Based on observations, and interviews, it was determined that the facility failed to provide a safe sanitary environment related to sewage water backup. This was found on 1 of 8 days of the survey.The Maryland Office of Health Care Quality (OHCQ) determined that concern met the Federal definition of Immediate Jeopardy and the facility was notified in writing of this determination at 3:25 PM on 7/15/25. The findings include:On 7/15/25 at 8:44 AM, at the entrance conference the Nursing Home Administrator (NHA) confirmed that the facility was having a problem with a drainage pipe and that they were dealing with a sewage issue.On 7/15/25 at 9:36 AM, the surveyor observed the kitchen. A pooling of sewer water was noted over a circular drain in the floor. …
F921 citations in Maryland
Safe, clean, comfortable environment · Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Maryland cites F921 more often than its own record predicts
1.71 times the share F921 takes of citations nationally.
Of every deficiency written in Maryland in 2025, this is the portion that was F921.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Maryland surveyors wrote
F921 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, facility documentation and interview, it was determined the facility failed to provide a safe and functional environment resulting in psychosocial and physical harm to a resident (Resident #9). This was evident for 1 of 79 residents in the facility on 1/24/25 and reviewed during the complaint survey.The findings include:Review of facility documentation provided by the Administrator on 8/27/25 revealed the Office of Health Care Quality (OHCQ) conducted a Life Safety Code complaint survey on 1/29/25 and found the facility was cited for not maintaining temperature in the attic to prevent pipes from freezing causing the pipes to rupture. …
Based on multiple observations and interviews with staff, it was determined that the facility failed to keep a safe, sanitary and clean environment for the residents. This was noted on 2 of 3 floors throughout the course of the survey. The findings include: 1. The facility was toured on 7/17/26 at 5:15 AM on the 2nd floor identified multiple concerns for resident safety and comfort starting in the resident lounge area. At the entrance to the immediate right there were 2 white square tiles adjacent to another set of tiles then a rug, none of which were aligned creating an uneven floor further tripping hazards for residents. Continued observations of the lounge area also noted 3 tables of varying heights next to each other. …
The short window
Recent years
| Year | Share of Maryland citations | vs expected |
|---|---|---|
| 2023 | 1.10% | 1.28× |
| 2024 | 0.53% | 0.67× |
| 2025 | 1.45% | 1.71× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maryland surveyors cite →
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