Based on record reviews and interviews, it was determined that the facility failed to use the Quality Assurance Performance Improvement (QAPI) process to track, review, and analyze residents at risk for illicit drug use/overdoses. This was evident during review of the facility's QAPI process after 11 residents (#56, #8, #4, #45, #31, #11, #33, #32, #7, #36 and #37) were reported by the facility to the state agency for suspected drug overdoses in the past 13 months and has the potential to affect all residents with Substance Use Disorders. As a result of this deficient practice, an Immediate Jeopardy was identified on 7/2/2025 at 10:00 AM and an IJ summary tool was provided to the facility. …
F867 citations in Maryland
QAPI improvement activities · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Maryland cites F867 less often than its own record predicts
0.80 times the national share — cited less often here than elsewhere.
Of every deficiency written in Maryland in 2025, this is the portion that was F867.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Maryland surveyors wrote
F867 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 record reviews and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify, track, analyze, and implement effective performance improvement plans to address a pervasive, year-long rodent infestation that directly impacted environmental quality, sanitation, and resident well-being. Specifically, despite documented pest sightings that surged to fifty-two in a single month and required repeated facility-wide extermination clean-outs over a twelve-month period, the QAPI committee failed to recognize the ongoing pest infestation as a critical systemic failure that required formal committee review, tracking, and root-cause analysis until the issue was brought to their attention by the survey team.Findings include:On 8/20/26 at… …
Based on surveyor review of the facility's Quality Assessment and Assurance minutes, social services consultant audits and interviews with facility staff, it was determined that the facility failed to develop and implement an appropriate plan of action to correct identified quality deficiencies in relationship to care plan conferences and social services. The findings include: On 07-19-19, surveyor review of the Social Work Consultant (SW #7)'s audit tools revealed that the audits identified that the Care Plan Conference Summary format needed to address the residents' problems and needs as based on the residents' assessment. The resident's inputs should be incorporated into the care plan. …
The short window
Recent years
| Year | Share of Maryland citations | vs expected |
|---|---|---|
| 2023 | 0.68% | 1.16× |
| 2024 | 0.27% | 0.59× |
| 2025 | 0.26% | 0.80× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maryland surveyors cite →
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