31Record 215097-20181221-F607