Based on surveyor review of clinical records, facility policies and procedures, and resident and staff interview(s), it was determined that facility staff failed to ensure that residents who lacked decision making capacity had an identified decision maker that could act on the resident's behalf for the resident's best interest. In addition, the facility failed to notify the hospital of the determination that a resident being transferred for evaluation lacked decision making capacity. This finding was the result of investigation of complaint #MD 746, which was evident for 1 (#49) of 2 residents reviewed for hospitalization during the survey. On 08-22-19 at 7:00 PM, an immediate jeopardy (IJ) for resident rights/exercise of rights was determined. …
F550 citations in Maryland
Resident rights and dignity · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Maryland cites F550 less often than its own record predicts
0.94 times the national share — cited less often here than elsewhere.
Of every deficiency written in Maryland in 2025, this is the portion that was F550.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Maryland surveyors wrote
F550 findings written in Maryland, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on record review, observation and interview, it was determined the facility staff failed to allow a competent resident (#6) their right to leave the facility. The facility physically stopped Resident #6 from leaving through the exit door and, as with their previous requests to depart, was told he/she had to wait 4 more days to leave. This failure to allow Resident #6 to leave resulted in actual psychosocial harm that was manifested in a mental state causing him/her to take desperate action on a cold winter night to break a window lock and escape through a ground floor window on foot. This desperate action reflected Resident #6's mental state that they had no other recourse but to break out. …
Based on observations and interviews it was determined that the facility failed to ensure residents' right to dignified experience was maintained. This was evident for 2 (#42, # 97) of 3 residents investigated for dignity and neglect during the facility's annual Medicare/Medicaid survey. The findings include: 1. During an interview on 08/24/2026 at 7:50 am, Resident #42 stated We have to make our own beds around here because staff doesn't offer to help. It has been two weeks since I got my bed changed and I've had the same linen on it for the entire time. I have a hard time reaching across from my chair to remove the sheet and put a new one on and when I go to the laundry cart, I sometimes think that the staff doesn't like me doing that. …
The short window
Recent years
| Year | Share of Maryland citations | vs expected |
|---|---|---|
| 2023 | 1.27% | 0.62× |
| 2024 | 2.23% | 1.02× |
| 2025 | 2.01% | 0.94× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maryland surveyors cite →
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