Levindale Hebrew: 10 Deficiencies, No Corrections - MD
Resident #7 eloped from the facility on March 6 at 3:04 PM, according to the facility's own incident report. Two months earlier, nursing staff had documented him "busy seeking exit and wanted to go to floor 2 and go home" in a progress note dated January 23.
Despite these clear warning signs, the facility's wandering risk assessments for Resident #7 remained incomplete with scores of zero. Federal inspectors found the assessments were filled out incorrectly both on admission and readmission, failing to capture his actual risk level.
Scores between 0-8 indicate low wandering risk under the facility's assessment tool. But the forms themselves were incomplete, rendering the scores meaningless for a resident who had already demonstrated exit-seeking behavior and successfully left the building.
The facility's own policy, updated November 13 during the inspection, requires wandering assessments on admission, quarterly, and whenever there's a change in wandering behavior. Staff missed multiple opportunities to reassess Resident #7 after documenting his exit-seeking attempts in January and his actual escape in March.
A second resident presented similar documentation failures. Resident #5 scored 13 on a wandering risk assessment completed June 27 — well above the low-risk threshold. The high score should have triggered inclusion on the facility's official wander list and quarterly follow-up assessments.
Neither happened.
The resident remained off the wander list despite the elevated risk score. No quarterly assessment was completed after June, leaving a four-month gap in required monitoring. The resident's care plan, last revised May 1, noted "wandering behaviors related to adjustment to the nursing home" but wasn't updated to reflect the June assessment results.
During interviews November 14, both the Director of Nursing and administrator acknowledged they had missed the quarterly wandering assessment for Resident #5. They confirmed the resident's risk status wasn't reflected on the facility's wander list, despite the documented high-risk score.
The incomplete documentation "failed to represent the resident's current risk status and need for monitoring," inspectors wrote.
Only after inspectors raised concerns did staff complete the overdue wandering assessment for Resident #5 on November 14. The timing — the same day inspectors interviewed facility leadership about the missing assessment — highlighted the gap in routine monitoring.
The documentation failures affected safety protocols designed to prevent dangerous incidents. Wandering assessments help staff identify residents who might attempt to leave the facility unsupervised, triggering additional monitoring and potential use of electronic tracking devices.
For Resident #7, the assessment failures meant his demonstrated exit-seeking behavior and successful escape weren't captured in his official risk profile. Staff conducting routine checks wouldn't have access to this critical safety information through the formal assessment system.
The facility operates a WanderGuard electronic monitoring system, according to policy documents reviewed during the inspection. But the system's effectiveness depends on accurate risk assessments to determine which residents require monitoring devices.
Both residents' cases revealed fundamental breakdowns in the assessment process. Resident #7's situation showed how actual wandering incidents and documented exit-seeking behavior failed to trigger required reassessments. Resident #5's case demonstrated how high-risk scores didn't translate into appropriate monitoring protocols.
The Administrator and Director of Nursing told inspectors that all residents should be screened for wandering risk on admission, quarterly, and as needed. But the documented failures for both residents showed significant gaps between policy and practice.
Inspectors expressed concerns about "the accuracy and timeliness of the Wandering Risk Assessments" during their November 14 interview with facility leadership.
The inspection findings covered assessments spanning from January through November, revealing a pattern of missed evaluations and incomplete documentation rather than isolated incidents. Both residents remained at the facility during the inspection period, with their safety dependent on assessment systems that had already failed to capture their actual wandering risks.
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 violations during a health inspection on November 18, 2025.
Resident #7 eloped from the facility on March 6 at 3:04 PM, according to the facility's own incident report.
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.