LORIEN BULLE ROCK
For profit - Corporation
78 Beds
LORIEN HEALTH SERVICES
Data: November 2025
Trust Grade
80/100
#29 of 219 in MD
Photo by Lorien Bulle Rock
Photo by Lorien Bulle Rock
Photo by Lorien Bulle Rock
1 / 8 photos
Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Lorien Bulle Rock in Havre de Grace, Maryland has a Trust Grade of B+, which indicates it is above average and recommended for potential residents. It ranks #29 out of 219 facilities in Maryland, placing it in the top half, and #2 out of 6 in Harford County, meaning only one local option is rated higher. However, the facility is showing a worsening trend, increasing issues from five in 2022 to seven in 2025, highlighting some areas of concern. Staffing is a strength, with a 5/5 star rating and a turnover rate of 40%, which is average for the state. Notably, there have been concerning incidents, including failure to manage pain effectively for some residents and a reported case of verbal abuse by a staff member, which raises questions about the quality of care. Overall, while Lorien Bulle Rock has strong staffing and ratings, families should be aware of these issues when considering care for their loved ones.
- Trust Score
- B+
- In Maryland
- #29/219
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 40% turnover. Near Maryland's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Maryland facilities.
- Skilled Nurses ✓ Good
- Each resident gets 53 minutes of Registered Nurse (RN) attention daily — more than average for Maryland. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
80/100
Top 13%
No red flags
5 → 7 violations
★★★★★
5.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★★
5.0
Inspection Score
↔
Stable
2022: 5 issues
2025: 7 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (40%)
8 points below Maryland average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 40%
Near Maryland avg (46%)
Typical for the industry
Chain: LORIEN HEALTH SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 33 deficiencies on record
Jul 2025
7 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility reported incident details, resident medical records, facility staff personnel files, and interview w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility reported incident details, resident medical records, facility staff personnel files, and interview with facility staff, it was determined that the facility failed to ensure a resident was free from abuse. This was evident for 1 (Resident #76) out of 35 residents reviewed during the annual survey.
The findings include:
The Office of Health Care Quality received a facility reported incident on 3/22/23, MD00190490, that alleged a facility staff, Registered Nurse, RN #12, verbally abused Resident #76 on 3/20/23 during the 3 pm to 11 pm shift. In the investigation, the facility substantiated through multiple witnesses (Staff # 13, GNA #14, Staff #15, and GNA #16) that RN #12 used verbally abusive and inappropriate language while rendering care to Resident #76.
Resident #76 was was admitted to the facility on [DATE] for long term care services. At the time of the incident, Resident #76 was under hospice care with diagnoses including, Alzheimer's, Dementia, and Repeated Falls. Review of Resident #76's MDS assessment dated [DATE] showed the resident was dependent for all care, transfers with a mechanical lift, and his/her BIMS was 1/15.
A review of the facility investigation file showed:
Resident #76 does attempt to get out of bed on his/her own and requires frequent monitoring from staff to keep him/her safe. On the evening shift of 3/20/23, Resident #76 was brought into the hallway in a recliner to offer a change in environment and allow staff to monitor him/her more closely. The Resident was repeatedly attempting to climb out of her chair, putting himself/herself in danger of falling which required constant supervision and interaction with staff. Staff later reported that the assigned Nurse,RN #12, showed visible signs of stress secondary to the needs of the residents that were in her assignment. Staff report that RN #12 made comments loud enough to be heard by anyone in the area that were degrading .
On 6/25/25 at 12:25 PM further review of the investigation file revealed a handwritten statement by Housekeeping Staff #13 that reported that RN #12 was yelling at Resident #76 and grabbing his/her pant leg, pulling his/her leg violently and RN #12 said infront of the resident, If I could open the stairwell door, I would push the resident in there.
The file also revealed that another facility staff member, geriatric nursing assistant, GNA #14, wrote a statement that he/she witnessed RN #12 being verbally harsh to Resident #76 on 3/20/23 during the 3pm to 11pm shift.
Statements from a Dietary Aide, Staff #15, revealed that he/she saw RN #12 pushing a Resident into a chair and telling him/her to sit down, then stating you know what, get up and fall down, I don't care and then walked away.
An additional statement was reviewed which noted that GNA #16 wrote a statement that he/she saw with his/her own eyes on 3/20/23 RN #12 threaten to push Resident #76 down the back steps.
Review of a documented interview held on 3/24/23 between the Director of Nursing (DON) and RN #12 showed that: RN #12 reported that this Resident (Resident #76) and one other were restless that evening and he/she did not respond appropriately. RN #12 stated that he/she had an Emotional breakdown and realized he/she needed to remove himself/herself from the unit. He/She reports that he/she used inappropriate language stating that I have to get the he!! out and that he/she can't stand this damn s*!t. He/She reports that her words were not directed towards anyone, it was just his/her response to the situation.
On 6/25/25 at 1:09 PM the surveyor reviewed the facility's Abuse Prevention Policy which defined verbal abuse as: The use of oral, written or gestured language that willfully includes disparging and derogatory terms to residents {or their families}, or within their hearing distance, regardless of their age, ability to comprehend or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident
On 6/25/25 at 1:18 PM a review of RN #12's personnel file, revealed a front page that stated Do not rehire, he/she would have been terminated for verbal abuse. Term date 4/1/23, last day worked 3/20/23. The surveyor reviewed this information with the DON who confirmed the findings in RN #12's personnel file.
On 6/26/25 at 7:30 AM the surveyors held an interview with the DON. The surveyors reviewed the staff's witness statements and UM #12's statement with the DON. The DON confirmed that the allegation of verbal abuse was substantiated and even though UM #12 did not return to work since 3/20/23, the decision had been made to terminate UM #12's employment due to these findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interviews and record review, it was determined that the facility failed to immediately report an allegation of abuse to the State Office of Health Care Quality within the allotted two-hour t...
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Based on interviews and record review, it was determined that the facility failed to immediately report an allegation of abuse to the State Office of Health Care Quality within the allotted two-hour timeframe. This was found evident in 2 out of 4 (Resident #74 & 81) residents reviewed for abuse allegations during an annual and complaint survey.The findings include:
1a) On 6/30/25 at 9:15 AM, the surveyor reviewed the facility investigation into an allegation of abuse related to Resident #81. The investigation revealed that an allegation of abuse was reported to a staff member by Resident #81's family member on 4/12/25 in the afternoon, however, the date the allegation was reported to the Office of Health Care Quality (OHCQ) and the date the investigation was started was 4/13/25.On further review, a progress note written on 4/12/25 at 3:07 PM, by Licensed Practical Nurse (LPN) #10, stated that Resident #81's daughter reported that Resident #81 told her that someone working the night shift had been hurting him/her. On 6/3/25 at 10:58 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA). During the interview the NHA confirmed that the allegation was not reported to the OHCQ immediately (two hours after the allegation) and that the reason why the allegation was not reported or the investigation started, was due to the staff not notifying him until the following day.1b) On 06/25/25 at 11:20 am a review of the facility's investigation related to Resident #74 revealed Maintenance Tech #19 statement indicated the resident told them about the alleged incident on 10/11/22 10:30 am. EVS Director #18 reported on 10/11/22 at 2:30 PM that the resident reported being smacked by someone during the early hours on the 11 PM - 7 AM shift. At 12:02 PM further review of the investigation revealed the incident was reported to the state agency at 4:30 PM which was outside of the 2-hour allotted timeframe to report an allegation of abuse. On 06/25/25 at 2:02 PM during an interview with the Director of Nursing (DON) the surveyor asked what the expectation of the staff related to reporting allegations of abuse. The DON verbalized that the staff should report abuse immediately to the DON or Administrator. They are aware of the 2-hour window and there was no reason for the delay. They typically report allegations of abuse within 2 hours.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review and interviews it was determined that the facility staff failed to interview all the staff who worked on the unit during the investigative phase of an allegation of abuse. This ...
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Based on record review and interviews it was determined that the facility staff failed to interview all the staff who worked on the unit during the investigative phase of an allegation of abuse. This deficient practice was evidenced in 1 (#74) of 10 facility reported incident investigation reviewed during the recertification and complaint survey.
The findings include:
On 6/25/25 at 11:20 AM a review of the facility's investigation of Resident #74 allegation of abuse, the surveyor noted all the staff who worked on the unit during the alleged incident, statements were not included in the investigation.
On 6/26/25 at 2:02 PM during an interview with the Director of Nursing (DON) the surveyor asked what process they follow when completing an investigation. The surveyor asked if there were statements from two Geriatric Nursing Assistant's (GNA) and a nurse who also worked on the unit during the time of the alleged incident. The DON verbalized they are in the process of revamping the policy on how investigations will be done. There were only 2 GNA's working at that time. The other GNA came in at 3 AM. Usually they interview everyone who worked. Not sure why the interviews are not part of the investigation because they always do that.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on medical record review and an interview it was determined that the facility failed to hold care plan meetings with the interdisciplinary team for a resident at the time of the quarterly revisi...
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Based on medical record review and an interview it was determined that the facility failed to hold care plan meetings with the interdisciplinary team for a resident at the time of the quarterly revision of their care plan. This was evident for 1 (Resident #24) of 35 residents reviewed during the annual recertification survey.
The findings include:
Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable).
On June 26, 2025, at 4:25 PM, the medical records for Resident #24 were reviewed. This review showed that Resident #24 had a quarterly MDS assessment on October 24, 2024, and an annual MDS assessment on April 22, 2025. Review of the progress notes in Point Click Care (PCC) indicated that no care plan meetings were held with the interdisciplinary team for Resident #24 in October 2024 and April 2025.
On June 27, 2025, at 9:39 AM, Staff #4 was interviewed and asked if documentation could be provided for Resident #24's care plan meetings with the interdisciplinary team for October 2024 and April 2025. Staff #4 replied that they have documentation for January and June 2025 care plan meetings with the interdisciplinary team for Resident #24, but they do not have documentation for care plan meetings in October 2024 or April 2025 for Resident #24.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on record review and staff interview it was determined that the facility failed to reposition the resident, toilet or check the resident for being wet or being soiled for 4.5 hours. This was evi...
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Based on record review and staff interview it was determined that the facility failed to reposition the resident, toilet or check the resident for being wet or being soiled for 4.5 hours. This was evident for 1 (Resident #80) of 1 residents reviewed for ADL's during an annual and complaint survey
Findings include:
On June 30, 2025 at 9:45 AM during a chart review, it was noted that the Physical Therapist/Occupational Therapist had documented that after therapy on 3/25/2025, the resident was returned to his/her room at 11:00 AM and instructed to sit in the chair for 1 hour. The resident was given the call bell and told to alert the staff when he/she was ready to go back to bed.
The surveyor reviewed a complainant that stated that Resident #80's daughter called at 3:15 PM stating that he/she was left in the wheelchair since early that morning and that no one had responded to his/her call bell.
At 9:15 AM on July 1, 2025, a further chart review noted that on 3/25/2025 at 3:41 PM, Registered Nurse (RN) #20 received a call from the resident's daughter stating his/her parent had been in the chair since 11 AM and needed to be put to bed. The nurse reported that the resident stated he/she had been in the chair for 6 hours.
On July 1, 2025 at 9:49 AM the Director of Nursing (DON) was interviewed and stated that according to the documentation the resident was put back to bed at 3:21 PM on 3/25/2025. There was no documentation for the resident being re-positioned, toileted or checked for being wet or soiled.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to ensure proper medication storag...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility failed to ensure proper medication storage according to professional standards of practice. This was found to be evident for 1 out of 3 medication carts observed during the recertification survey.
The findings include:
During an observation of a second-floor medication cart on [DATE] at 9:04 AM, a bottle of Acetaminophen was found with a manufacturers expiration date of 4/2025 and was labeled opened on [DATE]. LPN #7 stated that the Acetaminophen expired and needed to be discarded. No open date was found on a bottle of Milk of Magnesia and an open bottle of Active Critical Care liquid protein labeled as opened [DATE]. LPN #7 stated that both bottles should be discarded.
On [DATE] at 10:22 AM the Director of Nursing was shown pictures of the bottles found in the medication cart. He acknowledged the concerns of unlabeled and expired bottles found in the medication cart.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1c) On 7/01/25 at 8:45 AM a review of Resident #225 printed medical record revealed there was no documentation to verify the res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1c) On 7/01/25 at 8:45 AM a review of Resident #225 printed medical record revealed there was no documentation to verify the resident was repositioned at least every two hours. In addition, the staff documented the type of assistance the resident needed to get dressed but the documentation did not specify whether the resident was dressed.
On 7/01/25 at 9:45 AM during an interview with the Director of Nursing (DON), the surveyor verbalized there was no documentation to verify the resident was being turned and/or repositioned. The DON verbalized they recently started having the GNA's sign off in Tasks. The staff should make sure the residents are turned every 2 hours.
Based on interviews, and record review, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by keeping complete and accurate documentation. This was found evident in 3 (Resident #62, #28 & #225) out of 35 residents reviewed during the survey.
The findings include:
1a) On 6/24/25 at 9:06 AM, the surveyor conducted an interview with Resident #62. During the interview Resident #62 stated that he/she had struggled with constipation at times but was also offered medications to help.
On 6/25/25 at 11:58 AM, the surveyor reviewed Resident #62's medical record. The review revealed that the TASK documentation had an area to document Bowel Movement (BM) size and consistency as well as control as in continent/incontinent. The surveyor reviewed the June 2025 documentation for size and consistency and noted Resident #62 was documented as having no bowel movement from 6/9/25-6/17/25, (9 days). On review of the control of bowel movement for June 2025 Resident #62 was documented as having no bowel movement from 6/9/25-6/13/25 (5 days).
On further review the surveyor noted a progress note written on 6/12/25 by Nurse Practitioner (NP) #11 that stated Resident #62 reported that he/she had to strain to have bowel movements. The note further addressed the concern with a medication adjustment.
On 6/26/25 at 7:40 AM, the surveyor interviewed the Director of Nursing (DON). During the interview the surveyor relayed the concern about prolonged days of no bowel movement for Resident #62. The DON stated he believed the documentation was inaccurate and that he would follow-up.
The surveyor conducted a follow-up interview with the DON. During the interview the DON provided the surveyor with a routine skilled note dated 6/13/25 in which Resident #62's Date of Last BM was documented as 6/11/25. He further stated he agreed that there were inconsistencies and inaccuracies in the documentation and that the facility started re-education in regards to documenting expectations.
1b) On 6/25/25 at 8:55 AM, the surveyor reviewed Resident #28's medical record. The record reviewed documentation that a wander bracelet was on Resident #28's left ankle.
On 6/27/25 at 10:47 AM, the surveyor reviewed Resident #28 Minimum Data Set (MDS) assessments. On the assessment dated [DATE] and 4/15/25 Resident #28 was documented as having no wandering behaviors in section E.
Next the surveyor reviewed resident #28's care plan. A care plan was initiated on 3/10/25 that stated Resident #28 is at risk for elopement related to exit seeking behaviors.
On 6/27/25 at 9:39 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor asked the DON why a care plan was initiated for elopement when there was not documentation in the medical record to indicate Resident #28 had exit seeking behaviors. The DON stated he would look into it and follow-up. He further stated he was not sure why the behaviors were not coded in the MDS assessment.
On 6/27/25 at 10:12 AM, the surveyor conducted a follow-up interview with the DON and Minimum Data Set Coordinator Staff #5. The DON stated that he spoke to the unit manager and the day the care plan was created the unit manager observed the resident in the hallway by the door, and that the Resident stated that he/she was going to go home. He confirmed that there was no documentation in the medical record of this incident. Staff #5 confirmed that the elopement/wandering was not coded in the MDS assessment because the behavior was not documented in the medical record. The DON confirmed that this behavior should have been documented in the medical record.
Jun 2022
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on medical record review, it was determined that facility staff failed to notify the physician of finger stick results below 100 as ordered by the physician for Resident #21. This was evident fo...
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Based on medical record review, it was determined that facility staff failed to notify the physician of finger stick results below 100 as ordered by the physician for Resident #21. This was evident for 1 of 27 residents reviewed during the survey process.
The findings include:
Medical record review for Resident #21 on 6/24/22 at 10:00 AM revealed on 2/7/22 the physician ordered: Glucose Check (finger stick) before meals and bedtime; call physician if finger stick is <100 or >350. A fingerstick is a minimally invasive procedure using a lancet to draw a drop or two of capillary blood from a finger and is an easy way to measure the amount of a certain substances in your blood (glucose).
Medical record review revealed the facility staff obtained and documented the resident's finger stick on:
3/2/22 at 4:31 PM as 91,
3/6/22 at 12:30 PM as 94,
3/8/22 at 11:30 AM as 80,
3/18/22 at 11:30 AM as 80,
3/21/22 at 11:42 AM as 91,
3/26/22 at 11:30 AM as 96,
4/10/22 at 11:30 AM as 84,
5/18/22 at 11:53 AM as 96,
5/22/22 at 6:22 AM as 71,
5/30/22 at 11:30 AM as 90,
6/2/22 at 12:09 PM as 83, and
6/8/22 at 11:30 AM as 97; however, there is no evidence the facility staff notified the physician of the finger stick below 100 per order. Interview with the Director of Nursing on 6/28/22 at 8:30 AM confirmed the facility staff failed to notify the physician when the finger stick was below 100 per order.
Interview with the Nursing Home Administrator and Director of Nursing on 6/28/22 at 2:00 PM were notified of the concern of the facility staff failure to notify the physician of finger sticks below 100 for Resident #21 as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on medical record review it was determined the facility staff failed to perform a bladder scan as ordered for Resident #199 and failed to notify the physician of the results of a bladder scan fo...
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Based on medical record review it was determined the facility staff failed to perform a bladder scan as ordered for Resident #199 and failed to notify the physician of the results of a bladder scan for Resident #300 as ordered by the physician. This was evident for 2 of 27 residents selected for review during the annual survey process.
The findings include:
A bladder scan is a safe, painless, reliable procedure that allows the facility staff to assess the volume of urine retained within the bladder. The bladder scan measures ultrasonic (sound wave) reflections within the resident's body to differentiate the urinary bladder from the surrounding tissue. It is a noninvasive portable tool for diagnosing, managing, and treating urinary outflow dysfunction. Bladder scans determine the need for catheterization.
1. The facility staff failed to perform a bladder scan as ordered for Resident #199 as ordered by the physician.
Medical record review on 6/23/22 at 12:00 PM for Resident #199 revealed on 6/22/22 at 3:00 PM the physician ordered: bladder scan x 1 and call physician with the results. Further record review revealed no evidence that the bladder scan was done. Interview with the Unit Manager #5 on 6/28/22 at 8:00 AM confirmed the facility staff failed to perform the bladder scan as ordered by the physician for Resident #199.
Interview with the Nursing Home Administrator and Director of Nursing on 6/28/22 at 2:00 PM were notified of the facility staff failure to perform a bladder scan as ordered for Resident #199.
2. The facility staff failed to notify the physician of the results of a bladder scan as ordered for Resident #300.
Medical record review for Resident #300 on 6/24/22 at 1:00 PM revealed on 12/22/21 the physician ordered: bladder scan x 1 related to bladder retention and call physician with results. Further record review revealed the facility staff performed the bladder scan on 12/22/22 as ordered; however, there is no evidence the facility staff notified the physician of the results as ordered. Interview with the Director of Nursing on 6/27/22 at 8:00 AM confirmed the notification of the results to the physician could not be obtained and assumed not done.
Interview with the Nursing Home Administrator and Director of Nursing on 6/28/22 at 2:00 PM revealed the concern that the facility staff failed to notify the physician of the results of a bladder scan as ordered by the physician for Resident #300.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observations and staff interviews it was determined the required staff posting information was not in prominent place readily accessible to residents and visitors. This was evident during the...
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Based on observations and staff interviews it was determined the required staff posting information was not in prominent place readily accessible to residents and visitors. This was evident during the entire survey process.
The finding includes:
On 6/21/22, 6/22/22, 6/23/22, 6/24/22 and 6/27/22 the required nursing staffing information per this regulation the facility staffing posting was not posted visible upon entering the facility or readily accessible to residents, family members and legal representatives of residents.
On 6/27/22 at 1:00 p.m. interview of Administrator and Director of Nursing verified the required staff posting was not available for resident or visitors during the survey process.
The finding was discussed with the Administrator and Director of Nursing in detail of this concerns prior and during survey exit conference held on 6/28/22 at approximately 2:30 p.m.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on medical record review it was determined that the facility staff failed to ensure Residents #4 and #300 were free from un-necessary medications. This was evident for 2 of 5 residents selected ...
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Based on medical record review it was determined that the facility staff failed to ensure Residents #4 and #300 were free from un-necessary medications. This was evident for 2 of 5 residents selected for review of un-necessary medications and 2 of 27 residents selected for review during the annual survey.
The findings include:
1. The facility staff failed to ensure Resident #4 was free from un-necessary pain medication.
Medical record review for Resident #4 on 6/22/22 at 11:30 AM revealed on 9/17/21 the physician ordered: Oxycodone 5 milligrams (mgs.) by mouth every 6 hours as needed for severe pain. Oxycodone belongs to a class of drugs known as opioid analgesics and is used to help relieve moderate to severe pain. It works in the brain to change how the body feels and responds to pain
Medical record revealed the facility staff assessed and documented the resident's pain level as 0 on:
6/1/22 at 9:01 AM,
6/1/22 at 4:04 PM,
6/5/22 at 2:17 PM,
6/6/22 at 3:14 PM (1),
6/7/22 at 5:06 PM (1),
6/11/22 at 8:34 AM,
6/11/22 at 3:09 PM,
6/15/22 at 3:15 PM,
6/20/22 at 2:34 PM,
6/21/22 at 1:30 PM,
6/25/22 at 6:36 PM and
6/26/22 at 2:49 PM; however, documented the administration of the Oxycodone.
Interview with the Director of Nursing on 6/27/22 at 10:45 AM confirmed the facility staff failed to ensure Resident #4 was free from un-necessary medication with the administration of Oxycodone with a documented pain of 0 and 1 on 2 occasions.
Interview with the Nursing Home Administrator and Director of Nursing on 6/28/22 at 2:00 PM were notified on the concern of the facility staff documenting a pain level of 0 and 1 on 2 occasions; however, documented the administration of Oxycodone.
2. The facility staff failed to ensure Resident #300 was free from unnecessary medication.
Medical record review for Resident #300 on 6/24/22 at 10:30 AM revealed on: 12/29/21 the physician ordered: Midodrine 10 milligrams (mgs.) by mouth 3 times a day related to orthostatic hypotension, hold for systolic blood pressure (SBP- top number) (>) greater than 135. On 12/29/21 the physician also ordered: Fludrocortisone Acetate .2 mgs by mouth 2 times a day related to orthostatic hypotension and hold for SBP > (greater than) 135.
Orthostatic hypotension - also called postural hypotension - is a form of low blood pressure that happens when standing after sitting or lying down. Midodrine is used to treat orthostatic hypotension. Fludrocortisone is a medication that seems to help some types of low blood pressure. It works by promoting sodium retention in the kidney. It works by causing blood vessels to tighten, which increases blood pressure fluid retention and some swelling, which is necessary to improve blood pressure.
Review of the Medication Administration Record (MAR) revealed on:
1/3/22 evening shift the facility staff documented the resident's blood pressure as 149/88 and 1/5/22 early shift documented the residents blood pressure as 180/80; however, documented the administration of the Fludrocortisone at that time.
Further review of the MAR revealed the facility staff documented the following blood pressures:
1/7/22- early shift 158/72,
1/8/22- early shift 159/75,
1/8/22- evening shift 153/74,
1/9/22- early shift 146/69,
1/10/22- early shift 150/74,
1/10/22- evening shift 157/74,
1/11/22- early shift 158/66,
1/11/22- evening shift 154/78,
1/12/22 evening shift 158/62 and
1/14/22 early shift 142/80; however, documented the administration of the Midodrine and Fludrocortisone when the SBP was above the set parameter of 135. Interview with the Director of Nursing on 6/27/22 at 9:30 AM confirmed the facility staff failed to hold Midodrine and Fludrocortisone as ordered when the documented SBP was above 135.
Interview with the Nursing Home Administrator and Director of Nursing on 6/28/22 at 2:00 PM were notified that the facility staff failed to ensure Resident #300 was free from un-necessary medications by documenting the administration of blood pressure medications when the SBP was above the set parameter as ordered by the physician.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
Based on clinical record review, observation, resident interview, and staff interview it was determined that the facility staff failed to ensure residents' pain management programs were overseen in a ...
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Based on clinical record review, observation, resident interview, and staff interview it was determined that the facility staff failed to ensure residents' pain management programs were overseen in a consistent manner. This was evident for 2 (#13 and #20) out of 27 residents in the survey sample.
The findings are:
1. Resident #20 was interviewed on 06/22/22 at 10:33 AM. The resident stated that he/she has chronic back pain that radiates throughout the body and gets creams to treat. The resident was not observed to be in pain.
A review of Resident #20's clinical record on 6/24, 6/27, and 6/28 revealed that the resident was ordered Oxycodone (pain medication) 5 mg every 6 hours as needed for moderate to severe pain to address the resident's chronic back pain. The nursing staff monitor the effectiveness of the pain medication by asking the resident to rate their pain level before and after the administration of the pain medication.
The resident's plan of care includes interventions to: 1) Resident will experience relief or decrease in pain until score is met which allows for optimum and maximum functioning until next review. 2) Monitor for s/s of constipation related to use of pain medications and administer bowel medications as ordered. 3) Administer pain medication as per MD orders and note the effectiveness. 4) Give PRN meds for breakthrough as per MD orders and note the effectiveness. 5) Acknowledge presence of pains and discomfort. Listen to resident's concerns. 6) Document/Report complaints & non-verbal signs of pain.
The following is a list of days where the resident's pain level was the same but there was no mention of an alternative pain relief strategy that was implemented nor was the physician contacted. It some cases there was also a long time gap between the times the pain level was checked.
4/2 15:01 10 16:59 10
4/2 21:28 10 4/3 00:37 0
4/4 16:21 10 17:02 10 20:53 6 22:17 10 23:45 1
4/6 05:51 8 06:39 1 07:36 0
4/13 15:35 10 16:34 10
4/14 15:39 10 16:10 10
4/15 16:01 10 18:03 10
4/15 22:34 10 Not checked again.
4/18 17:20 10 17:59 10
4/19 15:58 10 16:57 10 22:29 10 22:30 10
4/22 15:54 10 17:58 10 21:09 10 22:44 10 23:35 0
4/25 15:01 10 17:20 10 No Further checks
4/26 15:25 10 18:36 10 20:29 10 23:03 10
4/27 15:16 10 15:48 10 18:01 10 21:38 0
5/03 17:36 10 19:33 10
6/23 08:54 10 18:15 3
6/27 13:51 9 14:11 6 17:47 7 Pain level checked after 12 midnight
6/28 00:07 0
This surveyor did not observe the resident to be pain nor was it clear in the clinical record that the resident was in any unresolved pain for any extended period of time on a consistent basis.
The Director of Nursing (DON) was interviewed on 6/28/22 at 8:42 AM. He was informed of the findings.
Unit Manager (Staff #5) was interviewed on 6/28/22 at 10:02 AM. She said the physician was aware of the pain management issue. She said, and showed where the physician documented, that the physician suspects the pain is related to depression, so he decreased the Oxycodone in December and increased the Cymbalta (medication to treat depression) to 60 mg. The physician ordered in December 2021 Biofreeze (pain relieving spray) to be administered twice a day. The physician ordered a Kenalog (steroid) injection 40 mg to be administrated on 11/20/21 and 6/10/22. The physician also ordered acetaminophen 500 mg twice a day. Staff #5 stated that it is an education issue with the nurses. They should be addressing and/or documenting how they address when the resident states the pain level has not changed. She said the resident participates in all activities and has had no limitations related to pain.
Staff #5 provided a copy of a physician's note from 12/27/21. The physician wrote: I suspect the patient has a component of depressive symptoms presenting as physiologic complaints. [He/She] is currently on Cymbalta 60 mg daily. I will continue to monitor the patient with help from psychiatry. I will increase the patient's gabapentin [pain medication] to 600 mg every 8 hourly. I will monitor [him/her] for symptom relief.
2. A review of Resident #13's clinical record revealed that the resident has a diagnosis of acute pain related to trauma. Further review revealed that the resident was identified as having pain at a self identified level of 10 out of 10 on 4/25/22 and 4/30/22. There was no evidence that the physician was notified and/or that the nursing staff attempted an alternative intervention.
The resident has a care plan that includes: 1. Administer pain medication as per MD orders and note the effectiveness. 2. Give PRN meds for breakthrough as per MD orders and note the effectiveness. 3.
Acknowledge presence of pains and discomfort. Listen to resident's concerns. 4. Document/Report complaints & non-verbal signs of pain.
The Director of Nursing (DON) was interviewed on 6/28/22 at 8:42 AM. He was informed of the findings.
No further information to contradict the findings was presented prior to the team exiting the facility.
Oct 2018
21 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and staff interview it was determined the facility staff failed to provide Resident #35 with the most dignified existence. This was evident for 1 of 39 residents selected for revi...
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Based on observation and staff interview it was determined the facility staff failed to provide Resident #35 with the most dignified existence. This was evident for 1 of 39 residents selected for review during the survey process.
The findings include:
During initial surveyor interview with Resident #35 on 10/2/18 at 10:00 AM facility staff nurse #1 and Geriatric Nursing Assistant (GNA) #1 entered the room without knocking and proceeded to attend to Resident #35's roommate.
Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff nurse #1 and GNA #1 failed to knock on the door of Resident #35's room and wait for permission to enter prior to entering the room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility staff failed to properly void an old MOLST form when a new one is cr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility staff failed to properly void an old MOLST form when a new one is created. This was evident for 1 (Residents #62) of 9 residents reviewed for advance directives during an annual recertification survey.
The findings include:
A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options for a specific patient.
Instructions for completing a Maryland MOLST include: A Physician, Nurse Practitioner (NP), or a Physician Assistant (PA) must be accurately and legibly complete the form and then sign and date it.
Voiding the Form: to void this medical order form, a physician or nurse practitioner shall draw a line through the sheet, write VOID in large letters across the page, and sign and date below the line. A nurse may take a verbal order from a physician or nurse practitioner to void the MOLST order f orm. Keep the voided order form in the patient's active or archived medical record.
Review of Resident #62's medical record on [DATE] revealed Resident #62 had 2 active MOLST forms in his/her medical record that were incongruent. The first MOLST form was dated [DATE] and indicated Resident #62's had completed the MOLST form and wanted to be a Full Code/Attempt CPR. The second MOLST was dated [DATE] and was also created by Resident #62. The second MOLST form indicated Resident #62 want to be a No CPR, Option B, Palliative and Supportive Care, May use only CPAP or BiPAP for artificial ventilation, as medically indicated, May give blood products, May transfer to the hospital for any situation requiring hospital-level care, May perform any medical tests to diagnose and/or treat a medical condition, May use antibiotics, may give fluids for artificial hydration as a therapeutic trial, but do not give artificial nutrition. The facility staff must take steps to properly void an older MOLST form as this may lead the nursing staff to perform or not perform a Resident's correct end of life wishes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on complaint, reviews of a closed record, and staff interview, it was determined that the facility staff failed to notify residents and/or representative and the Ombudsman of transfer and reason...
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Based on complaint, reviews of a closed record, and staff interview, it was determined that the facility staff failed to notify residents and/or representative and the Ombudsman of transfer and reason for transfer to the hospital in writing. This was evident for 2 (Resident #216 and #66) of 2 residents reviewed for Hospitalization during an annual recertification survey.
The findings include:
1. Review of complaint MD00126182 on 10/3/18 revealed an allegation that Resident #216 was not allowed to return to the facility after a brief hospitalization.
Review of the medical record for Resident #216 revealed the resident was transferred to an acute care facility on 4/29/18. There was no documentation found in the medical record that the resident, the resident's responsible party, or the Ombudsman was given written notice of Resident #216 being transferred to the hospital and the reason for the transfer to the hospital.
On 10/5/18 at 9:15 AM, the facility Administrator stated that Resident #216 and the Resident's responsible party did not receive written notice as to why Resident #216 was being transferred to the hospital and the reason for the transfer to the hospital
2. Review of the medical record for Resident #66 revealed the resident was transferred to an acute care facility on 8/3/18 and returned to the facility on 8/6/18. There was no documentation found in the medical record that the resident or the resident's responsible party was given written notice of Resident #66 being transferred to the hospital and the reason for the transfer to the hospital.
On 10/5/18 at 11:06 AM, the Director of Nurses confirmed that Resident #66 and the Resident's responsible party did not receive written notice as to why Resident #66 being transferred to the hospital and the reason for the transfer to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on review of the medical record and staff interview, it was determined that the facility staff failed to provide the resident and their representative with a written notice of bed hold policy, a...
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Based on review of the medical record and staff interview, it was determined that the facility staff failed to provide the resident and their representative with a written notice of bed hold policy, at the time of the resident transfer for hospitalization. This was evident for 1 (Resident #66) of 5 residents reviewed for Hospitalization during an annual recertification survey.
The findings include:
Review of the medical record for Resident #66 revealed the resident was transferred to an acute care facility on 8/3/18 and returned to the facility on 8/6/18. There was no documentation found in the medical record that the resident or the resident's responsible party was given a copy of the bed hold policy upon transfer to the hospital.
On 10/5/18 at 11:06 AM, the Director of Nurses confirmed that Resident #66 and the Resident's responsible party did not receive the facility bed hold policy when Resident #66 was transferred to the hospital on 8/3/18.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on medical record review, observation and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions for ...
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Based on medical record review, observation and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions for residents (#30 and #35). This was evident for 2 of 39 residents selected for investigation during the survey process.
The findings include:
The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems.
Once the facility staff completes an in-depth assessment of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan is accurate and appropriate for the resident.
1. The facility staff failed to update and revise care plan for Resident #30 to reveal an accurate assessment and interventions.
Medical record review for Resident #30 revealed on 5/13/16 the facility staff initiated a care plan for Resident #30 addressing: Resident has exit seeking behavior related to impaired cognition and wandering behavior. Surveyor observation of Resident #30 during the survey process revealed Resident #30 no longer has exit seeking behavior related to decline in physical mobility and cognition. Further record review revealed the facility staff assessed the resident on 8/17/17, 11/17/17, 2/17/18, 5/31/18 and 8/3/18; however; failed to update the care plans to reflect accurate assessments and interventions.
Interview with the Director of Nursing (DON) on 10/5/18 at 2:00 PM confirmed the facility staff failed to review and revise care plans for Resident # 30 to reflect current and appropriate interventions related to exit seeking behavior. The DON confirmed Resident #30 is not exit seeking related to declined physical mobility and decline in cognition.
2. The facility staff failed to conduct a care plan meeting for Resident #35.
Medical record review revealed the facility staff assessed Resident #35 on 3/9/18, 3/19/18 and 5/10/18. Further record review revealed the facility conducted a care plan meeting on 3/9/18; however, there is no evidence the facility staff conducted a care plan meeting to address the MDS assessments and ensure accurate interventions were noted on care plans for assessments done on 3/19/18 and 5/10/18.
Interview with the Director of Nursing (DON) on 10/5/18 at 2:00 PM confirmed the facility staff failed to conduct a care plan meeting for Resident #35 for each MDS completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on medical record review, observation and interview, it was determined the facility staff failed to apply ace wraps to Resident #35 according to the standard of practice. This was evident for 1 ...
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Based on medical record review, observation and interview, it was determined the facility staff failed to apply ace wraps to Resident #35 according to the standard of practice. This was evident for 1 of 39 residents selected for review during the annual survey process.
The findings include:
Medical record review for Resident #35 revealed on 5/12/18 the physician ordered: ace bandage to bilateral lower extremities, apply in morning and remove at bedtime. Typically, legs swell during the day because of dependent edema, meaning because a resident is up (even in a chair) fluid settles in feet, ankles and lower legs. This swelling should disappear at night when laying down. Typically, health care providers recommend wrapping legs or support stockings when the resident is up and then nothing during the night to give them a break and let the skin breath. It is the standard of practice to apply the ace bandage to the knee (unless thigh high is ordered). Surveyor observation of the resident on 10/4/18 at 12:30 PM revealed the facility staff applied an ace wrap; however, the ace wrap only encompassed the lower portion of the resident's leg, just above the resident's ankle. The ace wrap failed to extend to the resident's knee. Interview with the Director of Nursing on 10/4/18 at 2:00 PM confirmed the standard of practice is to apply an ace wrap to the knee (unless thigh high is ordered).
Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to apply ace bandages to Resident #35 according to the standard of practice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on observation and interview, it was determined the facility staff failed to provide services that would allow residents the ability to achieve the greatest independence with performing Activiti...
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Based on observation and interview, it was determined the facility staff failed to provide services that would allow residents the ability to achieve the greatest independence with performing Activities of Daily Living to Residents (# 116). This was evident for 1 of 39 residents selected for review during the survey process.
The findings include:
Activities of daily living are routine activities people do every day without assistance. There are six basic ADLs: eating, bathing, getting dressed, toileting, transferring and continence. It is the expectation the facility staff will provide dietary assistance to residents; cut food up, open milk and juice containers, butter breads and ensure the food is within reach to the resident
1. The facility staff failed to provide straws, plastic lid for liquids and to aid in opening of dietary packages for Resident #116.
Surveyor observation of the resident's breakfast on 10/3/18 at 8:00 AM revealed the facility staff provided the resident with a carton of milk and coffee. The milk was unopened, and the facility staff failed to provide a straw and lid for the coffee however, it was further noted at that time, the resident open her/his cream and sugar for the coffee however, the resident's severe tremors prevented her/him from adding it to the coffee.
Medical record review revealed a physician order dated 9/27/18 that all liquids with straw (helps with tremors), set-up with meals and distant supervision with all intake.
An interview with Speech and Language pathologist on 10/03/18 at 10:34 AM revealed that set ups are all open container with lids and straws and distant observation is to observer resident from outside the room frequently while eating and drinking.
Interview with the Director of Nursing on 10/4/18 at 2:00 PM confirmed the facility staff failed to provide Resident #116 with dietary assistance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility staff failed to obtain consultations a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, it was determined the facility staff failed to obtain consultations as ordered for Resident #20; failed to ensure the validity of a fluid restriction for Resident #35 and it was determined the facility staff failed to follow a physician order and obtain daily weights for Resident #66. This was evident for 3 of 39 residents selected for review during the annual survey process.
The findings include:
1 A. The facility staff failed to obtain a neurological consultation for Resident #20.
Medical record review for Resident #20 revealed on 11/3/17 the physician ordered: Neurological consultation.
Neurology consultation is an appointment with a neurologist for the diagnosis, management, or treatment of conditions that affect the nervous system. A neurologist is a doctor with specialized training in diagnosing and treating diseases of the brain, spinal cord, peripheral nerves, and muscles. Further record review revealed the facility staff failed to obtain that consultation as ordered.
1 B. The facility staff failed to obtain an endocrinology consultation as ordered.
Medical record review for Resident #20 revealed on 1/30/18 the physician ordered: endocrinologist consultation in 4 months. Endocrinology is the field of hormone-related diseases. An endocrinologist can diagnose and treat hormone problems and the complications that arise from them. Hormones regulate metabolism, respiration, growth, reproduction, sensory perception, and movement. Hormone imbalances are the underlying reason for a wide range of medical conditions. Endocrinology focuses both on the hormones and the many glands and tissues that produce them. Further record review revealed the facility staff failed to obtain that consultation as ordered.
Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to obtain a neurological and an endocrinologist consultation as ordered for Resident #20.
2. The facility staff failed to ensure the validity of a fluid restriction for Resident #35.
Medical record review for Resident #35 revealed on 4/28/18 the physician ordered: free water restriction. Fluid restriction means that the resident can only have a certain amount of liquid each day. Surveyor observation of Resident #35's room on 10/2/18 and 10/3/18 noted behind the resident's bed was signage that the resident was on restricted fluids and was not to have a water pitcher at the bedside. Surveyor observation of the resident revealed a water pitcher at the bedside on 10/2/18 and 10/318. Further review of the resident's meal trays revealed the facility staff failed to maintain a fluid restriction. On 10/2/18 at lunch the resident was noted to have: jello, ice tea, milk and apple juice. Interview with the Director of Nursing on 10/3/18 at 1:30 PM revealed on 4/24/18 the physician ordered: free water restriction. It was revealed by the Director of Nursing the resident was admitted to the hospital on [DATE] and returned on 5/3/18 not on restricted fluids; however, the facility staff failed to remove the signage of restricted fluids from behind the resident's bed. The facility staff failed to remove signage related to restricted fluids for 5 months for Resident #35.
Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to ensure the validity of restricted fluids for Resident #35 by failing to remove signage behind the bed indicating Resident #35 was on restricted fluids and not to have a water pitcher.
3. The facility staff failed to follow a physician order and obtain daily weights.
Review of Resident #66's closed medical record revealed a physician's orders instructing the nursing staff to obtain daily weights and to notify the physician if Resident #66 had a 2-pound weight gain in one day or a greater than 5-pound weight gain in one week to monitor congestive heart failure. A further review of Resident #66 closed medical record failed to reveal the nursing staff obtained a weight on Resident #66 on 8/1, 8/2, or 8/3/2018. The nursing staff must follow a physician's order and obtain daily weights on each resident as instructed. Resident #66 was sent to the emergency room on 8/3/18 and admitted to the hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, the facility failed to provide treatment/services to maintain vision (Resident #21). This is evident for 1 out of 39 residents selected for review during ...
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Based on medical record review and interview, the facility failed to provide treatment/services to maintain vision (Resident #21). This is evident for 1 out of 39 residents selected for review during the investigation stage of the survey process.
The findings include:
During interview with Resident #21 on 10/2/18 at 11:55 AM, the resident stated he/she is waiting for a follow up appointment with the eye doctor. The resident stated I can't see out of my right eye. I have a cataract and was supposed to have surgery. Cataract surgery is a procedure to remove the lens of your eye and, in most cases, replace it with an artificial lens.
Review of the resident's medical record revealed the resident did see the eye doctor on 4/26/18. The new orders for the resident at that time was a referral for Ophthalmology consult for low vision and cataract. Further review of the medical record revealed an Ophthalmology Consult was never scheduled.
Interview with the Director of Nursing on 10/4/18 12:43 PM confirmed the surveyor's findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
2. The facility staff failed to assist in making the requested podiatry appointment for diabetic preventive care.
On 10/4/18 at 8:30 AM during observation of medication pass Resident #25's daughter re...
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2. The facility staff failed to assist in making the requested podiatry appointment for diabetic preventive care.
On 10/4/18 at 8:30 AM during observation of medication pass Resident #25's daughter requested to speak with this surveyor. Resident #25 and s/he daughter were concerned that they had requested a podiatrist visit due to resident having diabetes and toenail problems.
Observation of the toenails revealed on the right foot the 4th toe was greater than 1 cm over the nailbed and making an indention into the middle toe. The right middle toenail had blood on it and the left small toenail had fallen off and had dried blood. The other toenails had a nail disorder and were misshapen.
Review of the medical record revealed a care plan meeting on 9/26/18 where the daughter requested the podiatry consult and the facility as of 10/4/18 had not arranged.
Interview with the Director of Nursing on 10/4/18 at 12:15 PM revealed the request had been forgotten.
Based on medical record review and interview, the facility failed to obtain a podiatry consultation as ordered by the physician for Resident (#17) and the facility staff failed to assist in making the requested podiatry appointment for diabetic preventive care (Resident #25). This is evident for 2 out of 39 residents selected for review during the investigation stage of the survey process.
The findings include:
1. The facility staff failed to obtain a podiatry consultation as ordered by the physician.
Medical record review for Resident #17 revealed on 9/17/18 the physician ordered: podiatry consultation related to painful toes. Podiatry is the branch of medicine that treats the foot, ankle, and related structures of the leg. Interview with Resident #17 on 10/2/18 at 10:00 AM revealed the resident resting in bed; however, complained to toe nail pain; however, the facility staff failed to obtain the podiatry consultation as ordered.
Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to obtain podiatry consultation for Resident #17 as ordered to assess painful toes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on medical record review, observation and interview, it was determined the facility staff provided care to Resident #30 to prevent a potential accident. This was evident for 1 of 39 residents se...
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Based on medical record review, observation and interview, it was determined the facility staff provided care to Resident #30 to prevent a potential accident. This was evident for 1 of 39 residents selected for review during the annual survey process.
The findings include:
Medical record review for Resident #30 revealed on 8/21/18 the physician in collaboration with Speech Language Pathologist (SLP) ordered: nectar thick liquids by spoon only and monitor for swallow completion. Liquids to be given by teaspoon only. SLPs specialize in the evaluation, diagnosis, and treatment of communication disorders (speech disorders and language disorders), cognitive-communication disorders, voice disorders, and swallowing disorders. Nectar-thick liquids are easily pourable and comparable to apricot nectar or thicker cream soups. Surveyor observation of lunch on 10/3/18 at 1:00 PM revealed the resident being fed by Geriatric Nursing Assistant (GNA) #2. It was further noted at that time, GNA #2 failed to provide liquids to the resident via teaspoon. The GNA #2 poured the liquids into a cup and put the cup to the resident's mouth and put the liquid into the resident's mouth via cup. The Director of Nursing aware of concern at 1:20 PM.
Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to provide Resident #30 with liquids via a teaspoon as ordered by the SLP and physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on medical record review, observation and interview, it was determined the facility staff failed to obtain weights as ordered for Resident #20 and the facility staff failed to offer Resident #30...
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Based on medical record review, observation and interview, it was determined the facility staff failed to obtain weights as ordered for Resident #20 and the facility staff failed to offer Resident #30 alternative foods. This was evident for 2 of 39 residents selected for review during the annual survey process.
The findings include:
1. The facility staff failed to obtain weekly weights as ordered by the physician for Resident #20.
Medical record review for Resident #20 revealed on 7/30/18, the physician ordered: weekly weights- on Mondays. Further record review revealed the facility staff documented the weights on the following days:
8/6/18,
8/13/18,
8/21/18---Tuesday,
8/27/18,
9/7/17-Friday,
9/10/18,
9/18/18-Tuesday and
9/27/18- Thursday.
Further record reviews the facility staff failed to obtain a weight for Resident #20 on 10/1/18.
Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to obtain weekly weights on Mondays for Resident #20 as ordered by the physician.
2. The facility staff failed to offer an alternative food choice to Resident #30.
Surveyor observation of Resident #30 on 10/4/18 at 12:55 PM revealed the resident in the dining room. It was further noted the resident's lunch tray placed beside the resident; however, no facility staff was noted in the area to feed the resident. During continued surveyor observation it was also noted the resident's lunch tray contained: magic cup, pureed fruit, carton of ensure and a container of nectar thick juice. Further observation revealed the facility staff removed the resident's lunch at 1:20 PM; however, revealed no facility staff attempted to feed or offer the resident's any of the liquids on the tray during the surveyor's observation. It was further noted, none of the above liquids had been opened. The unit manager was noted to verbalize that Resident #30 was allowing food to run out of his/her mouth. Although, the resident was noted to allow food to run out of his/her mouth, the facility staff failed to offer another alternate variation of nutrition to Resident #30.
Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to offer Resident #30 alternative food choices when 1 type of food was noted to run out of Resident #30's mouth.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on record review, observation and interview, it was determined the facility staff failed to administer DuoNeb treatment to Resident #118 in accordance with the standard of practice. This was evi...
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Based on record review, observation and interview, it was determined the facility staff failed to administer DuoNeb treatment to Resident #118 in accordance with the standard of practice. This was evident for 1 of 39 residents selected for review during the annual survey process.
The findings include:
Surveyor observation of Resident #118 on 10/2/18 at 1:00 PM revealed the resident sitting in his/her room next to the nebulizer. A nebulizer changes medication from a liquid to a mist so that it can be more easily inhaled into the lungs. An interview of the resident at that time revealed that the resident had a change of condition on 10/1/18 that included coughing and fever and the physician ordered that he/she receive nebulizer treatments. The resident stated that he/she did not receive the first treatment until today.
Review of the medical record revealed an order written on 10/1/18 at 10:30 AM for DuoNeb treatments every 8 hours for 2 days. Review of the Medication Administration Record (MAR) revealed documentation for the first DuoNeb was on 10/2/18 at 6 AM.
Interview of the Nurse Manager on 10/2/18 revealed that the nebulizer machines are stock and available for the resident's needs. The Nurse Manager stated that the medication is not in the stock inventory. Further review of the stock medication inventories the medication is available for immediate use.
Interview with the Director of Nursing on 10/4/18 12:43 PM confirmed the surveyor's findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, it was determined the facility staff failed to act upon the consultant pharmacist recommendation in a timely manner for Resident #35. This was evident for...
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Based on medical record review and interview, it was determined the facility staff failed to act upon the consultant pharmacist recommendation in a timely manner for Resident #35. This was evident for 1 of 39 residents selected for review during the annual survey process.
The findings include:
Medical record review for Resident #35 revealed on 5/5/18 the consultant pharmacist was in the facility and noted: Resident on Lorazepam .5 milligrams by mouth every 4 hours as needed. The consultant pharmacist also noted the medication should be limited to 14 days and with the following information: indication for use (the medical record must show documentation of adequate indications for the medications' use and the diagnosed condition for which the medication was prescribed. The consultant pharmacist also indicated the attending physician believed the medication was to be extended beyond 14 days should: document the rationale and indicate the duration of the as needed order. Further medical record review revealed the facility staff failed to address those recommendations in a timely manner. It was further noted the physician was in the facility on: 5/9/18, 6/13/18, 7/2/18, 7/19/18, 8/15/18 and 9/27/18; however, failed to address the recommendations made by the consultant pharmacist. It was also noted, the resident is a hospice resident and additional record review revealed Hospice staff documented assessment of the resident and in the facility a minimum of 2 times a week; however, failed to address the consultant pharmacist recommendations.
Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to address consultant pharmacist recommendations for Resident #35 in a timely manner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, it was determined the facility staff failed to document the heart rate and blood pressure for Resident #44 when the physician ordered parameters. This was...
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Based on medical record review and interview, it was determined the facility staff failed to document the heart rate and blood pressure for Resident #44 when the physician ordered parameters. This was evident for 1 of 39 residents selected for review during the annual survey process.
The findings include:
Medical record review for Resident #44 revealed on 6/23/18 the physician ordered: Hydralazine 25 milligrams by mouth 3 times a day for blood pressure and Metoprolol extended release, 200 milligrams by mouth every day, hold for heart rate less than 50, hold for systolic blood pressure (top number) less than 110. Hydralazine is a medication used to treat high blood pressure and heart failure. Metoprolol is prescribed to treat high blood pressure and prevent angina (chest pain) and it works by relaxing blood vessels and slowing heart rate, which improves blood flow and lowers blood pressure. Review of the Medication Administration Record for the above medications revealed the facility staff failed to obtain/document the blood pressure and heart rate as ordered by the physician for parameters.
Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to obtain/document the blood pressure and heart rate for Resident #44 when parameters were ordered by the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, it was determined the facility staff failed to identify specific targeted behaviors to monitor and assess for the continued use of psycho-active medicatio...
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Based on medical record review and interview, it was determined the facility staff failed to identify specific targeted behaviors to monitor and assess for the continued use of psycho-active medication for Residents (#20 and #35). This was evident for 2 of 39 residents selected for review during the survey process.
1. The facility staff failed to identify specific targeted behaviors to monitor and assess for the continued use of psycho-active medication for Resident #20.
Medical record review for Resident # 20 revealed on 11/3/17 the physician ordered: Abilify 2.5 milligrams by mouth 2 times a day for psychosis. Abilify is an antipsychotic medication. It works by changing the actions of chemicals in the brain. Abilify is used to treat the symptoms of psychotic conditions such as schizophrenia and bipolar I disorder (manic depression). Further record review revealed the facility staff failed to identify specific target behaviors monitor and to justify the continued use of the medication.
Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to identify specific target behaviors for Resident #20 to monitor and justify the continued use of Abilify.
2. The facility staff failed to identify specific targeted behaviors to monitor and assess for the continued use of psycho-active medication for Resident #35.
Medical record review for Resident #35 revealed on 5/3/18 the physician ordered: Lorazepam .5 milligram by mouth as needed. Lorazepam is used for the management of anxiety disorders, the short-term relief of symptoms of anxiety or anxiety associated with depression. Further record review revealed the facility staff failed to document the rationale for the medication and the facility staff failed to identify and monitor for targeted behaviors for the medication to justify the continued use of the Lorazepam.
Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to identify specific target behaviors for Resident #35 to monitor and justify the continued use of Lorazepam.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
Based on medical record and staff interview, it was determined that the facility staff failed to provide treatment to maintain dental health for Resident #21. This is evident for 1 out of 39 residents...
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Based on medical record and staff interview, it was determined that the facility staff failed to provide treatment to maintain dental health for Resident #21. This is evident for 1 out of 39 residents selected for review during the investigation stage of the survey process.
The findings include:
During interview with Resident #21 on 10/2/18 at 11:55 AM, the resident stated he/she is waiting for treatment after a follow up appointment with the dentist.
Review of the resident's medical record revealed the resident did see the dentist on 6/12/18. The new orders for the resident at that time was for Biotene to treat resident's Dry Mouth Syndrome. Biotene is an oral rinse to managing Dry Mouth symptoms. Dry Mouth Syndrome is a condition in which the salivary glands in the mouth don't make enough saliva to keep your mouth wet. Dry Mouth Syndrome is often due to the side effect of certain medications or aging issues. Dry Mouth Syndrome can cause problems speaking, tasting, chewing, and swallowing.
Further review of the medical record revealed that the Biotene was never ordered to treat Resident's #21 Dry Mouth Syndrome.
Interview with the Director of Nursing on 10/4/18 12:43 PM confirmed the surveyor's findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation and interview, it was determined facility staff failed to label with an expiration date individual serving containers of fruit juice.
The findings included:
On 10/3/18 at 9:00 AM...
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Based on observation and interview, it was determined facility staff failed to label with an expiration date individual serving containers of fruit juice.
The findings included:
On 10/3/18 at 9:00 AM during a tour of the kitchen refrigerator and all unit nourishment refrigerators it was determined the individual packaged fruit juices were not labeled with an expiration date. The shipping box containing the fruit juices in the kitchen refrigerator was not labeled with an expiration date.
Further review with the dietitian confirmed on 10/4/18 at 12:00 PM that the individual fruit juice containers had not been labeled with an expiration date nor had the shipping box.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to maintain the medical record in the most complete and accurate form for Residents # 25.
Medical ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to maintain the medical record in the most complete and accurate form for Residents # 25.
Medical record review for Resident #25 revealed on [DATE], Resident MOLST (Maryland Medical Orders for Life-Sustaining Treatment) reviewed with resident reports that resident has expressed that he/she does not want (Cardiopulmonary resuscitation) CPR and the MOLST was coded to reflect that the resident was a DNR/DNI.
Further medical record review revealed a Social Worker Care Plan Meeting on [DATE] and [DATE] with the resident, son and daughter present at the Care Plan meetings. The Social Worker documented in the medical record that the resident was a full code both times.
Interview with the Director of Nursing on [DATE] at 1:30 PM confirmed the facility staff failed to maintain the medical record in the most complete form for Resident #25.
Based on medical record review and interview, it was determined the facility staff failed to maintain the medical records for Residents ( #23, #35 and #25) in the most complete and accurate form. This was evident for 3 of 39 residents selected for review during the survey process.
The findings include:
A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.
An advance directive is a written document, electronic document, or oral directive that indicates a patient's wishes about medical treatment and/or appoints a health care agent to make medical decisions.
In the event, the resident does not have an advance directive, and no one is appointed a health care agent, a surrogate decision maker is appointed for the resident in accordance with the Health Care Decision Act. A surrogate decision maker are advocates for incompetent patients. A surrogate may consent to the withholding or withdrawal of life-sustaining procedures if the patient's attending physician and a consulting physician certify, to a reasonable degree of medical certainty, that the patient has a terminal or end-stage condition or is in a persistent vegetative state.
Mental capacity is the ability to make decisions for yourself. People who cannot do this are said to 'lack capacity'. This might be due to injury, a learning disability, mental health problem or a condition such as dementia. A person may also have the capacity to make some decisions and not others, as some decisions require the person to understand more complex information, or weigh up more options, than others. You should not assume a person lacks capacity to choose what to wear or eat just because they cannot make difficult financial or medical decisions
Maryland MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a resident's wishes about medical treatments. A do not resuscitate or DNR is a legal order written to respect the wishes of a patient not to undergo CPR or advanced cardiac life support if their heart were to stop or they were to stop breathing.
1. The facility staff failed to maintain the medical record in the most accurate form for Resident #23.
Medical record review for Resident #23 revealed on [DATE] the facility staff completed a MOLST and indicated the MOLST was reviewed and completed by the resident's surrogate as per the authority granted by the Health Care Decisions Act. Further record review revealed on [DATE] the facility staff assessed the resident and documented the resident was:
able to understand and sign admission documents,
able to understand the nature, extent, or probable consequences of the proposed treatment and course of treatment,
able to understand and make a rational evaluation of the burdens, risks and benefits of the treatment and
able to effectively communicate a decision.
Further observation of the medical record revealed the physician documented: the resident was incapable of making an informed decision regarding the provision, withholding, or withdrawing: all medical treatment.
Record review revealed the facility staff failed to maintain the medical record in the most accurate form in failing to determine if Resident #23 is able or unable to make informed decisions regarding medical care.
Interview with the Director of Nursing on [DATE] at 2:00 PM confirmed the facility staff failed to maintain the medical record for Resident #23 in the most accurate form.
2. The facility staff failed to maintain the medical record for Resident #35 in the most complete form.
Medical record review for Resident #35 revealed on [DATE], the resident in collaboration with the health care agent completed a MOLST. At that time, it was determined the resident was to be a DNR.
Further record review revealed on [DATE] at 17:25 the social documented the following note: Patient is a Full code.
Interview with the Director of Nursing on [DATE] at 2:00 PM confirmed the facility staff failed to maintain the medical record for Resident #35 in the most complete form in the discrepancy of the social worker note.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility staff failed to post an isolation sign on room [ROOM NUMBER] door to alert...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility staff failed to post an isolation sign on room [ROOM NUMBER] door to alert visitors, residents, and staff to see the nurse before entering the room. This was true for 1 out of 39 residents selected for review during the annual survey process.
The findings include:
1. The facility staff failed to post a sign on a resident door indicating isolation.
On 10/2/18 and 10/3/18, an observation outside resident's room [ROOM NUMBER] was a box. When opened contained items necessary for respiratory isolation, gowns, masks, and gloves. The box had no signage indicating the items needed to be worn before entering the room or to see the nurse before entering. The resident has an infection requiring isolation. No one entering without previous knowledge would be alerted that the box meant isolation was expected.
On 10/3/18 at the Director of Nursing confirmed there was not signage to indicate to stop and see a nurse before entering room [ROOM NUMBER].
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected multiple residents
4. The facility staff failed to ensure Resident #21 received showers.
Resident #21 was interviewed on 10/2/18 at 10:30 AM. The resident stated that he/she had only received showers half of the time. M...
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4. The facility staff failed to ensure Resident #21 received showers.
Resident #21 was interviewed on 10/2/18 at 10:30 AM. The resident stated that he/she had only received showers half of the time. Medical record review for Resident #21 revealed the resident was to have showers on Mondays and Thursdays on day shift. The resident's clinical record revealed the resident received a shower on 9/3/18 and 9/28/18 in the months of September.
Interview with the Director of Nursing on 10/4/18 at 2:00 PM confirmed the facility staff failed to administer showers to Resident #21.
Based on record review and interviews it was determined the facility staff failed to provide showers to Residents (#20, #23, #35 and #21). This was evident for 4 of 39 residents selected for review during the annual survey process.
The findings include:
1. The facility staff failed to provide showers to Resident #20.
Medical record review for Resident #20 revealed the resident was to have showers on 3-11 shift on Wednesday and Saturday. Review of staff documentation revealed the facility staff documented showers for Resident #20 on 8/29/18, 9/7/18, 9/15/18 and 9/22/18 (4 showers in 2 months).
Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to provide Resident #20 showers at least 2 times a week.
2. The facility staff failed to provide showers to Resident #23.
Interview with Resident #23 on 10/2/18 at 12:00 PM revealed Resident #23 revealed he/she did not get 2 showers a week. The resident also indicated she/he would like to have a shower on 10/2/18. Facility staff documentation revealed Resident #23 is to have showers Monday/Wednesday/ Thursday/ Friday and Saturday. Review of facility staff documentation revealed the facility staff documented the resident received showers on 9/12/18, 9/19/18, 9/21/18 and 9/30/18 (4 showers, although showers are ordered 5 days a week).
Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to provide Resident #23 showers at least 4 times a week as ordered by the physician.
3. The facility staff failed to provide showers to Resident #35.
Interview with Resident #35 on 10/2/18 at 12:30 PM revealed the resident stated he/she did not receive 2 showers a week and has not had a shower for a while. Medical record review for Resident #35 revealed the resident was to receive showers at a minimum on Thursday 3-11 shift. Further review of staff documentation from 8/21/18 to 10/2/18 revealed the facility staff documented Resident #35 received a shower on 8/30/18 and 9/13/18 (2 showers in 2 months).
Interview with the Director of Nursing on 10/5/18 at 2:00 PM confirmed the facility staff failed to provide Resident #35 showers at least 2 times a week.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Grade B+ (80/100). Above average facility, better than most options in Maryland.
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Maryland facilities.
- • 40% turnover. Below Maryland's 48% average. Good staff retention means consistent care.
Concerns
- • 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
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About This Facility
What is Lorien Bulle Rock's CMS Rating?
CMS assigns LORIEN BULLE ROCK an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Maryland, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Lorien Bulle Rock Staffed?
CMS rates LORIEN BULLE ROCK's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 40%, compared to the Maryland average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Lorien Bulle Rock?
State health inspectors documented 33 deficiencies at LORIEN BULLE ROCK during 2018 to 2025. These included: 33 with potential for harm.
Who Owns and Operates Lorien Bulle Rock?
LORIEN BULLE ROCK is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by LORIEN HEALTH SERVICES, a chain that manages multiple nursing homes. With 78 certified beds and approximately 71 residents (about 91% occupancy), it is a smaller facility located in HAVRE DE GRACE, Maryland.
How Does Lorien Bulle Rock Compare to Other Maryland Nursing Homes?
Compared to the 100 nursing homes in Maryland, LORIEN BULLE ROCK's overall rating (5 stars) is above the state average of 3.1, staff turnover (40%) is near the state average of 46%, and health inspection rating (5 stars) is much above the national benchmark.
What Should Families Ask When Visiting Lorien Bulle Rock?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Lorien Bulle Rock Safe?
Based on CMS inspection data, LORIEN BULLE ROCK has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Maryland. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Lorien Bulle Rock Stick Around?
LORIEN BULLE ROCK has a staff turnover rate of 40%, which is about average for Maryland nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Lorien Bulle Rock Ever Fined?
LORIEN BULLE ROCK has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Lorien Bulle Rock on Any Federal Watch List?
LORIEN BULLE ROCK is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.