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 resident with obesity, impaired mobility, and anticoagulant use was injured during incontinent care when a GNA continued pulling a brief after the resident complained of pain and did not remove the plastic fastening tabs first. The tab cut the resident’s left posterior thigh, causing uncontrolled hemorrhage, EMS transport, hospitalization, and blood product transfusions.
Dignified Dining Not Maintained on Dementia Unit: Staff were observed standing while feeding residents and serving seated residents at different times instead of together. During meals, some residents waited while others ate, and one resident had a fly near the head and food. The dining area also had crumbs, spills, and trash on the floor, and the NHA and DON acknowledged the dignity concerns.
Surveyors found multiple maintenance and housekeeping issues, including water-stained ceiling tiles, missing or damaged room fixtures, exposed drywall, a broken wheelchair armrest, and trash and food debris in a unit dining area. A resident with dementia was also observed in a room without a sheet on the bed, with ant and roach spray on the bedside table, and the UM confirmed the spray belonged to the family and that the bed had been cleaned earlier but not yet made up.
The facility failed to follow infection control practices after a complaint and surveyor observations found dirty meal trays, dried brown liquid, a stained pillow, and food debris in resident areas. Multiple bathrooms had unlabeled basins, bedpans, fracture pans, and urine collection items stored on floors, under sinks, or on toilets without plastic wrapping, and one bathroom had a fly on the toilet rim. The Chase Unit TV room also had numerous spills, crumbs, paper towels, cups, food pieces, and trash on the floor. The IP stated the facility did not have a policy for storing these items.
Failure to maintain an effective pest control program was cited after surveyors observed numerous flies throughout the facility, including in resident rooms, bathrooms, dining areas, and around resident food. An IP confirmed the fly problem, and the DOM acknowledged the facility had a fly issue despite routine pest control visits and prior logs showing fly activity throughout the building.
Failure to timely report an alleged abuse involving a resident who said a CMA withheld meals until medication was taken. A PTA heard the concern, but did not report it immediately after the first occurrence and only told management after the resident repeated the allegation. Interviews also reflected the resident reported the issue to staff and police, while the NHA learned of it from rehab staff.
Unsafe Incontinent Care Led to Severe Thigh Laceration and Hemorrhage
Penalty
Summary
The facility failed to ensure incontinent care was provided using safe techniques for one resident who required extensive assistance with activities of daily living and incontinent care due to obesity and impaired mobility. The resident also had multiple diagnoses including muscle wasting and atrophy, morbid obesity, systemic lupus, chronic respiratory failure, chronic kidney disease, chronic pain, lymphedema, atrial fibrillation, generalized edema, impaired mobility, and was receiving anticoagulant therapy. During incontinent care, a GNA continued removing the resident’s brief after the resident complained that something was sticking and that it was painful. The resident stated the staff normally removed the plastic fastening tabs before pulling the brief from underneath, but on this occasion the GNA did not stop when the resident complained and continued pulling the brief. Staff interviews and written statements confirmed that the resident complained of discomfort during the brief change and that bleeding began immediately afterward. The resident reported that the plastic fastening tab cut the back of the left thigh. EMS responded after facility staff reported the resident began bleeding during brief removal, and staff had been unable to identify the source or control the hemorrhage for approximately 35 to 40 minutes before 911 was called. EMS documented a large pool of blood, blood-soaked towels, and that the resident was on blood-thinning medication. The resident was transported to the hospital with dizziness, visual changes, and decreased level of consciousness, and the facility nursing note documented active bleeding from the left leg, low blood pressure, tachycardia, and uncontrolled bleeding requiring immediate transfer. The resident later required hospitalization for approximately three weeks and treatment including transfusion of four units of packed red blood cells and three units of platelets.
Dignified Dining Not Maintained on Dementia Unit
Penalty
Summary
Staff failed to provide a dignified dining experience on the Chase dementia unit by standing while feeding residents and by not serving all seated residents at the same time. During lunch, GNA #16 was observed standing to feed two residents, while an LPN and the Unit Manager were also standing to feed two other residents. During breakfast, one resident was eating while two other residents at the table watched until their breakfast arrived on the next food cart, and another resident sat waiting for a tray until the others at the table had finished eating. Staff stated that the kitchen did not send all trays up at the same time because some residents required feeding. The dining area on the Chase unit was also observed with excessive crumbs, spills, pieces of food, and trash on the floor under and around the tables while residents were eating. One resident had a fly flying around his or her head and food during breakfast. When questioned about the condition of the area, the NHA stated someone should have cleaned up after dinner the night before, and the DON agreed there were dignity issues with staff standing to feed residents and with residents at the tables receiving food at different times.
Maintenance and Room Conditions Not Kept Sanitary or Homelike
Penalty
Summary
The facility failed to provide maintenance services necessary to keep resident rooms and equipment sanitary and orderly. During a tour, surveyors observed water stains on ceiling tiles in multiple rooms, plastic plumbing pipes on the floor and in resident basins, missing toilet paper rollers, bathroom exhaust fans hanging down from the ceiling, missing drywall with exposed corner beading, holes in a bathroom door, a burned-out light bulb at a sink, a nightstand missing a drawer, and a resident wheelchair armrest with missing foam padding and cracked vinyl. In the Chase unit TV/dining area, surveyors also observed spills on the floor, crumbs, paper towels, plastic cups, pieces of food, and trash in the alcove. The DOM stated staff were supposed to enter maintenance issues into the TELS system and said he had been playing catch up changing ceiling tiles because of rain and had shop vacuumed an air conditioning leak. The NHA and DON were shown the Chase unit conditions and stated someone should have cleaned up after dinner and that the area should have been cleaned. The facility also failed to ensure a resident's room was a safe, comfortable, and homelike environment. Resident #6 was admitted with a diagnosis of dementia and was observed in a room without a sheet on the bed. Surveyors later observed the resident in the bed and the bed still did not have a sheet. Ant and roach spray was also observed on the resident's bedside table. The UM confirmed the spray had been brought in by the resident's family and stated it would be removed immediately, and also stated staff had cleaned the bed earlier that day but had not yet put a sheet on it when the resident placed himself/herself in the bed.
Infection Control Failures in Resident Bathrooms and Common Areas
Penalty
Summary
The facility failed to follow infection control practices and guidelines to prevent the development and transmission of disease, as identified during a complaint survey involving 3 of 5 nursing units. During a review of complaint 2965994, a visitor reported dirty meal trays, a dirty towel on the floor with a brown liquid on it, a puddle of dried brown liquid on the floor, a stained pillow, and dried food on the floor that appeared to have been there for some time. On tour with the Infection Preventionist, multiple rooms were observed with basins, bedpans, fracture pans, and urine collection items stored on floors, under sinks, on toilets, or on top of furniture without labels or plastic wrapping. In several bathrooms, toilet paper was not on a roller and was instead placed on the back of the toilet or on a hand rail. One bathroom also had a fly sitting on the toilet rim, and one basin contained a scrunched up brown soiled washcloth. Additional observations included a white basin and urine collection hat on the floor under a sink, a urine collection hat upside down on the floor by a door, and multiple basins nested together or sitting on the floor in resident bathrooms without labeling or protective covering. In the Chase Unit TV room, where most dining tables were located, there were numerous spills on the floor, along with crumbs, pieces of paper towels, plastic cups, pieces of food, and trash including napkins and newspaper ads. The Infection Preventionist stated that resident basins, fracture pans, and toilet collection hats should be dated with the resident's room number or last name and stored in a bag, then later stated the facility did not have a policy for this and had not had one previously when cited in December 2025. The NHA and DON were informed of the findings and agreed with the surveyor's observations.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by numerous flies observed throughout the building during a complaint survey. Surveyors observed a fly on the baby doll held by a resident on the dementia unit, flies in the back dining area and the 500 hallway, and a fly buzzing in a resident room and sitting on a toilet seat in the resident bathroom on the 100 hallway. The Infection Preventionist confirmed there was a fly problem after seeing several flies during the tour and in resident bathrooms. Additional observations showed flies around resident food in the A/B day room while residents were eating lunch, and flies were also seen in the conference room where surveyors were located. The next morning, a resident eating breakfast on the dementia unit had a fly flying around his/her head and food. The Director of Maintenance stated the pest control company came every 2 weeks, but he was unsure what had been treated and acknowledged the facility had a fly problem that had been bad the day before. Pest control logs documented flies at the nurse's station and in multiple resident rooms on the Chase unit in March, and another log documented flies throughout the whole building in May. An invoice from late May documented verbal report of fly activity throughout the building, while a later invoice noted no concerns were reported at that visit.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an alleged abuse immediately to the Nursing Home Administrator and within 2 hours to the regulatory agency, the Office of Health Care Quality. The deficiency involved Resident #3, who alleged that Certified Medicine Aide #17 refused to give breakfast until the resident took medication. The record also included statements that the resident reported similar concerns to staff on more than one occasion, including that food was withheld when the resident would not take medication, and that the resident believed staff had twisted the resident’s arm and legs. A written statement from a PTA documented that the resident told him lunch had been withheld on one day and breakfast had been withheld the next day because the resident would not take medication. Interviews showed that the PTA did not report the allegation immediately after the first report and instead told his director later after the resident repeated the concern. The PTA stated he forgot to tell his supervisor after the first incident. The resident stated that the food was withheld more than 1 day and that the resident had reported the matter to staff at the desk and to police. The DOR stated staff should report such concerns to the nurse or closest nurse in management, and the NHA stated he learned of the matter from rehab staff.
Find your facility
Search by name to see its inspection history, citations and penalties — and how to prepare for the next survey.
Get alerted when Immediate Jeopardy citations hit in Maryland — free
You're all set
Compliance trends in Maryland
Data through May 2026Comparisons below measure the most recent period Jun 2025 – May 2026 against the prior period Jun 2024 – May 2025 (two equal 12-month windows). The most recent 2 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 2-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): Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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: Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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 Jun 2025 – May 2026 vs the prior period Jun 2024 – May 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 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jun 2025 – May 2026 vs the prior period Jun 2024 – May 2025; the most recent 2 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 2 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
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.
