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.
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 2025-12-01Record 215145-20250924-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 2025-12-01Record 215145-20250924-F558
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 2025-12-01Record 215145-20250924-F561
F578Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-01Record 215145-20250924-F578
F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-01Record 215145-20250924-F628
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-01Record 215145-20250924-F641
F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-01Record 215145-20250924-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 DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-01Record 215145-20250924-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 2025-12-01Record 215145-20250924-F657
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-01Record 215145-20250924-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 2025-12-01Record 215145-20250924-F677
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-01Record 215145-20250924-F686
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-01Record 215145-20250924-F695
F730Observe each nurse aide's job performance and give regular training.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-01Record 215145-20250924-F730
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 2025-12-01Record 215145-20250924-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-12-01Record 215145-20250924-F812
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 2025-12-01Record 215145-20250924-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 2025-12-01Record 215145-20250924-F880
F919Make sure that a working call system is available in each resident's bathroom and bathing area.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-01Record 215145-20250924-F919
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 2025-12-01Record 215145-20250924-F921
F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-12-01Record 215145-20250924-F947
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 JHarm
Medication
Isolated; immediate jeopardy to resident health or safety.Corrected 2023-05-07Record 215145-20230309-F761
F578Honor 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F578
F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F580
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 FStandard
Dignity & rights
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F584
F610Respond appropriately to all alleged violations.Scope/severity EStandard
Abuse & neglect
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F610
F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F623
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 2023-07-17Record 215145-20230309-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 2023-05-07Record 215145-20230309-F636
F641Ensure each resident receives an accurate assessment.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-07-17Record 215145-20230309-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 2023-05-07Record 215145-20230309-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 2023-05-07Record 215145-20230309-F657
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-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 2023-05-07Record 215145-20230309-F677
F679Provide activities to meet all resident's needs.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F679
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 2023-05-07Record 215145-20230309-F684
F685Assist a resident in gaining access to vision and hearing services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F685
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F686
F687Provide appropriate foot care.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F687
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 EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F690
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F692
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-07-17Record 215145-20230309-F697
F698Provide safe, appropriate dialysis 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 2023-05-07Record 215145-20230309-F698
F699Provide care or services that was trauma informed and/or culturally competent.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-07-17Record 215145-20230309-F699
F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F700
F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Scope/severity EStandard
Staffing
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F711
F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F740
F741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.Scope/severity DStandard
Care planningStaffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-07-17Record 215145-20230309-F741
F742Provide 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.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F742
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F757
F791Provide or obtain dental services for each resident.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F791
F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F800
F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F804
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F812
F825Provide or get specialized rehabilitative services as required for a resident.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F825
F840Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F840
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 2023-07-17Record 215145-20230309-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 2023-05-07Record 215145-20230309-F880
F908Keep all essential equipment working safely.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-05-07Record 215145-20230309-F908
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 2023-05-07Record 215145-20230309-F921
F924Put firmly secured handrails on each side of hallways.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-07-17Record 215145-20230309-F924