Based on observation and interview with facility staff, it was determined that the facility failed to ensure to provide proper airflow local exhaust ventilation systems. This was evident for 3 out of 3 shower rooms, 1 of 2 used linen rooms, soiled laundry room, and a chemical storage room reviewed during the annual survey.The findings include:Airborne transmission occurs when pathogens are so small that they can be easily spread in the air, and because of this, there is a risk of transmitting the disease through inhalation. These small particles containing infectious agents may be spread over long distances by air currents and may be inhaled by individuals who have not had face-to-face contact with (or been in the same room with) the infectious individuals. …
F923 citations in Maryland
Environmental Deficiencies
Have enough outside ventilation via a window or mechanical ventilation, or both.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Maryland cites F923 more often than its own record predicts
3.86 times the share F923 takes of citations nationally.
Of every deficiency written in Maryland in 2025, this is the portion that was F923.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Maryland surveyors wrote
F923 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 surveyor observation, it was determined that the facility failed to have adequate ventilation to ensure good air circulation. This was evident for both floors of the facility affecting all residents, staff and visitors. The findings include: On 6/23/2019 at 8:30 AM surveyors entered and began and initial tour of the facility. Immediately upon entering the building, a distinct smell of ammonia and feces was observed by all surveyors and was persistent throughout both floors (Ground and 1st) of the facility. At 8:46 AM the exhaust vents in two downstairs bathrooms adjacent to room [ROOM NUMBER] were observed to have no detectable airflow. …
The short window
Recent years
| Year | Share of Maryland citations | vs expected |
|---|---|---|
| 2023 | 0.17% | 5.51× |
| 2024 | 0.11% | 4.79× |
| 2025 | 0.13% | 3.86× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Maryland surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction