Edenwald

determined that the facility failed to thoroughly investigate an allegation of physical abuse.

This was

include: On 08/20/25 the Office of Health Care Quality received a facility reported incident regarding an allegation a resident was a victim of physical abuse. Resident #1 was admitted to the facility on [DATE] with diagnoses that include but are not limited to dementia with aggression. Resident #1 had a BIMS score of 5/15 which indicates severe cognitive impairment.

The BIMS (Brief Interview for Mental Status) score is a 0-15 point tool used in healthcare, particularly long-term care, to assess cognitive function, with higher scores indicating better cognition. It evaluates immediate recall, temporal orientation, and short-term memory. A score of 13-15 indicates intact cognition, 8-12 moderate impairment, and 0-7 severe impairment. A review of the facility investigation on 03/30/26 revealed that the facility became aware of an allegation of staff to resident physical abuse on 08/20/25 at 2:30 pm.

The facility received the allegation of physical abuse from one of the construction company foremen completing renovations on the skilled nursing unit.

The foreman stated that one of the construction staff witnessed a staff member hitting Resident #1 in the head sometime during the previous week. On 08/22/25, during the facility investigation, the construction company foreman sent an email to the facility regarding the allegation of staff to resident physical abuse. In the email, the construction foreman indicated elaborated on the construction staff's original statement. In the email, the construction staff reported that they had heard crying and pleas for help coming from Resident #1's room. As they approached the area, they claimed to have witnessed what appeared to be the staff member striking an elderly wheelchaired patient.

The construction foreman indicated that they made a note of the incident and decided to keep an eye and an ear on any cries coming from that corridor. On 08/20/25 at approximately 2:225 pm, the construction foreman wrote in the email that they heard crying and pleas for help accompanied by noises resembling slapping coming from Resident #1's room.

The construction foreman indicated in the email they felt strongly that someone in Resident #1's room was being assaulted during the times they heard crying and pleas for help. At 2:50 pm on 08/20/25, the construction foreman indicated they informed one of the facility staff members in the parking lot of what they heard and what was reported to them days earlier. In an interview with the facility director of nurses (DON) on 03/30/26 at 11:40 am, the DON indicated the alleged perpetrator was a private duty assistant (Staff#1) hired by Resident #1's family.

The DON stated that the facility did not have any type of human recourse records for Staff#1 including abuse training, background checks, or licensing information for Staff #1. In a follow-up interview with he facility DON on 03/30/26 at 2:10 pm, the facility DON stated the facility investigation did not have separate facility conducted interviews with each of the construction staff.

215372 03/30/2026

Edenwald 800 Southerly Road Towson, MD 21286

prevent accidents.

reviews of a facility investigation and record review, and staff interview, it was determined that the

identified as a fall risk.

This was evident of 1 (Resident #2) of 2 residents reviewed during a complaint survey.

The findings include: On 07/23/25 the Office of Health Care Quality received a facility reported incident, #2569932, regarding an allegation of possible mistreatment. Resident #2 was identified with a fractured right femur (an injury of unknown source). Resident #2 was admitted to the facility on [DATE] with diagnoses that include but not limited to vascular dementia (Vascular dementia is a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, robbing brain cells of oxygen), glaucoma (poor vision), and a history of bilateral knee replacements (Bilateral knee replacements involves replacing both knee joints, either simultaneously or in stages, for patients with severe arthritis to improve mobility). Resident #2 was deemed incapable of being able to make medical decisions by two physicians in November of 2022. Resident #2 is non-ambulatory and requires the use of a mechanical lift for all transfers in and out of bed. Resident #2 is also dependent upon the nursing staff for all activities of daily living. A review Resident #2 medical record on 03/30/26 revealed a physician's order, dated 03/08/2024, instructing the nursing staff to use a Hoyer (mechanical lift) lift for all transfers. A review of Resident #2's fall prevention/ADL care plans on 03/30/26 revealed a nursing intervention, dated 07/31/24 indicating the nursing staff are to use a Hoyer (mechanical lift) lift for all transfers. A review of the facility investigation on 03/30/26 revealed that the facility became aware of an injury of unknown source on 07/11/25 at 9:27 pm when Resident #2 was identified with a fractured right distal femur. Resident #2 was unable to inform the facility staff with any information or details as to when or how the fractured femur may have occurred. A review of the facility investigation on 03/30/26 revealed that the facility administrative staff viewed surveillance camera footage of the nursing units and in particular Resident #2 hallway footage. A review of GNA #1's employee warning notice, dated 07/14/25, the DON and unit manager interviewed GNA #1 about using a Hoyer lift and a second staff member with Resident #2's transfer on 07/07/25 during the 3-11 pm shift.

Initially, the employee warning notice indicated, GNA #1 stated that they used a Hoyer lift with a second staff member on 07/07/25 during the 3-11 pm shift when transferring Resident #2.

Then later, the employee warning notice indicated GNA #1 admitted to using only themselves when transferring Resident #2 on 07/07/25 during the 3-11 pm shift. In an interview with the facility director of nurses (DON) on 03/30/26 at 2:30 PM, the DON indicated that during the investigation into Resident #2's fracture femur, the administrative staff reviewed facility camera footage covering the entrance to Resident #2 rooms.

The DON stated that the administrative staff viewed GNA#1 enter Resident #2's room, alone, with a Hoyer lift (mechanical lift) and after a period of time observed GNA #1 exit the room, alone, with the Hoyer lift.

The DON stated that at not time did the administrative staff witness a second staff member entering the room to assist GNA #1 with Resident #2's transfer.