Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 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.
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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 Towson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Towson Rehabilitation And Healthcare Center | 0.5 mi | ★★★★★ | 18 | 0 |
| Orchard Hill Rehabilitation And Healthcare Center | 0.9 mi | ★★★★★ | 42 | 0 |
| Pickersgill Retirement Community | 1.3 mi | ★★★★★ | 6 | 0 |
| Chestnut Grn Hlth Ctr Blakehur | 1.4 mi | ★★★★★ | 13 | 0 |
| Complete Care At Multi Medical Center Llc | 1.4 mi | ★★★★★ | 13 | 0 |
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