Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lorien Bulle Rock during CMS and state inspections, most recent first.
A resident with advanced dementia and high care needs was subjected to verbal abuse and rough handling by an RN, as witnessed by multiple staff. The RN made degrading remarks, threatened the resident, and used inappropriate language in the presence of the resident, in violation of the facility's abuse prevention policy.
The facility did not report allegations of abuse involving two residents to the state agency within the required two-hour timeframe. In both cases, staff received reports of abuse but failed to notify the appropriate authorities promptly, resulting in delayed investigations. Interviews with the NHA and DON confirmed that staff were aware of the reporting requirements and that there was no justification for the delays.
Facility staff did not interview all personnel present during the investigation of an alleged abuse incident involving a resident. The investigation file was missing statements from all GNAs and a nurse who were on duty at the time, and the DON confirmed that these interviews were not conducted as typically required.
A resident was left in a chair for over four hours without being repositioned, toileted, or checked for incontinence after therapy. Despite being given a call bell, staff did not respond to the resident's needs, and the issue was only brought to attention after a family member contacted the facility. Documentation confirmed the lack of care and monitoring during this period.
Surveyors identified that the facility did not maintain complete and accurate medical records for several residents, including missing documentation of repositioning, inconsistent bowel movement records, and a care plan for elopement risk without supporting documentation. The DON acknowledged these documentation gaps and inconsistencies.
Verbal Abuse of Resident by Registered Nurse
Penalty
Summary
A deficiency occurred when a registered nurse (RN) verbally abused a resident who was under hospice care with diagnoses including Alzheimer's, dementia, and repeated falls. The resident was dependent for all care, required frequent monitoring, and had a very low BIMS score, indicating severe cognitive impairment. On the evening in question, the resident was placed in a hallway recliner for closer supervision due to repeated attempts to get out of bed, which posed a fall risk. Multiple staff members witnessed the RN using degrading and inappropriate language toward the resident, including yelling, making threats, and physically handling the resident in a rough manner. Specific statements included threats to push the resident down the stairs and dismissive comments about the resident's safety. The facility's investigation substantiated the verbal abuse through several staff witness statements and a review of the RN's own admission of inappropriate language and emotional breakdown during the shift. The RN's personnel file indicated a decision not to rehire and noted that the RN would have been terminated for verbal abuse. The facility's abuse prevention policy defined verbal abuse as the use of disparaging or derogatory language within hearing distance of residents, which was consistent with the actions observed and reported by staff.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to immediately report allegations of abuse to the State Office of Health Care Quality within the required two-hour timeframe for two out of four residents reviewed during an annual and complaint survey. In one instance, a resident's family member reported to an LPN that the resident had been hurt by a night shift staff member. Although this was documented in a progress note, the allegation was not reported to the state agency or investigated until the following day, as the staff did not notify the Nursing Home Administrator until then. In another case, a resident informed a maintenance technician about an incident of being smacked during the night shift, which was later reported to the EVS Director. The incident was not reported to the state agency until several hours after the initial disclosure, exceeding the two-hour reporting requirement. During interviews, both the Nursing Home Administrator and the Director of Nursing confirmed awareness of the two-hour reporting policy and acknowledged that there was no valid reason for the delay in reporting these allegations.
Incomplete Staff Interviews During Abuse Investigation
Penalty
Summary
Facility staff failed to interview all personnel who worked on the unit during the investigation of an alleged abuse incident involving Resident #74. Record review revealed that statements from all staff present during the time of the alleged incident were not included in the investigation documentation. During an interview, the DON acknowledged that not all relevant staff, including two GNAs and a nurse who were on duty, had been interviewed as part of the investigative process, despite the facility's usual practice to do so. The omission of these interviews was not explained, and the investigation file lacked statements from all staff who were present during the alleged event.
Failure to Provide Timely ADL Assistance and Repositioning
Penalty
Summary
A deficiency was identified when a resident was left in a chair for approximately 4.5 hours without being repositioned, toileted, or checked for incontinence. Documentation showed that after therapy, the resident was returned to their room at 11:00 AM, instructed to sit in a chair for one hour, and given a call bell to alert staff when ready to return to bed. However, there was no record of staff responding to the resident's needs during this period. The resident's family member called the facility at 3:15 PM, reporting that the resident had been left in the chair since early morning and that no one had responded to the call bell. Further review confirmed that the resident was not put back to bed until 3:21 PM, with no documentation of any checks, repositioning, or toileting during the interval.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for multiple residents. For one resident, there was no documentation verifying that the resident was repositioned at least every two hours, and staff records did not specify whether the resident was dressed, only the type of assistance provided. The Director of Nursing (DON) acknowledged the lack of documentation and stated that staff had recently begun signing off on tasks, but the records still did not confirm that required care was provided. In another case, a resident's medical record showed inconsistent and inaccurate documentation regarding bowel movements, with discrepancies between task documentation and progress notes. Additionally, a third resident had a care plan for elopement risk initiated without corresponding documentation of exit-seeking behavior in the medical record, and the behavior was not coded in the Minimum Data Set (MDS) assessment due to lack of documentation. These findings demonstrate that the facility did not ensure medical records were complete, accurate, and reflective of the care provided.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Havre De Grace
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Citizens Care Center | 4.3 mi | ★★★★★ | 15 | 0 |
| Lorien Nsg & Rehab Ctr Belair | 8.1 mi | ★★★★★ | 9 | 0 |
| Sterling Care Riverside | 9 mi | ★★★★★ | 0 | 0 |
| Sterling Care Bel Air | 11.4 mi | ★★★★★ | 18 | 0 |
| Sterling Care Forest Hill | 12 mi | ★★★★★ | 27 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.