Edenwald

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on reviews of 2 facility reported incidents, all pertinent facility documentation and staff interview, it was determined that the facility failed to report allegations of staff to resident abuse to local law enforcement. This was found to be evident for 2 (Resident #1 and Resident #2) of 2 residents reviewed during a complaint survey. The findings include: 1) On 08/20/25 the Office of Health Care Quality received a facility reported incident regarding an allegation that a resident was a victim of physical abuse. 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 who was 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. Further review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility investigative material, medical records, and interviews with facility staff, it was determined that the facility failed to thoroughly investigate an allegation of physical abuse. This was evidenced by 1 (Resident #1) of two residents reviewed during a complaint survey. The findings 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on reviews of a facility investigation and record review, and staff interview, it was determined that the facility failed to implement an intervention, determined to be necessary, for a resident who was 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview it was determined that the facility 1) failed to store, prepare, distribute and serve food in accordance with professional standards for food service and 2) failed to maintain food service equipment in a manner that ensures sanitary food service operations. This was evident during the recertification/complaint survey and has the potential to affect all residents. The findings include: On 06/16/25 at 8:15 AM during the initial tour of the kitchen, an observation of the entrance of the kitchen revealed that there were no hair nets available at the entrance. When the surveyor asked for a hair net, Staff #14 had to go to the opposite side of the kitchen to obtain a hair net for the surveyor to wear. Upon entrance into the kitchen on 6/16/25 at 8:20 AM, Staff member #15 was observed handling lettuce by pouring it into a pan without any gloves on and was wearing a baseball cap with a long braid of hair not covered with a hair net. Staff member #16 was also observed wearing a baseball cap with hanging down braided hair to shoulders and not covered by a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of beneficiary protection notification reviews, and staff interview, it was determined that the facility staff failed to ensure proper notification of discontinued Medicare coverage was provided to the resident or their responsible party (RP). This was evident for 2 (Residents #91 and #92) out of the 3 residents reviewed for Beneficiary Protection Notifications during the recertification/complaint survey. The findings include: A review of three Beneficiary Protection Notifications for Residents #90, #91, and #92 was conducted on 6/17/25 at 8:30 AM. The documents were handed to the Administrator. The Administrator returned the three documents on 6/17/25 at 1:42 PM. For Residents #91 and #92, facility staff reviewed part one of the review form that asked, Was an SNF ABN [Advance Beneficiary Notice], CMS-10055 provided to the resident and then checked the box that said, If NOT issued and should have been. The Administrator was interviewed on 6/17/25 at 1:44 PM. She said, the residents did not get an ABN because we were adjusting to the new regs.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. A review of Resident #27's clinical record revealed the resident was discharged twice to the hospital on 2/6/25 and 4/9/25. A review of the clinical record, including the electronic health record, failed to locate evidence that notification was sent to the ombudsman. The Administrator was asked to provide a list of residents whose discharge or transfer was forwarded to the ombudsman on 6/23/25. The list did not include Resident #27. The Administrator was interviewed on 6/23/25 at 1:34 PM. She was shown the provided list of transfers and discharges. This surveyor explained the need to inform the ombudsman when a resident is admitted to the hospital. She replied I understand. Those are the names I was provided as to who was discharged or transferred. Based on record review and interview, it was determined that the facility failed to notify the State Ombudsman in writing at least 30 days prior to the residents' discharge and failed to notify the State Ombudsman when a resident was admitted to the hospital. This…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interviews, it was determined that the facility failed to ensure a resident received medication according to the physician's order set parameters (a specific instruction given for administration of medication). This was evident for 1 (Resident #22) of 5 residents reviewed for unnecessary medications during the recertification/complaint survey. The findings include: On 06/17/2025 at 12:37 PM a review of resident #22's medical record revealed a physician's order dated 3/10/2025 for Midodrine 10 mg tablet three times a day (a medication used to treat orthostatic hypotension, caused by a sudden drop in blood pressure when standing up). The medication had parameters to hold if Systolic Blood Pressure (the top number in a blood pressure reading, representing the pressure in the arteries when the heart contracts and pumps blood out of the body) is above 130. Further review on 06/17/2025 at 2:02 PM of resident #22's Medication administration record (MAR) for the months of April, May, and June of 2025 revealed that Resident #22 received this medication on:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview with staff, it was determined that the facility failed to ensure the residents' medication regimen was free from unnecessary medication by increasing psychotropic medication dose without documentation in the record explaining the reason for an increased dose. This was evident for one (Resident # 29) of five residents selected for unnecessary medication regimen review during this recertification/complaint survey. The findings include: Psychotropic medications are drugs that influence brain activity related to mental processes and behavior. They are commonly used to treat conditions like depression, anxiety, psychosis, and bipolar disorder by altering the brain's chemical balance, thereby impacting mood, thinking, and behavior. During a review of Resident #29's medication regimen on 6/20/25, at 12:09 PM, it was revealed that the resident was prescribed Lorazepam (Ativan), which is used to treat anxiety disorders. A further review of the Lorazepam order history indicated the following: - Lorazepam 0.25 ml via sublingual route, twice daily (6…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of facility investigative material, medical records, and interviews with facility staff, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for a resident. This was evidenced by 1 (Resident #140) of two residents reviewed for injury of unknown origin during this recertification/complaint survey. The findings include: During an investigation of the facility's internal investigation for MD00189789, on 06/16/2025 at 12:31 PM, it was revealed that on 03/05/2023, a night shift (11 PM - 7 AM) Geriatric Nurse Aide (GNA) reported a reddened area on Resident #140's right side of the face. A review of Resident #140's medical records on 06/17/2025 at 8:05 AM, revealed a progress note written by nursing staff on 03/05/2023 at 7:41 AM stated, Resident was reported by caregiver to have some discoloration to his/her face. Resident noted to have some rash-like redness to the right half side of the face, resident has some blood on his/her ear. Resident also noted to have some purple discoloration to the corner of his/her right eye.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.