Levindale Hebrew: Resident Rights Violations - MD
The oversight meant the resident went nearly five months without updated monitoring for wandering behaviors, despite a care plan documenting "wandering behaviors related to adjustment to the nursing home" as recently as May.
Federal inspectors found similar gaps for a second resident who actually escaped the facility in March. That resident had been "busy seeking exit and wanted to go to floor 2 and go home" in January, according to a nursing progress note. Yet staff scored them zero on wandering risk assessments both before and after the March 6 elopement.
A score of zero indicates low risk to wander on the facility's assessment scale, which runs from 0 to 8 for low risk. Resident #5's score of 13 fell well into the high-risk category.
The Director of Nursing and administrator acknowledged during the November inspection that they had missed the quarterly assessment and failed to include the high-risk resident on the wander monitoring list. Staff completed the overdue assessment only after inspectors pointed out the gap.
For the resident who eloped, the documentation failures were more extensive. Inspectors found that staff completed "incomplete" wandering risk assessments that failed to account for clear warning signs documented in the medical record.
The January nursing note specifically recorded the resident "seeking exit" and expressing a desire to leave the facility. Two months later, on March 6 at 3:04 PM, the resident successfully eloped from Levindale Hebrew.
Despite this incident triggering a facility investigation and incident report #329725, staff never updated the resident's wandering risk assessment to reflect the actual elopement or the previously documented exit-seeking behavior.
The facility's own policy, effective November 13, requires screening residents for wandering risk "upon admission, whenever there is a change regarding wandering, and quarterly." The policy specifically mentions using the WanderGuard system to monitor at-risk residents.
Inspectors reviewed 16 residents during their complaint investigation and found documentation failures for two of them. The problems extended beyond simple paperwork delays to fundamental mischaracterization of resident safety risks.
Resident #7's case showed a particularly concerning pattern. After showing clear exit-seeking behavior in January and actually eloping in March, the resident received a readmission wandering assessment that again scored them at zero risk.
The assessment instructions specify that evaluations should occur "on admission and readmission, with a change of condition, and annually on all residents." An elopement would clearly qualify as a change of condition requiring reassessment.
During interviews on November 14, the Administrator and Director of Nursing told inspectors that "all residents will be screened for wandering risk upon admission, quarterly, and as needed." However, the documented practice fell short of this stated policy.
The inspection findings indicate that staff either failed to recognize wandering behaviors documented in medical records or failed to translate that recognition into updated risk assessments and monitoring protocols.
For Resident #5, the disconnect between a high wandering risk score and absence from the facility's wander list meant months without appropriate monitoring. The resident's care plan had identified wandering as an ongoing concern related to nursing home adjustment, yet the formal tracking systems never reflected this documented risk.
The timing of the inspection suggests ongoing problems with wandering risk management. Inspectors conducted their review in November, nearly eight months after Resident #7's elopement and five months after Resident #5's last risk assessment.
Neither resident appeared to suffer physical harm from the documentation failures, according to the inspection report. However, the gaps in risk assessment and monitoring created potential safety vulnerabilities for residents with demonstrated wandering behaviors and exit-seeking tendencies.
The facility completed corrective actions during the inspection period, updating overdue assessments after inspectors identified the deficiencies. However, the underlying system failures that allowed high-risk residents to go unmonitored for months remained a concern for federal surveyors.
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 similar gaps for a second resident who actually escaped the facility in March.
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.