Levindale Hebrew: Abuse Response Failures - MD
Federal inspectors found the nursing home failed to maintain proper medical records for residents at risk of wandering or escaping, documenting problems with two patients during a November complaint investigation.
Resident #5 received a wandering risk assessment in June that produced a high-risk score of 13. But the facility never added the resident to its wander list, and staff failed to complete the required quarterly follow-up assessment.
The resident's care plan, last updated in May, noted "wandering behaviors related to adjustment to the nursing home." The incomplete documentation meant staff couldn't track the resident's current risk status or determine appropriate monitoring levels.
When inspectors pointed out the missing assessment on November 14, the Director of Nursing and administrator acknowledged they had missed the quarterly requirement. Staff didn't complete the overdue assessment until that same day, after inspector intervention.
A second resident presented even more troubling gaps in monitoring.
Resident #7 escaped from the facility on March 6. Four months earlier, a nursing note documented the resident "was busy seeking exit and wanted to go to floor 2 and go home."
Despite these clear warning signs and an actual elopement, the facility's wandering risk assessments for Resident #7 remained incomplete with scores of zero. Scores between 0-8 indicate low wandering risk, according to facility protocols.
The facility failed to update the resident's risk assessment after the January exit-seeking behaviors. Staff also failed to complete an accurate assessment after the March elopement that would have reflected the resident's demonstrated ability and willingness to leave the building.
Facility policy requires wandering risk assessments on admission, readmission, with any change of condition, and annually for all residents. The policy, dated November 13, also mandates quarterly screenings.
The Director of Nursing told inspectors that all residents should be screened for wandering risk upon admission, quarterly, and as needed. But the facility's own records showed systematic failures to follow these protocols.
For Resident #5, staff missed the quarterly assessment deadline and failed to include a high-risk resident on the monitoring list for months. The care plan acknowledged wandering behaviors but the assessment system didn't capture the resident's actual risk level.
For Resident #7, the documentation failures were more extensive. Staff documented exit-seeking behavior in January but never updated the risk assessment. When the resident actually eloped in March, staff still failed to revise the assessment to reflect this dramatic escalation in wandering risk.
The incomplete assessments meant the facility couldn't properly monitor residents who had demonstrated wandering behaviors or actual escape attempts. Without accurate risk scores, staff couldn't implement appropriate safety measures or surveillance levels.
Inspectors discovered these problems during a complaint investigation in November. The facility's own incident report documented Resident #7's elopement, but staff never translated that information into updated risk assessments or safety protocols.
The wandering risk assessment is designed to identify residents who might attempt to leave the facility unsupervised. Accurate scoring helps determine which residents need electronic monitoring devices, increased observation, or other safety interventions.
When assessments remain incomplete or inaccurate for months, residents face increased risk of injury from falls, exposure, or getting lost outside the facility. The documentation failures also prevent staff from tracking changes in residents' cognitive status or mobility that might affect their likelihood of wandering.
Federal inspectors found minimal harm to residents but noted the potential for actual harm from the assessment failures. The facility received citations for failing to maintain medical records according to accepted professional standards.
The inspection revealed a pattern of missed deadlines and incomplete documentation that left vulnerable residents without appropriate safety monitoring for extended periods.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Levindale Hebrew Ger Ctr & Hsp from 2025-11-18 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 24, 2026 · Our methodology
LEVINDALE HEBREW GER CTR & HSP in BALTIMORE, MD was cited for abuse-related violations during a health inspection on November 18, 2025.
Resident #5 received a wandering risk assessment in June that produced a high-risk score of 13.
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.