Lorien Rehab Bel Air: Pressure Ulcer Care Failures - MD
The resident, who has multiple sclerosis and relies entirely on staff for basic care, remained soiled from 8:30 PM until after 11 PM on May 23, 2025. The facility substantiated the neglect after a November investigation.
Staff member #13 was explicitly asked by the resident's nurse around 8:30 PM to change the resident after they had a bowel movement. But when the nursing assistant finally entered the room at 11 PM, she only emptied the resident's urinary catheter and claimed she "did not realize the Resident needed to be changed."
The resident was cognitively intact with a mental status score of 14 out of 15, meaning they understood exactly what was happening to them.
When the next shift arrived at 11 PM, nursing assistant #15 immediately noticed something was wrong. The room "smelled bad," she told investigators. The resident then told her that "the previous GNA never came in and changed him/her."
The resident had been living at the facility since 2017. Federal assessments from May showed they were completely dependent on staff for self-care activities. They couldn't change themselves, couldn't clean themselves, couldn't call for help beyond asking staff directly.
For nearly three hours, this cognitively aware person sat in their own waste while the nursing assistant assigned to their care ignored a direct order from their nurse.
The facility's administrator confirmed to inspectors on November 14 that staff had failed to provide basic care during the 3 PM to 11 PM shift on May 23.
This wasn't discovered until months later when the facility reported the incident as part of an internal investigation numbered 336885. The inspection report doesn't explain why it took from May until November for the facility to substantiate what happened, or what triggered the internal review.
The resident was discharged from the facility in June 2025, one month after the incident.
Federal regulations require nursing homes to provide care and assistance with activities of daily living for residents who cannot perform these tasks themselves. The violation was classified as causing "minimal harm or potential for actual harm," though the psychological impact on a cognitively intact person forced to remain in soiled conditions for hours isn't captured in that clinical language.
Staff #13's failure represents a basic breakdown in the most fundamental aspect of nursing home care. When a nurse identifies that a resident needs to be changed and assigns that task to a nursing assistant, the expectation is that it happens promptly. Leaving someone in feces for nearly three hours crosses the line from poor care into neglect.
The resident's multiple sclerosis diagnosis meant they had no ability to address the situation themselves. They were entirely at the mercy of staff who were supposed to provide dignified, timely care.
The next shift's immediate recognition that something was wrong suggests the smell and condition were obvious to anyone who entered the room. Staff #13's claim that she didn't realize the resident needed changing becomes harder to believe given that she was specifically told about the bowel movement hours earlier.
The facility reported this as a substantiated incident of failed care, confirming that their own investigation found the nursing assistant's actions fell below acceptable standards.
For the resident, those hours represented a complete failure of the system designed to protect them. Cognitively intact but physically helpless, they could only wait and hope someone would eventually provide the basic dignity of being clean.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lorien Nsg & Rehab Ctr Belair from 2025-11-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
LORIEN NSG & REHAB CTR BELAIR in BEL AIR, MD was cited for violations during a health inspection on November 17, 2025.
The resident, who has multiple sclerosis and relies entirely on staff for basic care, remained soiled from 8:30 PM until after 11 PM on May 23, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.