Citations in Maryland
Statistics, citations and compliance trends for long-term care facilities in Maryland.
Statistics for Maryland (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Maryland
A facility failed to accurately code MDS assessments for multiple residents. Documentation showed one resident had a Stage 3 pressure ulcer, a surgical wound, and wound treatments that were not captured; another resident’s admission MDS missed glaucoma, hyperparathyroidism, and scheduled pain treatment; a third resident’s annual MDS missed a diuretic and anticoagulant; and a fourth resident’s quarterly MDS incorrectly coded corrective lenses as no despite documented and observed use of glasses.
A resident's dignity was not maintained when staff left a breakfast tray uncovered in the resident's room despite the resident's stated preference to have the meal covered when not eating. The resident was observed asleep while multiple flies landed on the uncovered food, and a GNA said the resident had refused to allow staff to remove the tray.
Resident wheelchairs and a reclining geriatric chair were observed in disrepair, including torn vinyl, missing foam padding, and missing armrests. Staff described an inconsistent repair reporting process, with verbal reports to the charge nurse, unit manager, ADON, or DON, while the DOM stated there was no specific wheelchair process and that housekeeping or staff would sometimes submit work orders or report issues informally.
The facility failed to timely report an alleged abuse involving a resident found restrained by a sheet and an alleged misappropriation involving another resident’s missing money. Staff accounts showed the abuse concern was not reported to OHCQ within 2 hours, and the missing funds concern was not reported within 24 hours. The NHA stated the abuse allegation should have been reported immediately, and staff had only completed a grievance form for the missing money.
Incomplete Annual MDS Assessment: A resident’s annual MDS was incomplete because cognition and mood were not assessed. The record showed no BIMS score and no assessment of memory, recall, or daily decision-making skills, and the mood section was also left blank. The issue was identified during review of an incident in which the resident alleged money had been stolen from a wallet, and the MDS Coordinator stated the sections were assigned to social work but the assessment window was missed due to staffing issues.
Failure to provide grooming and personal hygiene services for a dependent resident. The resident, who had a stroke and was coded as dependent for personal hygiene on the MDS, was observed unshaven with long untrimmed fingernails and black debris under the nails on more than one occasion. The care plan included weekly grooming, beard shaving, and nail trimming, but the resident remained unkempt and stated he should not have to beg for the care.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for 4 residents reviewed during a complaint survey. For one resident, the 6/2/26 skin and wound note documented a left Achilles pressure injury present on admission that was assessed as a Stage 3 pressure ulcer measuring 3 cm by 2 cm by 0.1 cm, along with a surgical wound on the left hip, but the 6/7/26 MDS coded no pressure ulcer/injury, no unhealed pressure ulcers/injuries, no surgical wounds, and no skin or ulcer/injury treatments. The MDS Coordinator later confirmed the findings. For another resident admitted with end stage renal disease on dialysis, spinal stenosis, and knee effusions, the admission MDS failed to capture glaucoma and hyperparathyroidism documented in the physician history and physical, and also coded no scheduled pain medication regimen despite daily Lidocaine 4% patches being applied to both knees for pain. A third resident’s annual MDS failed to capture use of Furosemide and Apixaban even though the June 2026 MAR showed both medications were administered. For a fourth resident, the quarterly MDS coded corrective lenses as no even though the resident wore glasses, had glasses documented on the admission record, and was observed with glasses at the bedside while requesting to be seen by an eye doctor; the DON confirmed the incorrect coding.
Uncovered Meal Tray Left Exposed to Flies
Penalty
Summary
The facility failed to maintain a resident's dignity by not ensuring the resident's meal was protected from environmental contaminants in accordance with the resident's expressed preference to have the tray covered when not actively eating. During observational rounds, Resident #42 was found in bed with eyes closed and appearing to be sleeping while the breakfast tray remained on the overbed table with the food uncovered. Multiple flies were observed flying around and landing on the resident's uncovered food. When asked why the meal had been left uncovered, GNA #21 stated the resident had refused to allow staff to remove the breakfast tray. The resident stated that although it takes time to eat and the resident prefers to keep the meal in the room, the resident routinely asks staff to cover the meal tray when it is delivered because of the fly/gnat problem, but the tray remained uncovered while flies landed on the food.
Resident Equipment Maintenance Process Failure
Penalty
Summary
The facility failed to have an effective process to maintain resident equipment, affecting 6 of 21 residents reviewed during a complaint survey. During walking rounds, surveyors observed resident wheelchairs in disrepair for Residents #17, #16, #18, #19, #20, and #14, with damage or missing components including torn vinyl covering, missing foam padding, and missing armrests. An unattended reclining geriatric chair in the hallway by room [ROOM NUMBER] also had a missing armrest. Interviews showed staff used inconsistent reporting methods for repairs: a GNA stated she reported repairs verbally to the charge nurse or unit manager, an LPN stated she would tell the ADON or DON, and the DOM stated there was no specific wheelchair process, that housekeeping would normally clean wheelchairs and submit work orders if they were in disrepair, and that staff sometimes reported issues informally to maintenance. The NHA was informed of the concern.
Failure to Timely Report Alleged Abuse and Missing Resident Funds
Penalty
Summary
The facility failed to report an alleged abuse involving Resident #8 immediately to the Nursing Home Administrator and within 2 hours to the Office of Health Care Quality (OHCQ). Facility records showed that GNA #18 alleged she found Resident #8 sitting in a chair at the nurses’ station restrained by a sheet when she came on duty for the 11:00 PM to 7:00 AM shift. The facility’s investigation documented that the alleged incident occurred on 7/5/26 at 11:10 PM, but the initial report was not submitted to OHCQ until 7/10/26 at 6:09 PM. During interview, the NHA stated that the staff member’s story changed and that the report should have been made immediately when the incident allegedly occurred. The facility also failed to report an alleged misappropriation of Resident #7’s property within 24 hours to OHCQ. Resident #7 reported that $106 was missing from the resident’s wallet, and staff statements documented that the resident told GNA #27 and RN #25 on 7/3/26 that the money was missing. RN #15 stated she was notified by the charge nurse and told the charge nurse to complete a concern/grievance form, but no incident report was started at that time. The facility reported the incident to OHCQ on 7/6/26 at 4:06 PM, and the NHA was later informed that the missing money had not been reported within 24 hours.
Incomplete Annual MDS Assessment
Penalty
Summary
The facility failed to complete a complete and accurate annual assessment for Resident #7 by not assessing cognition, mood, and behavior on the resident’s annual MDS. The annual MDS had an assessment reference date of 6/3/26, but Section C, Cognitive Patterns, was not assessed. There was no BIMS summary score, and the resident’s short-term and long-term memory, memory/recall ability, and cognitive skills for daily decision making were not assessed. Section D, Mood, was also not assessed. The deficiency was identified during review of facility reported incident 3094393 and the resident’s medical record on 7/29/26. The incident report stated that Resident #7 alleged money had been stolen from the resident’s wallet and initially reported the concern to a GNA on 7/3/26, stating the money had been stolen sometime over the prior month. During interview on 7/30/26, the MDS Coordinator stated that social work was responsible for completing Sections C and D and that the assessment time period had been missed because of staffing issues in the department.
Failure to Provide Grooming and Personal Hygiene Services
Penalty
Summary
Facility staff failed to provide thorough grooming and personal hygiene services for one resident who was unable to perform activities of daily living independently. The resident was admitted with a diagnosis including cerebral infarction (stroke), and the most recent Quarterly MDS coded the resident as dependent for personal hygiene in Section GG Self-Care. The resident’s care plan for ADL self-care performance deficit included an intervention for complete grooming services, including beard shaving and weekly nail trimming. During observation, the resident was found to be unshaven with long untrimmed fingernails and black debris under the fingernails. When asked if he would like to be shaved and have his fingernails trimmed, the resident said yes. A later observation showed the same condition, with the resident still unshaven and with long untrimmed fingernails with black debris under them. The resident again stated yes when asked about shaving and nail trimming and said, "I don't feel like I should have to beg them to do it." A Unit Manager confirmed the resident was unshaven and had dirty untrimmed nails, and the DON was informed of the findings.
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Compliance trends in Maryland
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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