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.
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 2025-09-09Record 215338-20250805-F561
F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-09-09Record 215338-20250805-F568
F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-09-09Record 215338-20250805-F585
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-09-09Record 215338-20250805-F600
F602Protect each resident from the wrongful use of the resident's belongings or money.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-09-09Record 215338-20250805-F602
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 2025-09-09Record 215338-20250805-F609
F641Ensure each resident receives an accurate assessment.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-09-09Record 215338-20250805-F641
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 2025-09-09Record 215338-20250805-F689
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-09-09Record 215338-20250805-F726
F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-09-09Record 215338-20250805-F806
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 2025-09-09Record 215338-20250805-F812
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 2025-09-09Record 215338-20250805-F921
F924Put firmly secured handrails on each side of hallways.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-09-09Record 215338-20250805-F924
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 2024-01-04Record 215338-20231103-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 2024-01-04Record 215338-20231103-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 EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-01-04Record 215338-20231103-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 2024-01-04Record 215338-20231103-F609
F610Respond appropriately to all alleged violations.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-04Record 215338-20231103-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 2024-01-04Record 215338-20231103-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 2024-01-04Record 215338-20231103-F625
F637Assess the resident when there is a significant change in conditionScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-04Record 215338-20231103-F637
F641Ensure each resident receives an accurate assessment.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-01-04Record 215338-20231103-F641
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-04Record 215338-20231103-F645
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 2024-01-04Record 215338-20231103-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 2024-01-04Record 215338-20231103-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 2024-01-04Record 215338-20231103-F657
F679Provide activities to meet all resident's needs.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-01-04Record 215338-20231103-F679
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 2024-01-04Record 215338-20231103-F686
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 2024-01-04Record 215338-20231103-F689
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 2024-01-04Record 215338-20231103-F692
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 2024-01-04Record 215338-20231103-F693
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-04Record 215338-20231103-F726
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-01-04Record 215338-20231103-F756
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-04Record 215338-20231103-F757
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 2024-01-04Record 215338-20231103-F758
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 2024-01-04Record 215338-20231103-F801
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 FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-01-04Record 215338-20231103-F803
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 2024-01-04Record 215338-20231103-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 2024-01-04Record 215338-20231103-F842
F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Scope/severity DStandard
Records
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-04Record 215338-20231103-F867
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-01-04Record 215338-20231103-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 2024-01-04Record 215338-20231103-F919
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 2024-01-04Record 215338-20231103-F947
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 2019-12-25Record 215338-20191025-F584
F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-12-25Record 215338-20191025-F585
F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-12-25Record 215338-20191025-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 2019-12-25Record 215338-20191025-F625
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 2019-12-25Record 215338-20191025-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 DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-12-25Record 215338-20191025-F657
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 2019-12-25Record 215338-20191025-F658
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 2019-12-25Record 215338-20191025-F684
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity EStandard
Care planningFalls
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-12-25Record 215338-20191025-F689
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity EStandard
Care planning
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-12-25Record 215338-20191025-F698
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 2019-12-25Record 215338-20191025-F700
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 2019-12-25Record 215338-20191025-F740
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 EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-12-25Record 215338-20191025-F758
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2019-12-25Record 215338-20191025-F880
F926Have policies on smoking.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2019-12-25Record 215338-20191025-F926
F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.Scope/severity CPaperwork
Records
Widespread; potential for minimal harm.Corrected 2019-12-25Record 215338-20191025-F838
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity BPaperwork
Care planningRecords
Pattern; potential for minimal harm.Corrected 2019-12-25Record 215338-20191025-F842