Ellicott City Healthcare Center
Inspection Findings
F-Tag F0658
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, record review, and interview, it was determined that the facility failed to ensure medications were administered based on professional standards of practice. This was evident for 1 of 1 medication administration observed during a complaint survey. The findings include: On 11/03/2025 at 8:01 AM, review of Complaint #2656373 revealed an allegation that medications were not administered as ordered.On 11/04/2025 at 9:00 AM, a random observation of Licensed Practical Nurse (Staff #13) administering medications to Resident #11 revealed several medications administered, two of which being Fluticasone-Salmeterol and Albuterol (both are inhalers which are medications given through the mouth by taking a deep breath to help breathing).Further observation revealed that Staff #13 administered one puff (one breath) of Fluticasone-Salmeterol and one puff of Albuterol. On 11/04/2025 at 9:40 AM, review of the medication administration record revealed that Fluticasone-Salmeterol and Umeclidinium Bromide (another type of inhaler) were signed off as administered during the 9:00 AM observation.Further review of Resident #11's medical record revealed that the Umeclidinium Bromide was due and should have been administered along with Fluticasone-Salmeterol, instead of the Albuterol inhaler that was observed administered to the resident.On 11/04/2025 at 10:24 AM, the surveyor reviewed the concern with the Director of Nursing regarding the observation made and she understood the concern.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ellicott City Healthcare Center
3000 North Ridge Road Ellicott City, MD 21043
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0677
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint #2593162, observation, interview, and record review, it was determined that the facility failed to provide nail care to dependent residents. This was evident for 1 out of 1 resident (Resident #2) reviewed for Activities of Daily Living (ADL) care during the survey process.The findings include:The Brief Interview for Mental Status (BIMS) score is a number between 0 and 15 that indicates a person's cognitive health: 13-15 points: The person's cognition is intact; 8-12 points: The person has moderate cognitive impairment; 0-7 points: The person has severe cognitive impairment.Minimum Data Set (MDS) or MDS assessment, is a standardized, federally mandated clinical and functional assessment of residents in Medicare and Medicaid-certified nursing homes. The assessment helps nursing home staff understand a resident's strengths and needs to create an individualized care plan, monitor quality of care, and determine reimbursement. It is conducted upon admission, periodically (quarterly and annually), and upon discharge or when a resident's condition significantly changes.On 10/30/2025 at 8:41 AM, a review of complaint #2593162 alleged that Resident #2's care was not being met as evidenced by grossly long fingernails and black filth.On 10/30/2025 at 9:06 AM, surveyor's review of Resident #2's electronic health record revealed that he/she was admitted to the facility on [DATE REDACTED] with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, aphasia following cerebral infarction, and type 2 diabetes mellitus with other diabetic complications.On 10/30/2025 at 9:17 AM, review of the resident's quarterly Brief Interview for Mental Status (BIMS) assessment, dated 10/10/2025, indicated a score of 15, signifying that Resident #2 was cognitively intact and review of GG (functional abilities) section on the MDS assessment also revealed that he/she was dependent for self care.On 10/30/2025 at 9:50 AM, an observation of Resident #2 revealed he/she had long fingernails with brown-colored material underneath the fingernails. On 10/30/2025 at 9:53 AM, during an interview, when Resident #2 was asked about his/her care at the facility, he/she stated that overall care could be better because the facility seems short-staffed. He/she further reported needing fingernails trimming but had not received assistance.On 10/30/2025 at 10:23 AM, during an interview, the Unit Manager (Staff #3), when asked what the expectation was regarding general skin and nail care, he stated that the expectation for skin and nail care was for staff to assess skin integrity and nail condition during showers. Staff #3 added that fingernails should be trimmed if needed or per residents' requests, and nurses would notify the podiatrist for toenail concerns.On 10/30/2025 at 10:26 AM, with the resident's permission, the surveyor and Staff #3 conducted a joint observation of Resident #2. Upon viewing the resident's long fingernails with brown-colored material underneath the fingernails, Staff #3 acknowledged the condition and stated that the fingernails nails would be trimmed and cleaned immediately. Staff #3 further stated that the Geriatric Nursing Assistant (GNA) who provided shower care on 10/28/2025 should have checked the fingernails at that time.On 10/30/2025 at 12:12 PM, when the Director of Nursing (DON) was informed about the concern, she stated that she had been informed by Staff #3 and that the facility would implement measures to prevent recurrence.On 10/30/2025 at 7:17 AM, review of Resident #2's progress note, dated 10/30/2025 at 2:25 PM, documented that the resident's fingernails were trimmed and filed as part of routine care. The note indicated that nails were cleaned prior to trimming, with no redness, cuts, or signs of infection observed. The resident tolerated the procedure well, and hands were washed and moisturized after care.
The documentation further indicated that regular nail care would continue to promote hygiene and prevent skin injury.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/04/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ellicott City Healthcare Center
3000 North Ridge Road Ellicott City, MD 21043
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0804
F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
at 135°F or above, with coffee and hot beverages not exceeding 150°F. When asked to conduct a dual temperature test of the same tray, both the surveyor and Staff #7 observed the following temperature readings: Orange juice: 53°F Milk: 52°F Coffee: 131°F Hot cereal: 122°F Eggs: 111°F(Cinnamon rolls and toast were not tested.)
On 11/03/2025 at 8:59 AM, when Staff #7 was asked about the temperature decline, she stated that it was
the responsibility of GNAs and nurses to deliver trays immediately upon arrival to the unit. She added that
the facility previously used metal meal carts but transitioned to plastic carts after complaints about cold food persisted. When informed that the meal cart was left open during meal distribution, Staff #7 stated that carts should remain closed when not actively in use.
On 11/03/2025 at 10:11 AM, in an interview with Licensed Practical Nurse (LPN #16), when asked what the expectation was regarding residents getting their meals and the expectation regarding maintain the meals temperature, she stated that meal trays should be distributed to residents immediately upon arrival to the unit and confirmed that Geriatric Nursing Assistants (GNAs) are primarily responsible for tray delivery.
When informed that she was observed leaving the meal cart open, Staff #16 acknowledged the observation and stated she should have closed the cart while waiting for the GNA to retrieve trays to maintain the temperature of the meal.
On 11/03/2025 at 10:16 AM, in an interview with Geriatric Nursing Assistant (GNA #17), when she was asked her expectation regarding maintaining the temperature of the meals in the meal cart, she stated that
the expectation was to keep the meal cart closed after removing each tray. When informed she had left the cart open several times, GNA #17 acknowledged that this was inconsistent with expectations.
On 11/03/2025 at 11:22 AM, when the concerns were discussed with the Director of Nursing (DON), she acknowledged the observation of open meal carts and stated that going forward, all staff would assist with prompt tray delivery to residents and receive education regarding maintaining cart closure when not actively serving meals.
On 11/04/2025 at 8:24 AM, follow-up observation revealed that the facility had implemented a new practice of announcing meal cart arrivals to the units through an overhead speaker.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
ELLICOTT CITY HEALTHCARE CENTER in ELLICOTT CITY, MD inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ELLICOTT CITY, MD, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ELLICOTT CITY HEALTHCARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.