Lorien Health Systems - Columbia

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Manager and Director of Nursing who escorted the 2 providers from the facility. Interview with the Wound Doctor on 9/25/25 at 12:41 PM, the Wound Doctor stated he always obtains consent, either verbal or in writing, for wound debridement and documents that in the Resident's medical record. Interview with the Administrator on 9/26/25 at 10:10 AM confirmed the facility failed to ensure consent was obtained from the Resident's representative by outside providers for the debridement of Resident #9's right heel wound on 5/29/25.

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lorien Health Systems - Columbia

6334 Cedar Lane Columbia, MD 21044

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based on review of facility documentation and staff interview, it was determined the facility failed to provide documentation that allegations of abuse were thoroughly investigated. This was evident for 1 (#12) of 10 residents reviewed for facility reported incidents during a complaint survey. The findings include: On 9/26/25 at 11:22 AM a review of facility reported incident 344173 was conducted and revealed Resident #12 alleged to the social worker that a geriatric nursing assistant (GNA) pushed his/her head on the bed during ADL (activities of daily living) care. Review of the facility documentation revealed a written statement from Social Worker #20 who documented that during the conversation that she had with Resident #12, Resident #12 stated that he/she felt the nurses did not care about him/her. Resident #12 stated that some were rough when providing treatment and stated that one nurse made the resident cry because she was not gentle with him/her. The first nurse was Staff #18 and the second one that pushed his/her head back was Staff #17.

Review of statements from 3 other residents interviewed about Staff #17 revealed they stated, I really don't like her. She just always knocks you around. She thinks she too perfect no matter what she does. She always thinks I do everything wrong. She is very good at what she does, it's just the way she does it.

Another resident stated, She does not take care of me the way I want. When I say something, they treat me bad. She don't treat me good, from day one. When I see her she does not treat me well. The third resident stated, She seems to have a lot of anger at me. She unleashes a lot of anger at me. She is always telling me I am not doing things right. When I ask a question, she gets very angry at me. She says I am interfering with her work. She yells and says you always do that, you're not very patient. Further review of the investigation revealed only a written statement from Staff #18. There were no resident interviews about the care Staff #18 provided and there were no staff interviews about Staff #18. On 9/26/25 at 10:44 AM an

interview was conducted with the Director of Nursing (DON) who stated that he did not have any concerns related to both Staff #17 and Staff #18. The DON stated he was not aware of what the other interviewed residents had expressed.On 9/26/25 at 12:30 PM an interview was conducted with the Nursing Home Administrator (NHA). The investigation was reviewed with the NHA, and the concern was brought up that 4 of 10 residents interviewed about care had concerns with how Staff #17 treated the residents. The NHA was asked if Staff #18 was suspended and if questions were asked about the care she provided and her demeanor. The NHA stated that she was so focused on Staff #17 that she overlooked Staff #18. The NHA agreed that she should have done more following up with the residents and more investigation related to Staff #18.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lorien Health Systems - Columbia

6334 Cedar Lane Columbia, MD 21044

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Based on medical record review and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions. This was evident for 1 (#14) of 14 residents reviewed for complaints during a complaint survey.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. On 9/24/25 at 10:30 AM a review of Resident #14's medical record revealed Resident #14 was admitted to the facility in December 2024 with diagnoses that included but were not limited to cardiac arrest which resulted in anoxic brain damage, asthma, and dependence on a ventilator. Review of Resident #14's weekly skin assessment sheets documented on 12/20/24 there was a DTI (deep tissue injury) to the left heel. Weekly skin sheets from 12/20/24 to 1/24/25 documented the DTI to the left heel and

on 1/24/25 there was a Stage 2 pressure ulcer to the left ischium and a DTI to the right buttock. Review of Resident #14's care plans revealed a care plan, at risk for impairment to skin integrity to the sacrum and heels related to fragile skin that was created on 12/25/24. The interventions on the care plan documented, check for incontinence every 2 hours and as needed, use barrier cream with incontinence care to prevent skin breakdown, daily skin inspection, notify the nurse of any changes to skin integrity, monitor wound characteristics during weekly wound rounds, and notify MD/NP of deteriorations or ineffective treatments, weekly skin assessment, and documented new areas per protocol and notify MD/NP as indicated. The care plan was not updated to reflect what was being done for the resident's heels. There was no documentation of elevation/float heels, heel boots, skin prep to heels, or air mattress to the bed.On 9/26/25 at 10:44 AM an

interview was conducted with the Director of Nursing (DON) as he developed Resident #14's care plan. The DON stated that they should have updated the care plan with the interventions for what was being done for

the heel.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lorien Health Systems - Columbia

6334 Cedar Lane Columbia, MD 21044

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

Based on medical record review and interview, it was determined the facility failed to ensure residents received treatments per physician orders (Resident #18 and #19). This was evident for 2 of 24 residents reviewed during a complaint survey. The findings include: 1.Review of Resident #18's medical record on 9/22/25 revealed the Resident was admitted to the facility from the hospital on 7/14/24 with a diagnosis to include dermatitis. Dermatitis is a common condition that causes swelling and irritation of the skin. Review of Resident #18's July 2024 Treatment Administration Record (TAR) revealed on admission the Resident was being treated for the dermatitis by the facility staff through 7/30/24. Further review of Resident #18's medical record revealed she was seen and assessed by the Wound Doctor on 7/26/24 who diagnosed the Resident with fungal dermatitis and ordered Clotrimazole daily. Review of Resident #18's July TAR revealed

the Resident received Clotrimazole until 7/30/24. The Resident was seen again on 8/2/24 and 8/9/24 by the Wound Doctor for the fungal dermatitis and stated topical agent used is Clotrimazole. The Resident was seen by the Wound Doctor on 8/16/24 who documented the fungal infection had resolved. Review of a weekly skin assessment note on 8/14/24 at 4:18 PM states rash is resolved. Review of Resident #18's July and August TAR revealed the Resident did not receive Clotrimazole from 7/31/24 through 8/14/24. Interview with the Director of Nursing on 9/23/25 at 9:25 AM confirmed the facility staff should have been administering Clotrimazole treatment to Resident #18 from 7/31/24 until 8/14/24. 2. Review of Resident #19's medical record on 9/22/25 revealed the Resident was admitted to the facility in February 2024 with cerebrovascular disease, diabetes and peripheral vascular disease (PVD). Review of Resident #19's Wound Doctor notes on 8/2/24 revealed the Wound Doctor assessed the Resident to have a right distal lateral foot wound with the cause listed as PVD. The Resident was sent to the hospital on 8/3/24 and returned on 8/9/24 with a diagnosis to include amputation of distal aspect of 5th metatarsal and diabetic right lateral foot wound. Review of Resident #19's August 2024 through September 2025 TAR (Treatment Administration Records) revealed the facility staff failed to provide treatments to the Resident's right lateral foot wound per the Wound Doctor's orders from 11/19-11/25/24, 12/21-12/23/24 and 2/8-2/12/25. Interview with the Director of Nursing on 9/29/25 at 7:51 AM confirmed the Surveyor's findings.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lorien Health Systems - Columbia

6334 Cedar Lane Columbia, MD 21044

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686

says.

Level of Harm - Minimal harm or potential for actual harm

On 9/22/25 at 2:08 PM the DON stated, the order should have been for every day, not every shift.

Residents Affected - Some

On 9/26/25 at 12:30 PM an interview was conducted with the wound care physician, Staff #21 who stated,

the order was for once a day and prn (when necessary) if the dressing comes off. Just once a day. The intent was not for 3 times a day. It is intended to be done once a day and if the dressing falls off. It doesn't change the outcome of the wound. Santyl is a special kind of dressing and doing it 3 times of day has no value and is overkill. The intention was for once a day.

1. 3. On 9/29/25 at 8:06 AM a review of Resident #'23s medical record revealed the resident was admitted to

the facility on [DATE REDACTED] from an acute care facility for subacute rehabilitation as well as management of chronic health conditions.

Review of weekly skin team notes documented a 7/31/25 note that revealed 5 areas on the skin that required treatment for trauma injuries and a right and left heel DTI (deep tissue injury).

An 8/15/25 weekly skin team note documented the right and left heel DTI treatment as betadine LOTA (leave open to air).

An 8/22/25 weekly skin team note documented the right heel treatment as betadine LOTA and the left heel treatment as calcium alginate and wrap with Kerlix.

Review of Resident #23's August 2025 Treatment Administration Record (TAR) documented the treatment that was being done was, Xeroform Petrolatum Dressing Pad, apply to left heel topically in the morning for wound care. Cleanse wound to left heel with NSS (normal saline solution), pat dry, apply xeroform and dry gauze, wrap with kerlix and secure with tape daily. This treatment was done from 8/14/25 to 8/29/29. This treatment did not match what the wound physician had wanted, which was betaine to the left heel and leave open to air until 8/22/25. The treatment was then changed to calcium alginate. The calcium alginate was not initiated until 8/29/25.

Further review documented, Skin Prep Wipes Miscellaneous (Ostomy Supplies) Apply to RIGHT HEEL topically every day and evening shift for WOUND CARE apply to right heel every day and evening shift for protection. Start date 7/19/25 to d/c date 9/5/25. Betadine was never applied to the right heel per the wound care physician. The skin prep wipes was the only treatment to the right heel.

On 9/29/25 at 1:10 PM the treatments were reviewed with the Director of Nursing (DON). The DON stated that there appeared to be a problem on that unit. He can't believe the nurses are not following the wound care orders.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lorien Health Systems - Columbia

6334 Cedar Lane Columbia, MD 21044

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to be held if the systolic blood pressure was less than 110. The medication Metoprolol 50 mg. (2) tablets was to be given every 12 hours for atrial fibrillation. The medication was to be held if the systolic blood pressure was less than 110 or the heart rate was less than 60.Review of Resident #23's September 2025 MAR documented the blood pressure was 110/60. The medication was held at midnight. There was a corresponding nurses note that documented the medication was held. The medication was to be given according to the physician ordered parameters.Further review of the September 2025 MAR documented on 9/24/25 at 9 PM the blood pressure was 106/44. The medication was administered when it was outside of physician ordered parameters. The medication should have been held.A 9/15/25 physician's note documented that Resident #23's blood pressures are not well controlled. Start hydralazine 25 mg by mouth every 8 hours, hold for systolic blood pressure below. Continue Norvasc 10 mg daily, candesartan 60 mg daily, metoprolol 100 mg every 12 hours. Monitor blood pressure every shift.On 9/29/25 at 1:10 PM the MARs were reviewed with the DON. The surveyor brought up to the DON that it appeared that the same nurses were committing the repeat errors of not following physician ordered parameters. The DON shook his head and agreed that there appeared to be a problem with that unit with following physician ordered parameters. The DON stated, we are going to have to start educating.

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Facility ID:

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