Based on review of a facility reported incident, review of administrative and medical records, and staff interviews, it was determined that the facility failed to ensure a resident was free of a significant medication error when a nurse incorrectly administered the medication Methadone to a resident instead of the prescribed medication Methylphenidate. This was evident for 1 of 1 resident (Resident #1) reviewed for unnecessary medications during a complaint survey. The failure of the facility to ensure that Resident #1 was free of a significant medication error resulted in the determination of an immediate jeopardy situation being identified on February 25, 2025, at 6 PM. …
F760 citations in Maryland
Significant medication errors · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Maryland cites F760 less often than its own record predicts
0.53 times the national share — cited less often here than elsewhere.
Of every deficiency written in Maryland in 2025, this is the portion that was F760.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Maryland surveyors wrote
F760 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 staff failed to enter medication orders into a resident's electronic health record (EHR). This deficient practice was evidenced in 1 (R #238) of 5 resident records reviewed for medication administration during the recertification survey. The deficient practice resulted in harm to R#238.The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 3/13/2026. …
Based on record review and interview, it was determined that the facility failed to ensure that resident medications were administered as ordered by the physician. This was evident for 1 (Resident #14) of 3 residents reviewed for medication administration during the complaint survey.The findings include:On 08/11/2026 at approximately 2:15 PM, a review of Intake #3132187 revealed the complainant for Resident #14 had concerns related to Resident #14 not receiving his/her medications as prescribed for many illnesses.On 08/12/2026 at 9:49 AM, a review of Resident #14's July 2026 medication administration record (MAR) revealed multiple instances where medications were not administered in accordance with physician orders:-Digoxin (125 MCG): Ordered every other day for heart failure, this… …
The short window
Recent years
| Year | Share of Maryland citations | vs expected |
|---|---|---|
| 2023 | 0.85% | 0.76× |
| 2024 | 0.53% | 0.46× |
| 2025 | 0.69% | 0.53× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maryland surveyors cite →
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