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
Failure to Respect Resident Privacy and Dignity: A PT entered a resident’s room and opened the bathroom door without consent while the resident was unclothed from the waist up. The resident, who was cognitively intact and receiving rehab, reported that the PT ignored being told someone was inside and remained at the doorway while the resident tried to cover up. The Administrator confirmed the PT failed to treat the resident with respect and dignity.
Failure to Notify Provider of Elevated Heart Rate: A resident with CVA, HTN, atherosclerotic heart disease, and inappropriate sinus tachycardia had a documented HR of 122 bpm after prior readings were consistently lower, but the record did not show that the MD or NP was notified. The unit manager and NP both stated they would expect notification of the abnormal HR and further assessment of the resident's status.
Incomplete documentation of elevated heart rate and medication administration. A resident with cerebral infarction, HTN, atherosclerotic heart disease, and inappropriate sinus tachycardia had a documented HR of 122 bpm, but the record did not show a reassessment or any documentation of symptoms later that day. The MAR also showed evening meds as not given because the resident had died, while an RN stated the meds were actually given earlier and the DON confirmed the record did not match the nurse’s statement.
Discharge planning failed for multiple residents when the IDT did not develop resident-specific plans, update goals as needs changed, or ensure needed post-discharge services and equipment were arranged before discharge. A resident with impaired cognition was discharged home without wound care, PT, OT, and HHA services in place and was later found on the floor with serious medical complications. Other residents had generalized care plans that did not reflect their wishes or documented needs such as skilled nursing, therapy, DME, and home health support.
A resident returning from the hospital after right heel wound debridement became upset over a pain med order for Percocet, believing the dose should have been 2 tabs instead of 1. During the dispute, an RN was accused of slamming discharge paperwork onto the resident's chest and then went into the hallway yelling that the resident said she hit him and that police needed to be called, which was confirmed by staff statements and the resident's interview.
A resident with an order for a rescue inhaler for SOB and wheezing was observed in distress, but the inhaler was delayed while a CMA stocked the med cart and did not report the request to the nurse. The record showed the inhaler was later documented with a late entry, and there was no nurse assessment before administration, which was not consistent with the DON’s stated practice for PRN meds.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to treat a cognitively intact resident with dignity and respect when a physical therapist entered the resident’s room and bathroom area without consent while the resident was unclothed from the waist up. The resident, who had a BIMS score of 15 out of 15 and was admitted for rehabilitation after a hospitalization in April 2026, stated he/she was in the bathroom with the door closed when the therapist knocked, opened the door anyway after being told someone was inside, and remained at the doorway for about 2 to 3 minutes while the resident tried to cover up. The resident reported the incident to staff and completed a grievance. The physical therapist stated he had gone to the wrong floor, knocked twice, entered the room when no one answered, and then noticed the bathroom door was closed. He stated he knocked, heard the resident say he/she was in the bathroom, and then cracked the door open because he was worried about the resident’s safety. He stated he only opened the door a few inches and then closed it and apologized through the closed door. The Administrator confirmed that the physical therapist failed to treat the resident with respect and dignity by opening the bathroom door without the resident’s consent.
Failure to Notify Provider of Elevated Heart Rate
Penalty
Summary
The facility failed to notify the resident's physician or nurse practitioner when the resident had a change in vital signs that could have required physician intervention. Resident #2 was admitted in January 2026 with diagnoses including cerebral infarction, hypertension, atherosclerotic heart disease, and inappropriate sinus tachycardia. Review of the resident's heart rates from January 2026 through 3/4/26 showed rates ranging from 57 to 89 beats per minute, with no documented heart rate over 100 beats per minute during that period. On 3/5/26 at 9:00 AM, the resident's March 2026 MAR documented a heart rate of 122 beats per minute. The medical record did not show that the physician or NP was notified of this increase. During interview, the unit manager stated she would expect the physician to be notified because the rate was far outside the resident's usual range and said she would notify the doctor and recheck the heart rate after medication. The NP stated he would expect to be notified about a heart rate of 122 because he would want to know whether the resident was symptomatic, whether the respiratory rate was elevated, or whether other issues such as sepsis, pain, or positioning were contributing.
Incomplete Documentation of Elevated Heart Rate and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident. Resident #2 was admitted with diagnoses including cerebral infarction, hypertension, atherosclerotic heart disease, and inappropriate sinus tachycardia. The resident’s heart rates from one period in the record ranged from 57 to 89 bpm, but the MAR documented a heart rate of 122 bpm at 9:00 AM on one date. Nursing progress notes, evaluations, and the vital sign section of the electronic medical record did not show that the resident’s heart rate was reassessed between 9:00 AM and 8:00 PM, and there was no documentation about whether the heart rate decreased or whether the resident had symptoms related to the elevated heart rate. The MAR also showed that at 8:00 PM the medications Atorvastatin, Famotidine, Metoprolol, and Acetaminophen were signed off as not given because the resident had passed away suddenly. However, a change in condition note documented that the resident was assessed with no pulse, no BP, and no respiration at 10:00 PM, with a code blue and 911 called, and paramedics continuing CPR until the resident was pronounced deceased at 10:36 PM. RN #12 stated she gave the evening medications at 9:00 PM but did not sign the MAR until later, and the DON confirmed that the medical record did not reflect the medications were given or the resident’s status as described in the nurse’s statement.
Discharge Planning Failed to Ensure Resident-Specific Needs Were in Place
Penalty
Summary
The facility failed to implement an effective discharge planning process for multiple residents whose records were reviewed. For Resident #4, a discharge care plan was started after the resident chose to return to the community, but it was not developed by the interdisciplinary team, did not include the resident’s goals or treatment preferences, and did not identify the discharge location or post-discharge needs such as equipment or home health services. The plan was not regularly re-evaluated or updated as the resident’s situation changed, even though the resident later appealed insurance coverage decisions, considered long-term care Medicaid, and ultimately discharged home. Resident #4’s record also showed that a nurse practitioner documented the need for skilled nursing wound care, PT, OT, and a home health aide before discharge, but those services were not in place when the resident left the facility. Social services notes documenting discharge decisions and a referral for home health were entered late and were not added to the discharge care plan. After discharge, the resident was found on the floor in the apartment with vomit and urine, was hypotensive and hypothermic, and was diagnosed with traumatic rhabdomyolysis, acute kidney injury, and cellulitis in both lower legs. The ED record stated the resident reported wound care had not been provided since discharge. Similar discharge planning failures were identified for Residents #8, #9, and #10. Resident #8’s discharge care plan contained generalized interventions and was not updated to reflect the resident’s stated wish to go home or the specific equipment and services documented as needed, including skilled nursing, PT, speech therapy, OT, and a home health aide. Resident #9’s care plan also used generalized goals, did not reflect the resident’s discharge preferences, and did not address the need for skilled nursing, PT, OT, home health aide services, or the resident’s transfer difficulty noted during an IDT meeting. Resident #10’s discharge care plan likewise lacked resident-specific interventions and did not address the equipment and services needed after the resident’s bilateral lower-extremity amputations; the discharge summary omitted needed equipment and post-discharge services, and the resident was discharged without the hospital bed and other supports documented as needed.
Failure to Maintain Resident Dignity During Pain Medication Dispute
Penalty
Summary
Facility staff failed to ensure that a resident was treated with dignity and respect during a readmission after a hospital stay for debridement of a right heel wound. The resident had been ordered Percocet 5-325 mg every 4 hours as needed for pain. On readmission, the resident became upset when pain medication was delayed and when an LPN offered Tylenol while awaiting the Percocet from the pharmacy. The resident also believed the ordered Percocet dose should have been 2 tablets instead of 1. During the same incident, an RN was accused by the resident of slamming discharge paperwork onto the resident's chest. The RN's statement indicated that after the accusation, she left the room and yelled down the hallway that the resident said she hit him and that police needed to be called. Statements from a CNA and an LPN confirmed that the RN came out of the room yelling in the hall that the resident said she hit him and to call 911/cops. The resident later stated that staff had not treated him with dignity and respect and confirmed that the RN went out into the hallway yelling so staff and other residents could hear the accusation.
Failure to Assess Resident Before PRN Rescue Inhaler Administration
Penalty
Summary
Staff failed to provide nursing services that met professional standards of practice when a resident requested a rescue inhaler for shortness of breath and wheezing. During observation, the resident was seen sitting up in bed, pursed lip breathing, using accessory muscles, and appearing restless. The resident stated that an inhaler had been requested because breathing was difficult, but the medication had not yet been brought back, and the resident remained without the inhaler when first observed and again several minutes later. Record review showed the resident had an order for a rescue inhaler every 3 hours as needed for shortness of breath and wheezing, and the last documented dose had been given more than 4 hours earlier. A CMA stated she was aware the resident wanted the inhaler but had not returned to check on the resident and had not reported the request to the nurse. She also stated that she could administer some PRN medications without a nurse assessing the resident first, and that she was waiting because it had not yet been 3 hours. The record also showed a late entry documenting administration at a time that did not match the observation, and progress notes did not show that a nurse assessed the resident before the inhaler was given.
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Compliance trends in Maryland
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 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): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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 May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 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).
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