Lorien Bulle Rock

In the surveyor’s words

From the most serious findings on record at Lorien Bulle Rock, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF697Jun 28, 2022

  Based on clinical record review, observation, resident interview, and staff interview it was determined that the facility staff failed to ensure residents' pain management programs were overseen in a consistent manner. This was evident for 2 (#13 and #20) out of 27 residents in the survey sample. The findings are: 1. Resident #20 was interviewed on 06/22/22 at 10:33 AM. The resident stated that he/she has chronic back pain that radiates throughout the body and gets creams to treat. The resident was not observed to be in pain. A review of Resident #20's clinical record on 6/24, 6/27, and 6/28 revealed that the resident was ordered [MEDICATION(S)] (pain medication) 5 mg every 6 hours as needed for moderate to severe pain to address the resident's chronic back pain. […]

• No harm, potential for more than minimal, isolatedF600Jul 1, 2025

  Based on review of facility reported incident details, resident medical records, facility staff personnel files, and interview with facility staff, it was determined that the facility failed to ensure a resident was free from abuse. This was evident for 1 (Resident #76) out of 35 residents reviewed during the annual survey. The findings include: The Office of Health Care Quality received a facility reported incident on 3/22/23, MD00190490, that alleged a facility staff, Registered Nurse, RN #12, verbally abused Resident #76 on 3/20/23 during the 3 pm to 11 pm shift. […]

• No harm, potential for more than minimal, isolatedF609Jul 1, 2025

  Based on interviews and record review, it was determined that the facility failed to immediately report an allegation of abuse to the State Office of Health Care Quality within the allotted two-hour timeframe. This was found evident in 2 out of 4 (Resident #74 & 81) residents reviewed for abuse allegations during an annual and complaint survey.The findings include: 1a) On 6/30/25 at 9:15 AM, the surveyor reviewed the facility investigation into an allegation of abuse related to Resident #81. […]

• No harm, potential for more than minimal, isolatedF610Jul 1, 2025

  Based on record review and interviews it was determined that the facility staff failed to interview all the staff who worked on the unit during the investigative phase of an allegation of abuse. This deficient practice was evidenced in 1 (#74) of 10 facility reported incident investigation reviewed during the recertification and complaint survey. The findings include: On 6/25/25 at 11:20 AM a review of the facility's investigation of Resident #74 allegation of abuse, the surveyor noted all the staff who worked on the unit during the alleged incident, statements were not included in the investigation. On 6/26/25 at 2:02 PM during an interview with the Director of Nursing (DON) the surveyor asked what process they follow when completing an investigation. […]

• No harm, potential for more than minimal, isolatedF657Jul 1, 2025

  Based on medical record review and an interview it was determined that the facility failed to hold care plan meetings with the interdisciplinary team for a resident at the time of the quarterly revision of their care plan. This was evident for 1 (Resident #24) of 35 residents reviewed during the annual recertification survey. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). […]