Inspection Reports for
Lorien Taneytown
100 Antrium Boulevard, Taneytown, MD, 21787
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 25, 2025
Visit Reason
The inspection was conducted to investigate allegations of abuse and concerns related to food quality and safety at the facility.
Complaint Details
The complaint investigation found that abuse allegations were not fully substantiated due to incomplete investigations. The facility did not interview other residents or staff beyond the complainants and accused, and failed to suspend all implicated staff. The food temperature complaint was confirmed by observation and staff admission.
Findings
The facility failed to thoroughly investigate abuse allegations for two residents, including inadequate interviews and failure to suspend all involved staff. Additionally, food served was found to be at unsafe temperatures, with some items served cold when they should have been warm.
Deficiencies (2)
F 0610: The facility failed to thoroughly investigate abuse allegations for Residents #17 and #55, including not interviewing other staff or residents and not suspending all involved staff during the investigation.
F 0804: Food served to residents was bland and served at unsafe temperatures, with some hot foods below 140 degrees F and cold foods above 45 degrees F, contrary to facility policy.
Report Facts
Facility Reported Incident: 335697
Food temperature degrees F: 137
Food temperature degrees F: 121
Food temperature degrees F: 146
Food temperature degrees F: 63
Food temperature degrees F: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #8 | Unit Manager | Identified as head nurse involved in abuse allegation and investigation |
| Staff #12 | Dietary Director | Reported food temperatures and planned staff training on food safety |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding abuse investigations and acknowledged incomplete investigations |
| Chief Clinical Officer | Chief Clinical Officer (CCO) | Provided guidance on abuse investigation procedures |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Sep 25, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of abuse, neglect, and regulatory compliance concerns at the nursing home.
Complaint Details
The complaint investigation was substantiated with findings that the facility failed to timely report abuse, thoroughly investigate allegations, maintain accurate records, ensure infection control, and maintain food safety and equipment.
Findings
The facility failed to timely report and thoroughly investigate allegations of abuse, maintain accurate resident records, ensure proper infection control, maintain food safety and equipment, and comply with staffing posting requirements. Multiple deficiencies were identified including failure to administer medications properly, incomplete care planning, improper food storage and temperature control, and failure to post nurse staffing information as required.
Deficiencies (11)
F 0609: Facility staff failed to immediately report an allegation of resident abuse involving withholding medication.
F 0610: Facility failed to thoroughly investigate abuse allegations and protect a resident during the investigation.
F 0641: Facility failed to ensure Minimum Data Set assessments were accurately recorded for residents.
F 0657: Facility failed to develop a comprehensive care plan within 7 days after a significant change assessment.
F 0732: Facility failed to post required daily nurse staffing information in a clear and accessible location for 31 of 31 days reviewed.
F 0804: Facility failed to ensure food was served at safe temperatures and palatable quality.
F 0812: Facility failed to store food in accordance with professional standards including labeling and temperature control.
F 0842: Facility failed to maintain complete and accurate resident medical records including medication administration documentation.
F 0847: Facility failed to properly obtain a resident's signature on an arbitration agreement, allowing a spouse without legal authority to sign.
F 0880: Facility failed to follow proper infection control procedures including lack of isolation signage and failure to implement Enhanced Barrier Precautions for infected residents.
F 0908: Facility failed to maintain dishwasher in safe operating condition as evidenced by low temperature logs over several months.
Report Facts
Days with missing or incomplete nurse staffing postings: 31
Dishwasher temperature logs below minimum: 81
Residents reviewed for abuse allegations: 4
Residents reviewed for infection control: 12
Residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification: 3
Residents reviewed for care planning: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #4 | Nursing Supervisor | Named in failure to report abuse and medication withholding incident. |
| Staff #5 | Agency Nurse | Named in medication withholding and documentation errors. |
| LPN #7 | Licensed Practical Nurse | Named in failure to document blood pressure readings when holding medication. |
| LPN #8 | Nurse Unit Manager | Interviewed regarding medication documentation and staffing postings. |
| Staff #10 | MDS Coordinator | Named in inaccurate MDS assessment documentation. |
| Staff #12 | Dietary Director / Infection Preventionist Nurse | Named in food temperature, food storage, dishwasher maintenance, and infection control deficiencies. |
| Staff #13 | Chief Clinical Officer | Interviewed regarding infection control and arbitration agreement deficiencies. |
| Staff #14 | Staffing Coordinator | Named in failure to post nurse staffing information properly. |
| Staff #15 | Admissions Coordinator | Named in failure to properly obtain resident arbitration agreement signatures. |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding abuse reporting, investigations, medication documentation, and staffing postings. |
Inspection Report
Enforcement
Deficiencies: 6
Date: Jun 27, 2025
Visit Reason
The inspection was conducted due to a serious incident involving a resident fall resulting in death and concerns about staff competency, supervision, and training compliance.
Findings
The facility failed to provide adequate supervision to prevent falls, resulting in a resident's death. Staff failed to conduct proper injury assessments and delayed emergency response. The facility also lacked proper training and competency evaluations for agency and contracted staff, including communication, infection control, and compliance training.
Deficiencies (6)
F 0689: Facility staff failed to ensure adequate supervision to prevent falls, resulting in a resident's fatal fall and delayed emergency response.
F 0726: Facility failed to ensure nurses and nurse aides had appropriate competencies to care for residents, including lack of training and evaluation for agency staff.
F 0940: Facility failed to develop and maintain an effective training program ensuring all staff received required trainings including compliance, QAPI, and infection control.
F 0941: Facility failed to ensure all direct care staff received communication training, notably contracted staff lacked required training.
F 0945: Facility failed to develop mandatory infection prevention and control training that included facility-specific standards, policies, and procedures.
F 0946: Facility failed to ensure contracted staff received facility-specific compliance and ethics training.
Report Facts
Residents reviewed for falls: 3
Facility staff reviewed for training requirements: 4
Contracted staff reviewed for training requirements: 3
Minutes delay in calling 911: 31
Minutes EMS arrival after fall: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GNA #5 | Agency Staff | Named in supervision failure during resident fall incident |
| GNA #6 | Agency Staff | Named in supervision failure and lack of competency evaluation |
| RN #7 | Registered Nurse | Failed to conduct thorough injury assessment and delayed emergency response |
| Director of Nursing | Director of Nursing | Interviewed regarding staff supervision and training concerns |
| Director of Human Resources | Director of Human Resources | Interviewed regarding training program deficiencies |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding incident review and training compliance |
Inspection Report
Routine
Deficiencies: 7
Date: Jul 19, 2022
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident safety, medication management, food service, and other care standards at Lorien Taneytown, Inc.
Findings
The facility failed to thoroughly investigate and report a resident elopement, ensure adequate supervision and care planning for the resident at risk of elopement, maintain proper controlled substance reconciliation, implement pharmacy recommendations timely, limit psychotropic medication orders to 14 days, ensure menus accurately reflect meals served, and maintain food service safety standards.
Deficiencies (7)
F0609: The facility failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities after a resident eloped from the facility.
F0689: The facility failed to ensure the nursing home area was free from accident hazards and provide adequate supervision to prevent accidents related to a resident's elopement.
F0755: The facility failed to provide pharmaceutical services that included a system to reconcile all controlled medications with two licensed nurses at each shift change.
F0756: The facility failed to ensure a licensed pharmacist performed monthly drug regimen reviews and followed irregularity reporting guidelines.
F0758: The facility failed to implement pharmacy recommendations timely and failed to limit as-needed psychotropic medication orders to 14 days for certain residents.
F0803: The facility failed to ensure weekly menus displayed matched the meals actually served to residents.
F0812: The facility failed to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including ice buildup in the freezer and incomplete temperature logs.
Report Facts
Residents reviewed for accidents: 7
Narcotic count logs reviewed: 3
Residents reviewed for unnecessary medications: 6
Temperature logs missing entries: 1
Distance resident could have traveled: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Unit Manager | Interviewed regarding resident elopement incident. |
| DON | Director of Nursing | Interviewed multiple times regarding elopement, medication issues, and pharmacy recommendations. |
| Staff #8 | Receptionist who alerted administrator about resident elopement and reviewed cameras. | |
| Staff #18 | Activities Staff | Observed resident outside and alerted staff. |
| Maintenance Director #7 | Reported and fixed loose screw on exit door. | |
| LPN #25 | Nurse Manager | Interviewed about narcotic verification process. |
| Physician #27 | Attending Physician | Signed pharmacy recommendation for medication change. |
| Geriatric Nursing Assistant #28 | GNA | Assigned to resident after elopement. |
| Social Worker #17 | Facility Social Worker | Initiated care plan intervention for 1:1 supervision. |
| Kitchen Staff #30 | Confirmed menu being served did not match posted menu. |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Jan 22, 2019
Visit Reason
Annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of resident treatment refusals, inadequate maintenance of the environment, failure to provide written transfer notifications, untimely comprehensive assessments, incomplete and inaccurate care plans, medication errors, improper respiratory care, inaccurate medical record documentation, and ineffective quality assurance processes.
Deficiencies (13)
F0580: Facility staff failed to notify the physician of a resident's multiple refusal of prescribed breathing treatments.
F0584: Facility failed to maintain a sanitary, orderly, and comfortable interior environment; observed loose heating units and damaged doors.
F0623: Facility failed to notify residents or representatives in writing of facility-initiated transfers to acute care facilities.
F0624: Facility failed to document preparation and orientation provided to residents before transfer to acute care.
F0636: Facility failed to complete a comprehensive assessment within the regulatory timeframe for one resident.
F0656: Facility failed to develop and implement comprehensive person-centered care plans for respiratory care and unnecessary medications.
F0657: Facility failed to review and revise resident care plans within 7 days of comprehensive assessment.
F0684: Facility failed to provide appropriate treatment and care according to orders, including failure to apply a prescribed brace and document insulin administration.
F0695: Facility failed to provide safe and appropriate respiratory care, including failure to monitor oxygen use and label oxygen tubing.
F0757: Facility failed to ensure a resident's medication regimen was free from unnecessary drugs due to unclear medication orders for constipation and PRN breathing treatments.
F0760: Facility failed to keep residents free from significant medication errors, including incorrect medication administration schedules.
F0842: Facility failed to maintain accurate medical record documentation, including false documentation of treatment administration and oxygen use.
F0867: Facility failed to implement effective quality assessment and assurance processes to address repeat deficiencies from previous surveys.
Report Facts
Residents reviewed for unnecessary medications: 5
Residents reviewed for respiratory care: 3
Days resident #38 refused morning breathing treatment: 12
Days resident #38 refused evening breathing treatment: 5
Days resident #38 received Amlodipine in December 2018: 18
Days resident #38 received Amlodipine in January 2019: 10
Days evening insulin injection not signed off for Resident #2 in December 2018: 6
Days evening insulin injection not signed off for Resident #2 in January 2019: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #3 | Named in multiple medication and care plan findings, including medication error and care plan discrepancies. | |
| Director of Nursing | Director of Nursing | Interviewed regarding transfer notification and documentation practices. |
| Staff #6 | Confirmed untimely comprehensive assessment finding. | |
| Staff #7 | Interviewed regarding Quality Assessment and Assurance program deficiencies. |
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