Edenwald: Aide Skipped Required Lift, Resident Broke Femur - MD
The resident, identified in inspection records only as Resident #2, has vascular dementia and is non-ambulatory. She cannot make her own medical decisions, a determination two physicians made in November 2022. She depends on staff for every activity of daily living, and she requires a mechanical Hoyer lift for every transfer in and out of bed. That requirement has been written into a physician's order since March 2024 and into her care plan since July 2024. Both specify that two staff members must be present.
On the evening of July 7, 2025, during the 3-to-11 shift, a nursing aide identified in records as GNA #1 did not follow either order.
The fracture was discovered four days later, on July 11, at 9:27 p.m. Because of her dementia, the resident could not tell staff when the injury happened or how. The source was listed as unknown.
Facility administrators pulled surveillance footage from the hallway outside her room. What they found was straightforward: GNA #1 entered the room alone, pushing the Hoyer lift. After some time, GNA #1 left the room alone, with the Hoyer lift. No second staff member appeared in the footage at any point.
When the director of nursing and a unit manager interviewed GNA #1 on July 14, the aide's account shifted. According to a written employee warning notice reviewed by inspectors, GNA #1 initially said a second staff member had been present for the transfer. Then GNA #1 admitted that was not true, and that the transfer had been done alone.
The director of nursing described the surveillance review to a state inspector on March 30, 2026. "At no time," the DON said, did administrative staff witness a second staff member entering the room to assist with the transfer.
A femur fracture in a non-ambulatory resident with dementia, bilateral knee replacements, and glaucoma is not a minor event. The right distal femur, the lower portion of the thigh bone just above the knee, is a significant injury. In elderly residents with limited mobility and cognitive impairment, such fractures carry serious risks: pain, immobility, surgical intervention, and complications from both.
The inspection, completed March 30, 2026, was triggered by a complaint. The state's Office of Health Care Quality had received a facility-reported incident the previous July, logged under incident number 2569932, flagging the fracture as a possible mistreatment allegation. The survey covered two residents. Only one, Resident #2, showed a failure to implement a required fall-prevention intervention.
CMS rated the harm level as minimal harm or potential for actual harm, the lower end of the agency's severity scale. That designation reflects the regulatory classification, not a clinical one. The resident had already broken her femur.
What the inspection documents in full is a gap between what a care plan requires and what actually happened in that room on the evening of July 7. The Hoyer lift order existed. The two-person requirement existed. The aide knew the requirement, because when asked, the first instinct was to claim it had been followed.
The resident could not say what happened to her. She could not say when the pain began, or whether she called out, or how long it was before anyone noticed something was wrong. The surveillance camera captured who came and went from her hallway. It could not capture what happened inside the room.
Her femur fracture remains an injury of unknown source. That is how it appears in the record, and that is how it will stay.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Edenwald from 2026-03-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 18, 2026 · Our methodology
EDENWALD in TOWSON, MD was cited for violations during a health inspection on March 30, 2026.
The resident, identified in inspection records only as Resident #2, has vascular dementia and is non-ambulatory.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.