Based on medical record review and interview of facility staff it was determined the facility staff failed to ensure that care plan interventions were implemented: 1) the facility failed to intervene and revise Resident #175's care plan related to tobacco use. This failure occurred when Resident #175 showed signs of decline in cognitive status and activities of daily living, indicating that the resident was not safe to smoke without supervision. It was determined that the facility's failure to revise Resident #175's care plan interventions resulted in an actual harm to the resident from a smoking related accident with injury, and 2) the facility failed to revise and update the care plan that addressed Resident #51's care after a change in condition. …
F657 citations in Maryland
Care plan timing and revision · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Maryland cites F657 more often than its own record predicts
1.74 times the share F657 takes of citations nationally.
Of every deficiency written in Maryland in 2025, this is the portion that was F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Maryland surveyors wrote
F657 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 a review of complaint 3167646, interviews, and medical record review, it was determined that facility staff failed to update a person-centered care plan for a resident dependent on staff for assistance with activities of daily living. This was evident for 1 (Resident #5) of 8 residents during a complaint survey.The findings include: A care plan guides and addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. …
Based on surveyor review of the clinical records and interview with facility staff, it was determined that the facility failed to revise a comprehensive plan of care for resident #128 as indicated on the resident assessment. This finding was evident for 1 of 32 residents selected for review during the survey. The findings include: On 11-09-18, review of resident #128's activity care plan, dated 01-16-18, revealed that the resident preferred not to attend group activities due to a preference to stay in his/her room. The facility staff would allow the resident to familiarize himself/herself with the center environment and activity programs on a regular basis. …
The short window
Recent years
| Year | Share of Maryland citations | vs expected |
|---|---|---|
| 2023 | 3.05% | 1.42× |
| 2024 | 3.45% | 1.81× |
| 2025 | 3.26% | 1.74× |
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