Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure four (Resident #41, Resident #11, Resident #22, and Resident #33) of 23 residents reviewed for abuse were reported/timely reported to the Administrator and State Survey Agency (SSA) and failed to ensure the results of investigations were submitted to the SSA/submitted within five working days of the incident for four (Resident #11, #2, 22, and 34 of 23 reviewed for abuse. Specifically, the failed to report/timely report the following: 1. Resident #41 reported Registered Nurse (RN) #20 physically abused the resident on 09/13/2025. Staff reported the incident to the Director of Nursing (DON); however, the DON failed to report the allegation to the SSA.2. …
F609 citations in Maryland
Reporting alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Maryland cites F609 more often than its own record predicts
1.39 times the share F609 takes of citations nationally.
Of every deficiency written in Maryland in 2025, this is the portion that was F609.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Maryland surveyors wrote
F609 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 review of facility documentation, medical record review, and interviews, it was determined the facility failed to report an alleged abuse (Resident #3) and an injury of unknown origin (Resident #4) immediately to the Nursing Home Administrator and within 2 hours to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 2 of 8 residents reviewed for facility reported incidents during a complaint survey.The findings include: 1) Review of facility reported incident 3044037 was conducted on 8/25/26 revealed Resident #3 reported to Staff #27 on 6/11/26 that Staff #20 was rough and she throws me around like a bag of potatoes. …
Based on record review and interview, it was determined that the facility failed to have a process in place to ensure that facility staff reported resident abuse allegations immediately to state survey agency. This was evident for 9 of 9 self-reported incidents of alleged abuse and 1 of 1 incident of abuse. The findings include: 1) A record review on 10/7/20 at 10:00 AM, was completed of the Facility's investigation report of an incident of a Resident-to-Resident altercation between Resident #7 and Resident #9 that occurred on 10/1/18 at approximately 5:30 PM, involving abuse. The facility failed to report the incident until 10/2/20 to the State Survey Agency. …
The short window
Recent years
| Year | Share of Maryland citations | vs expected |
|---|---|---|
| 2023 | 2.54% | 1.28× |
| 2024 | 3.56% | 1.56× |
| 2025 | 3.39% | 1.39× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maryland surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction