Based on observation, interview and medical record review, it was determined that the facility failed to administer medication according to professional standards of nursing, monitor the administration of medication to residents and crush medications according to standards of nursing practice. This was evident during the observation of staff putting medication in resident food and not monitoring when the resident gets the medication, who gives the medication and how much of the medication the resident receives and if the appropriate staff administered the medication. Resident #11's ten medications were left unattended on his/her tray and Resident #13's five medications were left unattended. Both medications were administered by a geriatric nursing assistant (GNA) and incorrectly crushed. …
F658 citations in Maryland
Professional standards of care · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Maryland cites F658 more often than its own record predicts
1.03 times the share F658 takes of citations nationally.
Of every deficiency written in Maryland in 2025, this is the portion that was F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Maryland surveyors wrote
F658 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 medical record review and interviews it was determined that the facility nursing staff failed to document according to professional nursing standards. This deficient practice was evidenced in 2 (#2, #3) of 3 resident records reviewed during the complaint survey. The findings include:The Maryland Nurse Practice Act guide and governs nursing practice in the state of Maryland. Registered Nurses, Licensed Practical Nurses, and certificate holders are expected to practice within the established regulations defined by the Nurse Practice Act. According to 10.27.10.02 B (3) (c) (i) The LPN contributes to the nursing assessment by recording data in a manner which is complete, timely, and accurate. 1. …
Based on surveyor review of the clinical record and interview of the facility staff and attending physician, it was determined that the facility staff failed to meet the standards of nursing practice for clarifying physician's orders [REDACTED]. This finding was evident for 1(#32) of 6 residents selected for review. The findings include: a. On 06-04-18, review of a clarification order for resident #32, which was documented on 03-03-18 by the facility's Medical Director, revealed the nursing staff were instructed to administer [MEDICATION NAME] 4 mg every 8 hours Pain >5-10/10. (Pain rated as over 5 on a scale of 1-10) [MEDICATION NAME] ([MEDICATION NAME]) is a controlled II drug for pain relief. …
The short window
Recent years
| Year | Share of Maryland citations | vs expected |
|---|---|---|
| 2023 | 1.10% | 0.69× |
| 2024 | 1.28% | 0.78× |
| 2025 | 1.84% | 1.03× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maryland surveyors cite →
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