Levindale Hebrew: Care Plan Failures, No Fix - MD
Federal inspectors found the facility failed to maintain accurate medical records for residents at risk of wandering during a November complaint investigation. Two of 16 residents reviewed had incomplete or missing assessments that left their actual risk status undocumented.
Resident #7 had been "busy seeking exit and wanted to go to floor 2 and go home" according to a nursing note from January 23. On March 6 at 3:04 PM, that resident successfully eloped from the facility. Yet the person's wandering risk assessments both before and after the elopement showed scores of zero, indicating low risk to wander.
The facility's own policy requires wandering assessments upon admission, quarterly, and whenever there's a change in condition. Staff completed neither an updated assessment after documenting the January exit-seeking behavior nor an accurate assessment following the March escape.
Resident #5 presented different documentation failures. A June 27 assessment showed a high wandering risk score of 13, but staff never included the resident on the facility's official wander list. The person's care plan from April and May noted "wandering behaviors related to adjustment to the nursing home," yet no quarterly follow-up assessment was completed after June.
When inspectors reviewed the electronic medical record on November 14, they found the high-risk resident had been missing required monitoring for nearly five months.
The Director of Nursing and administrator acknowledged during interviews that quarterly assessments had been missed and risk statuses weren't properly reflected on monitoring lists. Only after inspector intervention was Resident #5's overdue wander assessment finally completed on November 14.
The facility's wandering policy, with an effective date of November 13 — one day before the inspection interview — states residents will be screened upon admission, quarterly, and as needed. According to assessment instructions, scores range from 0-8 for low risk, with higher numbers indicating increased wandering likelihood.
For Resident #7, the assessment failures created a dangerous gap between documented behaviors and safety precautions. The January nursing note clearly identified exit-seeking activity, yet the resident's risk score remained at zero. Two months later, when the person actually left the facility, staff still failed to update the assessment to reflect the successful elopement.
The incomplete documentation meant care teams lacked accurate information about which residents required enhanced monitoring or safety interventions. Wandering and elopement represent serious safety risks in long-term care facilities, particularly for residents with dementia or cognitive impairment who may become disoriented outside the building.
Inspectors noted the facility's investigative file documented the March 6 incident as Facility Reported Incident #329725, but the formal risk assessment process never incorporated this critical safety event.
During the November 14 interview, administrators told inspectors that all residents should be screened for wandering risk upon admission, quarterly, and as needed. However, the inspection findings revealed systematic failures in both timing and accuracy of these required assessments.
The documentation failures affected residents' care plans and safety monitoring protocols. Without accurate risk scores, staff couldn't implement appropriate precautions or determine which residents needed wandering alert devices or increased supervision.
Inspectors expressed concerns about both the accuracy and timeliness of the facility's wandering risk assessments during their interview with leadership. The violations were classified as minimal harm or potential for actual harm, affecting few residents.
The inspection occurred as part of a complaint investigation, suggesting the wandering assessment failures may have been reported by families, staff, or other concerned parties. Federal regulations require nursing homes to maintain medical records according to accepted professional standards, including accurate documentation of residents' safety risks and care needs.
Resident #7's case illustrated the real-world consequences of inadequate documentation — a person who showed clear exit-seeking behaviors and successfully left the facility remained classified as low-risk for wandering throughout the entire sequence of events.
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.
Federal inspectors found the facility failed to maintain accurate medical records for residents at risk of wandering during a November complaint investigation.
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.