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.)
- 8
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
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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