Inspection Reports for
HeartLands Senior Living at Ellicott City

3004 N Ridge Rd, Ellicott City, MD 21043, United States, MD, 21043

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Deficiencies (last 4 years)

Deficiencies (over 4 years) 23.5 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

84% worse than Maryland average
Maryland average: 12.8 deficiencies/year

Deficiencies per year

28 21 14 7 0
2019
2022
2024
2025

Inspection Report

Complaint Investigation
Deficiencies: 3 Date: Nov 4, 2025

Visit Reason
The inspection was conducted in response to multiple complaints alleging medication administration errors, inadequate nail care, and food temperature issues at the nursing facility.

Complaint Details
The investigation was based on complaints #2656373 and #2593162 regarding medication errors, inadequate nail care, and cold food delivery. The complaints were substantiated with observations and interviews confirming the issues.
Findings
The facility failed to ensure medications were administered according to professional standards, provide adequate nail care to dependent residents, and maintain appropriate food temperatures during meal delivery. These deficiencies were observed through direct observation, record review, and interviews with residents and staff.

Deficiencies (3)
F 0658: The facility failed to administer medications as ordered during a complaint survey. One resident received an incorrect inhaler medication instead of the prescribed one.
F 0677: The facility failed to provide nail care to a dependent resident, resulting in long fingernails with brown material underneath. Staff acknowledged the issue and planned immediate correction.
F 0804: The facility failed to ensure food was delivered at appropriate temperatures. Observations showed cold food temperatures and meal carts left open during distribution, risking food quality.
Report Facts
Complaint number: 2656373 Complaint number: 2593162 BIMS score: 15 Meal temperature reading: 40 Meal temperature reading: 39 Meal temperature reading: 152 Meal temperature reading: 140 Meal temperature reading: 143 Meal temperature reading: 53 Meal temperature reading: 52 Meal temperature reading: 131 Meal temperature reading: 122 Meal temperature reading: 111

Employees mentioned
NameTitleContext
Director of NursingAcknowledged medication administration and food temperature concerns
Licensed Practical Nurse (Staff #13)Observed administering incorrect inhaler medication
Unit Manager (Staff #3)Acknowledged nail care deficiency and planned immediate correction
Chef/Certified Dietary Manager (Staff #7)Interviewed regarding meal service and food temperature expectations
Licensed Practical Nurse (LPN #16)Observed leaving meal cart open during meal distribution
Geriatric Nursing Assistant (GNA #17)Acknowledged leaving meal cart open inconsistently with expectations

Inspection Report

Routine
Deficiencies: 4 Date: Jun 27, 2025

Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident notification of changes in condition, grievance handling, abuse investigation, and provision of care and assistance with activities of daily living.

Findings
The facility failed to immediately notify a resident's legal representative of an accident, failed to investigate and resolve resident grievances related to missing clothing, failed to thoroughly investigate an allegation of abuse, and failed to provide necessary grooming and personal hygiene care related to fingernail care and bathing for residents.

Deficiencies (4)
F 0580: The facility failed to immediately inform Resident #9's legal representative of an accident involving the resident falling from a wheelchair in an elevator, resulting in delayed notification despite the resident's guardian being identified in the admission record.
F 0585: The facility failed to investigate and resolve grievances related to missing clothing for Residents #1 and #10, with delays and incomplete documentation of grievance resolution.
F 0610: The facility failed to thoroughly investigate an allegation of abuse for Resident #6, including incomplete resident and staff interviews and inadequate follow-up.
F 0677: The facility failed to provide proper grooming and personal hygiene care for Resident #2, including failure to clean and trim fingernails and inconsistent bathing, despite resident requests and care plan directives.
Report Facts
Residents affected: 1 Residents affected: 2 Residents affected: 1 Residents affected: 1 BIMS score: 9 BIMS score: 15 BIMS score: 15 BIMS score: 15

Employees mentioned
NameTitleContext
Licensed Practical Nurse #3Licensed Practical NurseNamed in notification deficiency interview regarding Resident #9 fall
Director of Social ServicesDirector of Social ServicesInterviewed regarding notification and grievance processes
Director of NursingDirector of NursingInterviewed regarding notification, grievance, and abuse investigation expectations
Environmental Services DirectorEnvironmental Services DirectorInvolved in grievance investigation and communication with Resident Representative #4
AdministratorAdministratorInterviewed regarding grievance follow-up and notification expectations
Nursing Assistant #5Nursing AssistantInterviewed regarding fingernail care responsibilities for Resident #2
Nursing Assistant #6Nursing AssistantInterviewed regarding care provided to Resident #2
Licensed Practical Nurse #7Licensed Practical NurseInterviewed regarding Resident #2's fingernail care
Assistant Director of NursingAssistant Director of NursingInterviewed regarding expectations for bathing and nail care
Clinical Manager Licensed Practical Nurse #2Clinical Manager Licensed Practical NurseInterviewed regarding care expectations and fingernail condition of Resident #2

Inspection Report

Complaint Investigation
Deficiencies: 12 Date: Mar 4, 2025

Visit Reason
The inspection was conducted based on multiple complaints alleging failures in resident care, treatment, and facility conditions at Ellicott City Healthcare Center.

Complaint Details
The investigation was complaint-driven, triggered by multiple complaints alleging inadequate care, poor facility conditions, and failure to follow care plans and orders.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity, inadequate housekeeping and maintenance, inaccurate resident assessments, incomplete care plans, failure to provide needed activities of daily living, failure to administer treatments and medications as ordered, incomplete medical records, failure to provide timely outside professional services, and lapses in infection control procedures.

Deficiencies (12)
F 0550: The facility failed to treat residents with respect and dignity by attempting to restrict a resident's access to a family member during care, inconsistent with the resident's wishes.
F 0584: The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior on 3 of 4 nursing units observed.
F 0641: The facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded, missing documentation of a resident's nephrostomy tube.
F 0656: The facility failed to develop and implement a complete care plan for a resident's suprapubic catheter until surveyor intervention.
F 0677: The facility failed to provide needed activities of daily living, including showering and incontinence care, for residents dependent on assistance.
F 0684: The facility failed to provide appropriate treatment and care according to orders and failed to accurately assess and monitor a resident with a nephrostomy tube.
F 0757: The facility failed to keep a resident's drug regimen free from unnecessary drugs by not including the duration of time a lidocaine patch should be applied.
F 0790: The facility failed to provide routine and 24-hour emergency dental care as recommended for a resident.
F 0825: The facility failed to assess a resident's need for specialized rehabilitative services and failed to complete quarterly therapy evaluations.
F 0840: The facility failed to obtain outside professional services in a timely manner for a resident requiring urology follow-up.
F 0842: The facility failed to maintain complete and accurate medical records, including missing consult notes and incomplete medication administration documentation.
F 0880: The facility failed to maintain infection control procedures while providing patient care, including failure to wear gowns when required and improper handling of shared basins and bedpans.
Report Facts
Residents reviewed for complaints: 37 Residents affected by dignity deficiency: 1 Residents affected by housekeeping deficiency: 3 Residents affected by assessment deficiency: 1 Residents affected by care plan deficiency: 1 Residents affected by ADL care deficiency: 3 Residents affected by treatment administration deficiency: 3 Residents affected by medication documentation deficiency: 1 Residents affected by dental care deficiency: 1 Residents affected by rehabilitation services deficiency: 1 Residents affected by outside services deficiency: 1 Residents affected by medical record deficiency: 5 Residents affected by infection control deficiency: 2

Employees mentioned
NameTitleContext
Staff #52Licensed Practical NurseNamed in dignity and respect deficiency related to Resident #4 care incident.
Staff #21Geriatric Nursing AssistantNamed in dignity and respect deficiency related to Resident #4 care incident.
Staff #30Geriatric Nursing AssistantNamed in dignity and respect deficiency related to Resident #4 care incident.
Staff #46Regional Resident Assessment CoordinatorConfirmed inaccurate MDS assessments for Resident #18.
Staff #16Nurse PractitionerConfirmed failure to administer suprapubic catheter flushes and catheter changes for Resident #8.
Staff #34Registered NurseInterviewed regarding shower documentation for Resident #24.
Staff #26NurseInvolved in Resident #8 care incident and phone calls.
Staff #27NurseInvolved in Resident #8 care incident and phone calls.
Staff #50Licensed Practical NurseInterviewed about wound care documentation.
Staff #7Licensed Practical NurseAcknowledged infection control concerns.
Staff #5Geriatric Nursing AssistantAcknowledged infection control concerns.
Staff #40StaffConfirmed missing consult notes for Resident #14.

Inspection Report

Annual Inspection
Deficiencies: 17 Date: Sep 10, 2024

Visit Reason
Annual survey of Ellicott City Healthcare Center to assess compliance with healthcare regulations and resident care standards.

Findings
The facility was found deficient in multiple areas including resident dignity during feeding, failure to display survey results, inadequate beneficiary notifications, failure to notify bed hold policy in writing, inaccurate resident assessments, incomplete care plans, missed care plan meetings, inadequate assistance with activities of daily living, failure to meet resident activity preferences, improper respiratory care, pain management deficiencies, medication errors, consultant follow-up failures, medication storage and labeling issues, and infection control lapses.

Deficiencies (17)
F 0550: Facility failed to maintain residents' dignity by staff standing over residents while assisting them to eat.
F 0577: Facility staff failed to display annual recertification survey results and plan of correction in a place accessible to residents and visitors.
F 0582: Facility failed to issue Medicare Beneficiary Protection Notifications to residents discharged with benefit days remaining.
F 0625: Facility failed to notify residents or representatives in writing of bed hold policy upon transfer to hospital.
F 0641: Facility failed to ensure accurate Minimum Data Set (MDS) assessments for residents, including medication coding and fall documentation.
F 0655: Facility failed to create and implement baseline care plans within 48 hours of admission for residents with complex needs.
F 0656: Facility failed to develop and implement comprehensive care plans meeting residents' personalized needs.
F 0657: Facility failed to hold quarterly care plan meetings and revise care plans after significant events for residents.
F 0677: Facility failed to provide adequate assistance with activities of daily living and failed to maintain resident hygiene such as nail care.
F 0679: Facility failed to provide activities that met resident preferences and needs, including music, socialization, and outdoor activities.
F 0695: Facility failed to change oxygen tubing for a resident dependent on oxygen per facility policy.
F 0697: Facility failed to provide safe and appropriate pain management, including failure to administer ordered pain medications and document pain assessments.
F 0761: Facility failed to properly label multi-dose medications with opening dates and store medications in locked compartments.
F 0744: Facility consultants failed to appropriately assess a resident's psychiatric needs and correct documentation errors in mental health assessments.
F 0759: Facility failed to maintain medication error rate below 5%, including errors in medication preparation, administration, and documentation.
F 0840: Facility failed to ensure residents attended scheduled outside physician appointments in a timely manner.
F 0880: Facility failed to provide soap in a staff restroom, impairing infection prevention and control practices.
Report Facts
Medication errors: 9 Residents reviewed for care plans: 31 Residents reviewed for ADL: 4 Residents reviewed for activity: 4 Residents reviewed for consultant follow-up: 31

Employees mentioned
NameTitleContext
Staff #33Unit ManagerInterviewed regarding dignity during feeding, medication storage, and nail care.
Staff #41Observed feeding resident while standing, unaware of dignity concerns.
Staff #40Geriatric Nurse AideObserved feeding resident while standing, unaware of dignity concerns.
Staff #15Social Services DirectorInterviewed regarding beneficiary notifications and care plan meetings.
Staff #7MDS CoordinatorInterviewed regarding MDS assessment errors and care plan meetings.
Staff #4Unit ManagerInterviewed regarding care plan processes and missed appointments.
Staff #16Activity DirectorInterviewed regarding resident activity preferences and activity logs.
Staff #42Observed medication administration error with eye drops.
Staff #43Observed medication administration error with refusal documentation.
Staff #30Licensed Practical NurseObserved preparing medications for two residents at once.
Staff #35Regional NurseInterviewed regarding pain management and missed appointments.
Staff #21LPNInterviewed regarding medication authorization process.
Staff #32Psychiatric Mental Health NPInterviewed regarding psychiatric assessment transcription error.
Staff #31DNP StaffInterviewed regarding psychiatric assessment transcription error.
Director of NursingDONInterviewed multiple times regarding care plan processes, medication errors, and infection control.
Maintenance DirectorInterviewed regarding malfunctioning soap dispenser.
Staff #36Certified Nurse AideInterviewed regarding resident nail care.

Inspection Report

Annual Inspection
Deficiencies: 9 Date: Sep 10, 2024

Visit Reason
The inspection was conducted as part of an annual recertification survey including complaint investigations and review of quality of care and compliance with regulatory requirements.

Complaint Details
The survey included complaint investigations related to failure to notify representatives, abuse allegations, failure to provide pain medication, and failure to obtain ordered lab tests. Some complaints were substantiated, including verbal abuse by staff and failure to timely report abuse.
Findings
The facility was found deficient in multiple areas including failure to notify correct resident representatives of condition changes, failure to protect residents from abuse, failure to timely report abuse allegations, inaccurate resident assessments, failure to provide appropriate care and treatment including pressure ulcer care and pain management, failure to maintain accurate medical records, and failure to obtain ordered laboratory services.

Deficiencies (9)
F 0580: Facility failed to notify the correct resident representative of changes in condition for Resident #463, resulting in lack of communication with the power of attorney.
F 0600: Facility staff failed to protect residents from verbal abuse by housekeeping staff and failed to take appropriate corrective action.
F 0609: Facility failed to timely report allegations of abuse within 2 hours to the regulatory agency for 3 residents.
F 0641: Facility failed to ensure accurate Minimum Data Set (MDS) assessments for multiple residents, including medication use, falls, and range of motion.
F 0684: Facility failed to provide care meeting the physical, mental, and psychosocial needs of Resident #166, including inadequate bowel care and short staffing.
F 0686: Facility failed to provide appropriate pressure ulcer care and prevent new ulcers for Resident #263, including delayed treatment and incomplete assessments.
F 0697: Facility failed to provide safe and appropriate pain management for Resident #169 and others, including failure to administer ordered medications and document pain assessments.
F 0772: Facility failed to obtain ordered urinalysis and urine culture and sensitivity for Resident #106 due to failure to place lab orders and collect specimens.
F 0842: Facility failed to maintain complete and accurate medical records for Residents #169 and #166, including inaccurate medication dosages and late documentation.
Report Facts
Changes in condition requiring notification: 11 Residents reviewed for abuse: 8 GNA to resident ratio: 18 GNA to resident ratio: 28 Residents reviewed for MDS accuracy: 93 Residents reviewed for pressure ulcers: 4 Residents reviewed for pain management: 3 Residents reviewed for abuse reporting: 8

Employees mentioned
NameTitleContext
Staff #37Housekeeping StaffNamed in verbal abuse finding and termination for resident abuse.
Staff #35Regional NurseInterviewed regarding pain assessment errors and abuse reporting.
Staff #7MDS CoordinatorInterviewed regarding MDS assessment errors.
LPN #21Licensed Practical NurseInterviewed regarding medication administration process.
Nurse Practitioner #18Nurse PractitionerInterviewed regarding late documentation of resident visit.
Director of NursingDirector of NursingInterviewed regarding pain medication administration failures.
Assistant Director of NursingAssistant Director of NursingInterviewed regarding staffing and care deficiencies.
Nursing Unit ManagerNursing Unit ManagerInterviewed regarding failure to obtain lab specimens.
Regional NurseRegional NurseConfirmed failure to assess pressure ulcers and other deficiencies.

Inspection Report

Annual Inspection
Deficiencies: 28 Date: Oct 14, 2022

Visit Reason
The facility annual Medicare/Medicaid survey was conducted to assess compliance with regulatory requirements including quality of care, resident rights, infection control, abuse prevention, and other standards.

Findings
The survey identified multiple deficiencies including failure to honor residents' rights and preferences, inadequate staff training and supervision, failure to prevent abuse and neglect, incomplete and inaccurate resident assessments and care plans, medication administration errors, ineffective call bell system, and deficient quality assurance processes.

Deficiencies (28)
F 0550: Facility staff failed to provide a dignified environment during dining and failed to honor a resident's private space by entering without permission.
F 0558: Facility failed to ensure a resident's phone was working properly, affecting resident communication.
F 0561: Facility staff failed to honor a resident's preferences for daily activities scheduling.
F 0574: Facility staff failed to ensure residents received contact information for state agency and ombudsman.
F 0577: Facility failed to ensure residents and representatives had access to the most recent survey results.
F 0582: Facility failed to provide timely Advanced Beneficiary Notice of Non-coverage to residents/representatives.
F 0600: Facility failed to protect residents from abuse by other residents and staff, resulting in physical and emotional harm.
F 0602: Facility failed to replace a resident's lost personal property (cell phone) in a timely manner.
F 0607: Facility failed to provide complete investigations and properly screen employees with substantiated abuse allegations.
F 0608: Facility failed to notify the state agency of abuse allegations within mandated timeframes for multiple residents.
F 0609: Facility failed to report an abuse complaint timely and failed to notify state agency of investigation results within required timeframes.
F 0623: Facility failed to notify residents or representatives in writing of bed hold policy when transferred to hospital.
F 0638: Facility failed to complete quarterly Minimum Data Set assessments on time.
F 0640: Facility failed to timely transmit Minimum Data Set assessment data to CMS for multiple residents.
F 0641: Facility failed to ensure accurate resident assessments including pressure ulcer staging and bowel/bladder continence.
F 0656: Facility failed to develop and implement comprehensive care plans with measurable goals and interventions for multiple residents.
F 0684: Facility failed to provide treatment as ordered, administer medications per physician orders, and provide continuity of care for multiple residents.
F 0710: Facility failed to obtain a doctor's order for admission and ensure resident was under physician's care.
F 0711: Facility failed to ensure resident's doctor reviewed care, wrote, signed, and dated progress notes and orders at each required visit.
F 0732: Facility failed to maintain posted daily nurse staffing data for a minimum of 18 months.
F 0761: Facility failed to secure and store medications in locked medication carts and had expired medication on cart.
F 0835: Facility failed to provide alternative communication means for providers and failed to maintain effective call bell system for residents.
F 0842: Facility failed to maintain accurate medical records and treatment documentation for multiple residents.
F 0865: Facility failed to ensure effective Quality Assurance and Performance Improvement (QAPI) interventions to address identified quality deficiencies.
F 0868: Facility failed to ensure QAPI committee had required members and met at least quarterly.
F 0880: Facility failed to ensure staff and visitors completed COVID-19 declaration/surveillance forms as required.
F 0919: Facility failed to ensure effective call system was available in each resident's bathroom and bathing area.
F 0924: Facility failed to provide intact and securely anchored handrails on Magnolia unit hallways.
Report Facts
Residents affected: 79 Residents reviewed: 96 Deficiency counts: 31

Employees mentioned
NameTitleContext
Staff #15Geriatric Nursing AssistantNamed in dining dignity and resident privacy deficiency
Director of Nursing #5Director of NursingNamed in multiple findings including dining dignity, complaint investigations, and QAPI
Licensed Practical Nurse #2Licensed Practical NurseNamed in phone and call bell system observations
Registered Nurse Supervisor #1Registered Nurse SupervisorNamed in phone and call bell system observations
Geriatric Nurse Assistant #3Geriatric Nurse AssistantNamed in phone and call bell system observations
Social Worker Staff #13Social WorkerNamed in beneficiary notice deficiency
Assistant Director of Nursing #7Assistant Director of NursingNamed in multiple findings including abuse reporting and call bell system
Charge Nurse #25Charge NurseNamed in resident abuse incident
Nurse Practitioner (NP)Nurse PractitionerNamed in resident abuse incident
Divisional Director #9Divisional DirectorNamed in QAPI and call bell system discussions
Maintenance Director #12Maintenance DirectorNamed in call bell system and handrail deficiencies
Recreations Director Staff #17Recreations DirectorNamed in activity provision deficiency
MDS Coordinator #58MDS CoordinatorNamed in assessment and transmission deficiencies
Wound Nurse Staff #39Wound NurseNamed in wound care deficiencies
Wound Nurse Practitioner #44Wound Nurse PractitionerNamed in wound care deficiencies
LPN #38Licensed Practical NurseNamed in medication administration deficiency
LPN #60Licensed Practical NurseNamed in medication cart observation
Certified Medication Aid (CMA) #23Certified Medication AidNamed in medication cart observation
Regional Clinical Director #9Regional Clinical DirectorNamed in multiple findings including QAPI and resident representative issue
Assistant Director of Nursing (ADON)Assistant Director of NursingNamed in multiple findings including medication administration, abuse reporting, and QAPI

Inspection Report

Annual Inspection
Deficiencies: 21 Date: Sep 11, 2019

Visit Reason
Annual survey and complaint investigation of Ellicott City Healthcare Center to assess compliance with regulatory requirements including resident care, safety, and facility operations.

Findings
The survey identified multiple deficiencies including failure to maintain resident dignity, inadequate communication for treatment, failure to provide hygiene care, unsafe environment conditions, lack of timely notifications for transfers, inaccurate assessments, incomplete care plans, medication management errors, insufficient supervision leading to elopement risks, and failure to provide ordered medical and dental services.

Deficiencies (21)
F 0550: Facility staff failed to maintain resident dignity by not providing privacy covers for Foley drainage bags and not ensuring shower curtains were available for residents.
F 0552: Facility failed to provide documentation to treating office to ensure resident obtained ordered treatment, causing delay in gastrostomy tube removal.
F 0561: Facility failed to ensure resident received hygiene care according to wishes, including lack of showers and grooming.
F 0582: Facility failed to provide residents with adequate notice of Medicare coverage and potential financial liability for non-covered services.
F 0584: Facility failed to maintain a clean and sanitary environment in resident rooms, including soiled equipment and structural damages.
F 0623: Facility failed to provide timely notification to residents, representatives, and ombudsman before transfers or discharges.
F 0625: Facility failed to notify resident or representative in writing of bed-hold policy upon transfer to acute care.
F 0641: Facility failed to ensure accurate Minimum Data Set assessment for a resident, incorrectly coding cognitive status.
F 0656: Facility failed to develop and implement comprehensive, person-centered care plans addressing specific resident needs including elopement risk and hygiene.
F 0657: Facility failed to follow care plan interventions for pain management and failed to include residents in care plan development and review.
F 0658: Facility nursing staff failed to properly dispose of medication and document administration, causing narcotic count discrepancies.
F 0679: Facility failed to provide an organized activities program meeting resident preferences, resulting in social isolation of a resident with Down Syndrome.
F 0684: Facility failed to transfer a resident to hospital timely and failed to order and administer correct medication on readmission.
F 0689: Facility failed to ensure a nursing home area was free from accident hazards and provide adequate supervision to prevent elopements.
F 0755: Facility failed to maintain accurate controlled drug receipt and disposition records for residents' medications.
F 0756: Facility failed to ensure physician response to pharmacist recommendations, resulting in failure to discontinue a psychotropic medication as ordered.
F 0757: Facility failed to prevent excessive duration of administration of a medication for a resident.
F 0791: Facility failed to obtain dental services for a resident despite resident's expressed desire and documented requests.
F 0800: Facility failed to provide a resident with a meal according to physician orders including nectar thickened liquids.
F 0840: Facility failed to employ or obtain outside professional resources to provide ordered medical procedures, resulting in canceled colonoscopy.
F 0842: Facility failed to safeguard resident-identifiable information by maintaining multiple residents' wander observation tools in one resident's medical record.
Report Facts
Residents reviewed: 44 Residents affected: 5 Residents affected: 3 Residents affected: 2 Residents affected: 2 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 1

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