Edenwald
Inspection history, citations, penalties and survey trends for this long-term care facility in Towson, Maryland.
- Location
- 800 Southerly Road, Towson, Maryland 21286
- CMS Provider Number
- 215372
- Inspections on file
- 8
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Edenwald during CMS and state inspections, most recent first.
The facility failed to notify local law enforcement of two separate allegations involving possible abuse and mistreatment. In one case, a construction foreman reported that a staff member was seen hitting a resident in the head and later described hearing crying, pleas for help, and slapping sounds from the resident’s room, which was relayed to facility staff. In the second case, a resident with vascular dementia, glaucoma, and a history of bilateral knee replacements, who had been deemed incapable of making medical decisions, was found with a fractured right distal femur of unknown origin and could not explain how the injury occurred. In both incidents, the DON acknowledged that the allegations were not reported to the police.
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident with dementia and severe cognitive impairment (BIMS 5/15). A construction foreman reported that construction staff had previously heard crying and pleas for help from the resident’s room and believed they saw a staff member striking an elderly wheelchaired patient, and later again heard crying, pleas for help, and slapping sounds from the same room before notifying facility staff. The DON identified the alleged perpetrator as a private duty assistant hired by the resident’s family and acknowledged that the facility had no HR records for this individual, including abuse training, background checks, or licensing information, and that the facility’s investigation did not include separate interviews with each construction staff member.
A resident with vascular dementia, glaucoma, bilateral knee replacements, and non-ambulatory status was dependent on staff for all ADLs and transfers and had physician orders and a care plan requiring use of a Hoyer lift with staff assistance for all transfers. During one evening shift, a GNA transferred the resident alone, later admitting they did not use a second staff member despite the requirement. Facility review of surveillance footage showed the GNA entering and exiting the resident’s room alone with the Hoyer lift, and the resident was subsequently found to have a right distal femur fracture of unknown source, which the resident could not explain.
Surveyors observed that food was not stored, prepared, or served according to professional standards, with staff handling food without proper hair coverings or gloves, expired and undated food items in storage, and unsanitary equipment such as trays with residue and pans with rust. Temperature and sanitizer logs were incomplete, and food storage bins and containers lacked required dating, with the potential to affect all residents.
A resident receiving hospice care had their Lorazepam dose increased without documented clinical justification in the medical record. Despite multiple changes to the psychotropic medication regimen and involvement of a CRNP-PMH and the attending physician, there was no evaluation or explanation recorded for the increased bedtime dose, as confirmed by the DON.
A resident was found with unexplained facial bruising and swelling, and the facility did not conduct a thorough investigation into the injury. Although statements were collected from staff and private duty aides, the aide present during the incident initially denied any issues but later admitted to sleeping during the shift. The facility did not interview other residents or provide documentation of further investigative actions, and the only supporting evidence of follow-up was an agency email months after the event.
Facility staff did not provide the required SNF ABN (CMS-10055) to two residents or their responsible parties when Medicare coverage was discontinued. Staff acknowledged on review forms that the notices were not issued as required, and the Administrator confirmed this was due to adjustments to new regulations.
The facility did not provide timely written notification to the State Ombudsman for two residents who were either discharged or transferred to the hospital. In both cases, required notifications were either missing or sent after the event, with the NHA attributing the delay to an oversight.
A resident was administered Midodrine on multiple occasions despite having systolic blood pressure readings above the physician-ordered threshold. Documentation showed that staff were aware of the medication parameters but still administered the drug outside of those guidelines, as confirmed by MAR and blood pressure records.
Failure to Report Alleged Abuse and Possible Mistreatment to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of staff-to-resident abuse and possible mistreatment to local law enforcement as required. In the first incident, the facility became aware on 08/20/25 at 2:30 p.m. of an allegation that a staff member had physically abused a resident. The allegation was reported to the facility by a construction company foreman who stated that one of the construction staff had witnessed a staff member hitting the resident in the head sometime during the previous week. The foreman later documented in an email that on 08/20/25 at 2:25 p.m. they heard crying and pleas for help, along with noises resembling slapping, coming from the resident’s room and felt strongly that someone in the room was being assaulted. At 2:50 p.m. that same day, the foreman reported what they heard and what had been reported to them earlier to a facility staff member in the parking lot. Despite this information, the allegation of staff-to-resident physical abuse was not reported to local law enforcement. In the second incident, the facility became aware on 07/11/25 at 9:27 p.m. that another resident had sustained a fractured right distal femur, identified as an injury of unknown source and reported as a possible mistreatment incident. This resident had vascular dementia, glaucoma, a history of bilateral knee replacements, and had been deemed incapable of making medical decisions by two physicians in November 2022. The resident was unable to provide any information about when or how the fracture occurred. The facility’s investigation documented the injury as an injury of unknown source and an allegation of possible mistreatment; however, the local police were not notified. During an interview on 03/30/26 at 2:10 p.m., the DON confirmed that the facility did not report either of these allegations to the local police.
Failure to Thoroughly Investigate Allegation of Physical Abuse by Private Duty Assistant
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of staff-to-resident physical abuse. The facility became aware of an allegation on 08/20/25 at 2:30 pm, when a construction company foreman reported that one of the construction staff had witnessed a staff member hitting Resident #1 in the head sometime during the previous week. Resident #1 was admitted with dementia with aggression and had a BIMS score of 5/15, indicating severe cognitive impairment. The construction foreman later sent an email on 08/22/25 elaborating that the construction staff had previously heard crying and pleas for help from Resident #1’s room and, upon approaching, believed they saw a staff member striking an elderly wheelchaired patient. In the same email, the foreman reported that on 08/20/25 at approximately 2:25 pm, they again heard crying, pleas for help, and noises resembling slapping from Resident #1’s room and felt strongly that someone in the room was being assaulted. At 2:50 pm that day, the foreman informed a facility staff member in the parking lot about what they heard and what had been reported days earlier. During interviews, the DON identified the alleged perpetrator as a private duty assistant hired by Resident #1’s family and stated that the facility did not have any human resources records for this individual, including abuse training, background checks, or licensing information. The DON also stated that the facility’s investigation did not include separate, facility-conducted interviews with each of the construction staff, demonstrating that the allegation of physical abuse was not thoroughly investigated.
Failure to Follow Mechanical Lift Transfer Requirements for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a required fall-prevention intervention for a resident identified as a fall risk and dependent on staff for all ADLs and transfers. The resident had vascular dementia, glaucoma, a history of bilateral knee replacements, was non-ambulatory, and had been deemed incapable of making medical decisions by two physicians. The medical record contained a physician’s order dated 03/08/2024 requiring use of a Hoyer (mechanical) lift for all transfers, and the fall prevention/ADL care plan included an intervention dated 07/31/24 directing staff to use a Hoyer lift for all transfers. Despite these orders and care plan interventions, the resident was later found to have a fractured right distal femur, classified as an injury of unknown source. The facility’s investigation into the injury revealed that on 07/07/25 during the 3–11 pm shift, a GNA transferred the resident without following the ordered intervention. An employee warning notice documented that the GNA initially stated they had used a Hoyer lift with a second staff member for the transfer, but later admitted to performing the transfer alone. The DON reported that review of surveillance footage from the hallway outside the resident’s room showed the GNA entering the room alone with a Hoyer lift and later exiting alone with the lift, with no second staff member observed entering to assist. The facility became aware of the resident’s right distal femur fracture on 07/11/25 at 9:27 pm, and the resident was unable to provide any information about when or how the fracture occurred.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, and did not maintain food service equipment in a sanitary manner. During the survey, multiple staff members were observed handling food without proper hair coverings or gloves, and hair nets were not readily available at the kitchen entrance. Several food items in various refrigerators and storage areas were found to be undated, expired, or improperly covered, including tuna salad, cherries, celery, lemons, pudding, crab cake mix, grilled chicken, lettuce, and potatoes. Additionally, dry storage racks contained baking trays with visible black and brown substances, and frying pans with rust-like material. The walk-in freezer had broken ice and frost accumulation at the entrance, and temperature logs showed readings below the standard range. Food storage bins and sauce containers were undated, and large cans of food lacked expiration dates. Review of temperature and sanitizer logs revealed incomplete documentation for multiple days across several months. The Director of Culinary Services confirmed that food should be dated and is only good for three days, acknowledged the issues with the trays and pans, and verified that staff should be wearing hair nets and gloves when handling food. The DON was also made aware of the findings. No specific residents were identified as being directly affected in the report, but the deficiencies had the potential to impact all residents.
Lack of Documentation for Psychotropic Medication Dose Increase
Penalty
Summary
A deficiency was identified when a resident's medication regimen included an increase in the dose of a psychotropic medication, Lorazepam, without corresponding documentation in the medical record to explain the reason for the dosage change. The resident, who was enrolled in hospice care, had their Lorazepam regimen adjusted multiple times over a short period, including an increase in the bedtime dose. Although a psychiatric nurse practitioner initially recommended Lorazepam and the attending physician made subsequent changes, there was no documented evaluation or justification for the increase in the psychotropic medication dose on the date it was changed. Medical record review revealed that while provider notes and nursing documentation addressed some medication changes, there was a lack of documentation specifically regarding the rationale for the increased bedtime dose. The Director of Nursing confirmed that no further evaluation or provider documentation was available to support the psychotropic dose increase. This failure to document the clinical reasoning for the medication adjustment resulted in the facility not ensuring the resident's medication regimen was free from unnecessary psychotropic medication.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident who was found with facial discoloration, bruising, and swelling. The incident was first noted by a Geriatric Nurse Aide (GNA) during the night shift, who reported a reddened area and blood on the resident's ear, as well as purple discoloration near the eye. The resident had a private duty aide (PDA) present in the room throughout the night, and there were no reports of a fall or change in condition prior to the discovery of the injury. The initial assessment by nursing staff documented the findings and notified the physician and responsible party, but the cause of the injury remained unknown. The facility's internal investigation included obtaining written statements from six nursing staff and two PDAs, including the one assigned to the resident during the night of the incident. The statements indicated that the last care was provided around midnight with no facial markings observed, and the injury was first noticed around 5:30 AM. The PDA assigned that night initially claimed to have observed the resident throughout the shift and denied any incidents. However, it was later revealed through communication with the agency owner that the PDA had fallen asleep during the shift, contradicting the initial statement. The facility did not obtain statements from other residents, and there was a lack of documentation supporting further investigation or actions taken regarding the PDA's conduct. During interviews with facility leadership, it was clarified that the facility's process for investigating injuries of unknown origin typically included interviewing staff from the previous three days and, if staff involvement was suspected, interviewing other residents. In this case, the facility did not interview other residents, citing the presence of a PDA as a witness, despite the PDA not being a facility employee and later admitting to sleeping during the shift. The facility was unable to provide documentation of further investigation or actions taken in response to the PDA's admission, and the only supporting documentation was an email from the agency, dated several months after the incident, indicating the PDA was removed from overnight duties.
Failure to Provide Required Medicare Discontinuation Notices
Penalty
Summary
Facility staff failed to provide proper notification of discontinued Medicare coverage to residents or their responsible parties, as required. During a review of Beneficiary Protection Notifications for three residents, it was found that two residents did not receive the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, CMS-10055) when their Medicare coverage was discontinued. Staff indicated on the review form that the ABN was not issued when it should have been. The Administrator confirmed in an interview that the notices were not provided due to the facility adjusting to new regulations. This deficiency was identified during a recertification and complaint survey, based on both document review and staff interview, and involved two out of three residents reviewed for beneficiary protection notifications.
Failure to Notify Ombudsman of Resident Discharge and Hospital Transfer
Penalty
Summary
The facility failed to provide required written notification to the State Ombudsman regarding the discharge and hospital transfer of two residents. For one resident, there was no evidence in the clinical or electronic health record that notification was sent to the ombudsman following two separate hospital discharges. Additionally, the list of residents whose discharge or transfer was forwarded to the ombudsman did not include this resident. For another resident, documentation showed that written notification of a planned discharge was sent to the ombudsman only after the discharge had occurred, rather than at least 30 days in advance as required. The Nursing Home Administrator confirmed that notifications are typically sent monthly and attributed the late notification to an oversight due to the low number of discharges.
Failure to Follow Medication Administration Parameters for Blood Pressure
Penalty
Summary
A deficiency was identified when a resident received Midodrine, a medication prescribed to treat orthostatic hypotension, in violation of the physician's order parameters. The order specified that the medication should be held if the resident's systolic blood pressure was above 130. Record review showed that the resident was administered Midodrine multiple times when their systolic blood pressure readings exceeded this threshold, with documented values ranging from 131 to 149. Staff interviews confirmed awareness of the medication parameters, with an LPN stating that the medication should not be given if the systolic blood pressure is greater than 130. Despite this, the medication was administered on several occasions outside of the prescribed parameters, as evidenced by the medication administration record and blood pressure documentation.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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