Based on observation, interviews and review of facility documentation, the facility failed to effectively allocate resources to meet resident needs and to ensure their highest practicable well-being when (1) the facility administration failed to ensure effective management of dietary services without qualified staff managing the kitchen since April 2020; (2) the facility administration failed to ensure required maintenance was performed to provide a safe and sanitary food service operation in the facility kitchen when no hot water was available beginning on 7/6/20; (3) the facility administration for more than two months allowed unsafe practices regarding food preparation, food service, and infection prevention and control requirements, where these practices continued for at least 72 days,… …
F835 citations in Maryland
Administration · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Maryland cites F835 less often than its own record predicts
0.56 times the national share — cited less often here than elsewhere.
Of every deficiency written in Maryland in 2025, this is the portion that was F835.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Maryland surveyors wrote
F835 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 observations, review of video footage, record review, and staff interview, it was determined that the facility's administration failed to protect Resident #3 from egregious rights violations where facility GNA staff repeatedly placed Resident #3 into restraint with no documented clinical justification. The facility administration was aware of the noncompliant practices and related rights violations but failed to promptly take required steps to report, investigate and end the abusive conduct of its staff. This was evident for 1 of 3 residents (Resident #3) reviewed during survey. …
Based on record review and interview, it was determined that facility staff failed to: 1) ensure appropriate conditions in place, including contracts and physician orders when having a consultant in their facility, 2) complete a facility assessment and use this information to develop and implement a training program for all staff 3) ensure that all staff, contracted staff and visitors had the required trainings on hire and ongoing, and 4) evaluate the skill performances of their nurses aides and ensure that they had 12 hours of training annually. This was evident throughout the complaint survey. The findings include:1. Review of the medical records for at least 5 residents of the facility starting on 1/21/26 revealed completed 'nephrology' consultations completed by a nurse practitioner. …
The short window
Recent years
| Year | Share of Maryland citations | vs expected |
|---|---|---|
| 2023 | 0.76% | 2.65× |
| 2024 | 0.48% | 1.46× |
| 2025 | 0.16% | 0.56× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maryland surveyors cite →
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