Based on surveyor observation, interview and record review it was determined the facility staff failed to implement measures as per the resident's Plan of Care and standards of nursing practice to promote dignity for a resident with an indwelling urinary catheter. This was evident for 1 (Resident #5) of 5 residents reviewed during the complaint survey.The findings include: During a tour of the facility on 7/28/26 at 11:45 AM the surveyor observed Resident #5's bedroom door was open. From the hallway, the surveyor observed Resident #5 lying in bed, a urinary catheter bag containing a moderate amount of urine was lying on the floor beside the foot of the bed. The surveyor knocked on the door however Resident #5 appeared to be asleep and did not answer. …
F557 citations in Maryland
Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Maryland cites F557 less often than its own record predicts
0.70 times the national share — cited less often here than elsewhere.
Of every deficiency written in Maryland in 2025, this is the portion that was F557.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Maryland surveyors wrote
F557 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 surveyor observation, resident interview and interview of facility staff, it was determined that the facility staff failed to treat resident #192 in a dignified manner by giving an insulin shot to the resident in the hall way. This finding was evident in 1 of 2 residents selected for the residents' dignity review during the survey. (#192). The findings include: On 02-12-19, surveyor review of resident #192's clinical record revealed that the resident was admitted to the facility's rehabilitation unit after a brief hospital stay. …
The short window
Recent years
| Year | Share of Maryland citations | vs expected |
|---|---|---|
| 2023 | 0.25% | 1.00× |
| 2024 | 0.21% | 0.80× |
| 2025 | 0.16% | 0.70× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maryland surveyors cite →
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