Lorien Taneytown, Inc

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility failed to post the required daily nurse staffing information in a clear and accessible location. This was evident for 31 out of 31 days of staffing records reviewed.

Inspectors wroteDuring the initial tour of the facility on 09/22/2025, at 9:06 AM, Residents #67 and #17 reported that the facility's food was bland and cold for foods that needed to be warm. An observation of the facility's lunch tray line service was conducted on 9/22/2025 at 12:30 PM. The surveyor requested a test tray at that time. The tray contained Roast beef, steamed vegetables, one dinner roll, margarine, pumpkin pie, vanilla ice cream, cranberry juice, roasted red potatoes, salt, and pepper. Staff #12, the Dietary Director, who was present, took the temperatures of the food items, which showed 137 degrees for the steamed vegetables, 121 degrees for the roasted potatoes, 146 degrees for the Roast beef, 63 degrees for the pumpkin pie, and 61 degrees for the cranberry juice. [...]

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to store food in accordance with professional standards. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to ensure the dishwasher was maintained in a safe operating condition, as evidenced by low temperature logs. This deficient practice has the potential to affect all residents who receive meals from the facility's kitchen.

Inspectors wroteBased on a review of medical records and interviews, it was determined that facility staff failed to immediately report an allegation of resident abuse. This was evident for 1 ( Resident #69) of 4 residents reviewed for abuse during a survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to thoroughly investigate allegations of abuse. This was evident for 2 (Residents #17 and #55) of 4 residents reviewed for abuse allegations. In addition, the facility failed to protect a resident during the course of an investigation, which was evident for 1 (Resident #17) of 1 resident reviewed for abuse allegations.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded. This was evident for 2 (#30 and #70) of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to develop a comprehensive care plan within 7 days after the completion of the comprehensive assessment. This was evident for 1 (Resident #26) of 2 residents reviewed for care planning.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to maintain resident records that were complete and accurate. This was evident for 1) one (Resident #4) of five residents review for unnecessary medications, and 2) one (Resident #69) out of five residents reviewed for abuse.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to properly obtain a resident's signature on an arbitration agreement. This was evident for 1 (Resident #17) of 3 residents reviewed for arbitration agreements.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to follow proper infection control procedures. This was evident for 2 (Resident #25 and #67) of 12 residents reviewed for infection control during the recertification survey.

Inspectors wroteBased on observation, record review and interview, it was determined that facility staff failed to ensure that residents had adequate supervision to prevent falls with serious injury. As a result of this deficient practice Resident #2 died due to the injuries sustained from a fall. This was evident for 1 (#2) of 3 residents reviewed for falls. As a result of these findings, a state of immediate jeopardy (IJ) was declared on 6/20/25 at 4:55 PM and an IJ summary tool was provided to the facility at that time. The facility submitted the first draft of their plan to remove the immediacy on 6/20/25 at 6:40 PM and it was not accepted. The facility submitted a second draft at 7:52 PM, and it was not accepted. The third draft was submitted at 8:02 PM and the facility ' s written plan to remove the immediacy was accepted on 6/20/25 at 8:30 PM with an alleged date of compliance of 6/23/25.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to develop a mandatory training course that included the facility's standards, policies, and procedures regarding their Infection Prevention and Control (IPC) program. This was evident during the review of the facility's training program and has the potential to affect all residents.

Inspectors wroteBased on observation, record review, and interview it was determined that the facility failed to ensure that they had competent staff on duty to provide care to their residents. This was evident for 1 (#2) of 3 residents reviewed for falls with serious injuries.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to develop all the required training requirements and have a process in place to ensure that all staff received the required trainings. This was evident for 3 (#7, #9, and #15) of 4 facility staff reviewed training requirements and 2 (#5, #6) of 3 contracted staff reviewed for training requirements.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that all staff who worked directly with residents had communication training. This was evident for 1 (#5) out of 3 contracted staff.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to have a process in place to ensure that all staff received facility specific compliance and ethics training. This was evident for 2 (#5, #6) of 3 contracted staff reviewed for training requirements.

Inspectors wroteBased on observation, interview with staff, and medical record review, the facility failed to meet the requirement to provide a system to account for the reconciliation of all controlled medications and ensure that an account of all the controlled drugs was completed with two licensed nurses at the change of each shift. This was evident for 3 of 3 available narcotic count logs. Findings Include: Tour of the unit on 07/14/22 at 1:28 PM to check for compliance of Medication Storage and Labeling revealed the Controlled Drug Count Verification Sheets. Several empty spaces for signatures were observed in the shift to shift verification log noted from March 2022 through the present day July 2022. [...]

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility contracted pharmacist failed to identify recommendations were followed up on. This was evident for 1 of 5 residents reviewed for unnecessary medications. Pharmacy reviews are to occur monthly at a minimum to determine any irregularities in a resident drug regimen and report to the physician.

Inspectors wroteBased on medical record reviews and interviews with facility staff, it was determined that the facility failed to 1) implement pharmacy recommendations that were agreed upon by the physician and ensure that they were followed up on (#20) and 2) ensure that orders for as-needed psychotropic medications were limited to 14 days for residents #25 and #56. This was evident for 3 out of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and medical record review, it was determined that the facility failed to thoroughly investigate and report to the state agency when a resident eloped from the facility. This was evident during the review of 1 of 4 residents (#20) reviewed for accidents.

Inspectors wroteBased on medical record reviews, interviews, and observations, it was determined that the facility failed to thoroughly investigate and implement interventions related to an elopement documented for Resident #20. This was found to be evident for 1 out 7 (Resident #20) residents reviewed for accidents.

Inspectors wroteBased on observation and interview of staff, it was determined that the facility failed to ensure that the kitchen stored and prepared food in accordance with professional standards for food service safety. This practice had the potential to affect all residents.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to ensure that the weekly menus displayed in the corridor outside the nursing unit accurately reflected the menu being served. This practice had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This was evident for 1 (#28) of 2 residents reviewed for respiratory care and 3 (#50, #2, #38) of 5 residents reviewed for unnecessary medications. The findings Include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) Resident #28 was observed receiving 3.5 liters (L) of oxygen via nasal cannula on 1/16/19 at 6:52 PM, on 1/17/19 at 2:50 PM, and 1/18/19 at 10:10 AM. Resident #28's medical record was reviewed on 1/18/19 along with care plans. A care plan for oxygen therapy was not found. On 1/18/19 at 1:48 PM, Staff #3 confirmed that there was no respiratory care plan. [...]

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to notify the physician of a resident's multiple refusal of a prescribed breathing treatment. This was evident for 1 (#38) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation and resident and staff interview, during facility environmental rounds, it was determined that the facility staff failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed on 1 of 3 nursing units.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident but not limited to for 2 (#12, #55) of 4 residents reviewed for hospitalization.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to complete a comprehensive assessment within the regulatory time frame for 1 (#55) of 5 residents reviewed for hospitalization.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility staff failed to review and revise resident care plans. This was evident for 1 (#2) of 5 residents reviewed for unnecessary medications and 1 (#25) of 2 residents reviewed for respiratory care.

Inspectors wroteBased on family interview, observation, medical record review and staff interview, it was determined the facility failed to 1) apply a physician's ordered brace to the right elbow, 2) failed to accurately document the use of the brace 3) failed to document if the resident received insulin and what the blood glucose level was and 4) failed to follow the care plan for splinting and administering medications. This was evident for 1 (#2) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined the facility 1) failed to ensure that a resident who was placed on oxygen was monitored for difficulty breathing, failed to develop a resident centered care plan for a resident receiving oxygen, and failed to document the use of oxygen in the resident's medical record and on the Treatment Administration Record. 2) Staff failed to label and date oxygen tubing for a resident. This was evident for 2 (#28, #309) of 3 residents reviewed for respiratory care.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure a resident's medication regimen was free from unnecessary drugs by failing to assure prescribed medications for constipation had a clear indication as to when to give which one. This was evident for 1 (#38) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to keep residents free from significant medication errors. This was evident for 1 (#38) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined the facility failed to have accurate medical record documentation as evidenced by nursing staff signing off treatments when they were not done, and not documenting a resident's use of oxygen. This was evident for 2 (#25, #28) of 3 residents reviewed for respiratory and 1 (#2) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on review of facility documentation and interviews with the facility staff, it was determined the facility failed to ensure that effective quality assessment and assurance performance improvement interventions were implemented to address deficiencies from a previous survey. This was evident during review of the Quality Assurance program.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of a facility-initiated transfer/discharge of a resident, along with the reason for the transfer. This was evident for 4 (#12, 38, 55, 61) of 4 residents reviewed that were transferred to an acute care facility.