Levindale Hebrew Ger Ctr & Hsp

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

On 11/17/25 at 2:12 PM, the surveyor observed that Resident #10's catheter bag containing yellow liquid was again uncovered and visible from the hallway. At 2:17 PM, Staff #9, who stated they were covering the resident at that time, was alerted to the dignity concern and acknowledged the uncovered Foley bag.

The administrator was made aware of the resident dignity concerns during an interview on 11/18/25 at 2:30pm.

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Levindale Hebrew Ger Ctr & Hsp

2434 West Belvedere Avenue Baltimore, MD 21215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578

with.

Level of Harm - Minimal harm or potential for actual harm

On 11/18/25 at 2:23PM the surveyor shared concerns with the facility Administrator and DON.

Residents Affected - Few

On 11/20/25 at 10:15AM the surveyor conducted an interview with Ombudsman #25 who reported that previously, SWD #24 had informed them that s/he was the social worker.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Levindale Hebrew Ger Ctr & Hsp

2434 West Belvedere Avenue Baltimore, MD 21215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on record review and interview, it was determined that the facility failed to ensure an allegation of abuse was reported immediately, but not later than two hours, to the State Survey Agency. This deficient practice was evident for 1 of 5 facility reported incidents reviewed.The findings include:

On 11/14/25 at 11:27 AM, a review of the facility's incident report documentation revealed that staff were notified of an allegation of abuse on 8/15/25 at 8:40 AM. The administrator was notified at 9:54 AM the same morning. The initial report to the Office of Health Care Quality (OHCQ) was documented as being made on 8/15/25 at approx. 12 PM, more than two hours after staff were first made aware of the allegation.

During an interview with the Director of Nursing (DON) on 11/14/25 at 12:50 PM, she was made aware that

the allegation had not been reported within the required two-hour time frame and she stated that she would check the submission record and follow up. At 1:05 PM, the DON returned and confirmed that the report had been submitted late.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Levindale Hebrew Ger Ctr & Hsp

2434 West Belvedere Avenue Baltimore, MD 21215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based on review of a Facility Reported Incident (FRI), record review, and interview with staff, it was determined that the facility failed to maintain documentation of a thorough investigation. This was evident for 1(#329731) out of 5 FRI's reviewed during the complaint survey. The findings include:During a review of FRI #329731 and the facility's investigative file on 11/13/2025 at 10:50AM, the Surveyor discovered that on 6/17/2025 at approximately 3:55PM, Resident #7 eloped. An elopement alert, code grey, was initiated over

the loudspeaker at about 4:15PM and full sweep of the facility and surrounding areas were searched.

Campus security was immediately notified. At about 4:30PM, the police and transit authority were notified.

Resident representative notified. The resident returned to the facility at approximately 6:25PM.A review of

the Facility Reported Incidents Follow-Up Investigation Report revealed the facility verified the elopement in

the conclusion by stating [Resident #7] did leave the facility but was found shortly after. The facility failed to include the circumstance leading up to the resident's elopement, how the facility determined how the resident exited the facility, and how, when, and where the resident was found. Corrective actions were limited to patient was placed on a1:1 sitter.An additional review of the investigative file revealed a Nurses Note dated 6/17/2025 at 6:48PM with the nurse's depiction of the incident stating that the resident was located by police at 6:15PM and escorted back to the facility. A Behavioral note written by Unit Manager (UM) #10 dated 6/17/2025 at 8:33PM with the nurse's depiction of the incident and their involvement in the search for the resident. There was one staff statement, which was unsigned and did not identify the staff member's title. There were no other staff statements or evidence of interviews conducted with staff. There was no evidence of an interview with the resident or any other resident who resided on the unit with Resident #7.During a review of Resident #7's electronic medical record conducted on 11/13/2025 at 11:00AM, the failed to reveal documentation of how the resident was able to exit the unit and the facility.On 11/14/2025 at 11:48AM, during an interview with the Director of Nursing (DON) and the Administrator, the Surveyor expressed the concern that the investigative failed to identify any evidence as to how the facility determined the circumstances of the resident having eloped and how the resident exited the unit and the building. The Surveyor also expressed the concern that the corrective measures implemented, as stated in

the follow up report only included a 1:1 sitter. The DON informed the Surveyor that they reviewed camera footage and were able to determine that Resident #7 was able to elope because a staff member did not ensure the doors were fully closed behind them when they exited the unit. Per film, the resident waited until

the staff member exited HH 5 doors, went to the door, held it open with their foot, and waited until the staff member entered HH 6. The resident then slipped out the door quickly and proceeded to the elevators. Once

on the 1st floor, the resident exited the facility through the double doors to the left of the main entrance doors. The resident caught an MTA bus downtown, where the resident was found by police. Resident #7 returned to the secure unit in HH 5. The facility staff implemented 1:1 sitter for a week and then 1:1 rounding observation sitter for supervision, 7am and 7pm huddle meetings to inform staff of the elopement and increased supervision of the residents at risk for wandering/exit seeking. The staff member was educated to wait for the all unit doors to fully close behind them before walking away, staff continue to receive education on elopement risk resident and identifying exit seeking behaviors. The Surveyor reiterated the concern that this information was not included in the investigative file or in the resident's electronic medical record.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Levindale Hebrew Ger Ctr & Hsp

2434 West Belvedere Avenue Baltimore, MD 21215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interview with staff, it was determined that the facility failed to develop and implement a person-centered care plan for a resident who has eloped. This was evident for 1 (Resident #7) out of 16 residents reviewed for wandering/elopement during the complaint survey. The findings include:A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the Interdisciplinary team after the completion of a comprehensive Minimum Data Set assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility.Elopement is when a person leaves the premises or a safe area without

the facility's knowledge and supervision.On 11/13/2025 at 10:25AM, during a review of Facility Reported Incident #329725 and the facility's investigative file on, the Surveyor discovered that on 3/6/2025 at 3:04PM Resident #7 eloped.A review of Resident #7's electronic medical record on 11/14/2025 at 12:20PM, revealed a Behavior Note dated 5/2/2025 which stated at approximately 9am [Resident #7] followed a staff thru the locked door and went down the elevator towards the front door, [the resident] was brought back to [his/her] room and assessed a WNL, [the resident]was asked not to sit by the door.On 11/13/2025 at 10:50AM, during a review of FRI #329731 and the facility's investigative file the Surveyor discovered that on 6/17/2025 at approximately 3:55PM, Resident #7 eloped again. On 11/14/2025 at 2:30PM, during a review of Resident #7's electronic medical record the Surveyor discovered that the resident had been transferred to the specialty hospital on 8/5/2025 and was readmitted to the facility on [DATE REDACTED]. On 10/30/2025, the facility initiated a care plan with a focus, Resident is at risk for elopement related to Dx of Unspecified dementia with other behavioral disturbance, a goal, [Resident] will not successfully elope from the facility and will have whereabouts monitored on an ongoing basis through the next review date, and Interventions: Wander guard to the left ankle Monitor each shift every shift for Elopement risk (initiated on 10/31/2025), and Monitor [Resident] for tailgating when visitors are on the unit. A review of the care plan failed to identify and reflect that the resident had actual elopements from the facility on 3/6/2025 and 6/17/2025, and an elopement off the secured unit on 5/2/2025, and failed to include resident specific interventions based on identified triggers, enhanced monitoring including behaviors, redirectional activities, wander risk assessments, and the increased need for supervision such as 1:1 rounding supervision as ordered.On 11/17/2025 at 2:28PM during an interview with the DON and the Administrator, the Surveyor was informed that safety measures were put into place when the resident returned from the specialty hospital 10/29/2025. The resident was admitted to the secured nursing unit, a wander guard bracelet was placed on

the resident, and the resident was supervised by staff including a 1:1 non-clinical observation sitter at all times.

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Levindale Hebrew Ger Ctr & Hsp

2434 West Belvedere Avenue Baltimore, MD 21215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interviews, it was determined that the facility failed to revise the care plan to meet the needs of a resident identified as a high wander risk. This is evident for 1 (Resident #5) of 16 residents reviewed for wander/elopement risk.The findings include:

On 11/14/25 at 11:12 AM, a review of the electronic medical record showed that Resident #5 had a Wander Risk Score of 13, with scores above 11 indicating high risk, based on an assessment dated [DATE REDACTED].

Resident #5's care plan, initiated 4/3/25 and revised on 5/1/25, identified the resident as resistive to care and exhibits wandering related to adjustment to nursing home. Despite this high-risk score and documented wandering behaviors, the care plan was not revised to include interventions addressing increased risk and

the need for increased supervision.

During an interview on 11/14/25 at 1:14 PM, the DON and NHA confirmed that Resident #5 was not included on the wander list and that the required quarterly assessment had not been completed since 6/27/25. The concerns with the lack of care plan interventions appropriate to the resident's high Wander Risk score and the lack of revision to the care plan after the assessment on 6/27/25 were brought forward at this time.

On 11/17/25 at 8:29 AM, the overdue wander risk assessment was found to have been completed on 11/14/25, after surveyor identification. Resident #5 now had a Wander Risk Score of 17, indicating a higher risk than on the previous assessment.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Levindale Hebrew Ger Ctr & Hsp

2434 West Belvedere Avenue Baltimore, MD 21215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm

Diet order history of Resident #9 having received only a heart healthy diet from 6/7-7/17/25 with directions written in the order for low sodium, diabetic heart healthy and low fat, and a regular diet from 7/18-7/20/25.

On 11/18/25 at 2:23PM the surveyor shared concerns with the facility Administrator and DON.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Levindale Hebrew Ger Ctr & Hsp

2434 West Belvedere Avenue Baltimore, MD 21215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

representative from the company educated staff on how the WanderGuard electronic system works. All facility residents were reassessed with the Wandering Risk Assessment to confirm who needed a wander guard electronic bracelet. HH 5 and HH 6 are secured units, and the majority of the wandering/exiting seeking residents reside on those units. There have been no other elopements from the facility. After surveyor review, interview, and observation and based on the above actions taken by the facility and verified by the surveyor on-site, it was determined that the facility had corrected the deficient practice by 6/17/2025, prior to the start of the survey.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Levindale Hebrew Ger Ctr & Hsp

2434 West Belvedere Avenue Baltimore, MD 21215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observation and interview it was determined the facility failed to ensure safe storage of medications. This was evident during the surveyor's initial tour of the facility for 1 medication cart on 1 out of 10 nursing units during the facility's complaint survey. The findings include:

During the survey team's initial tour of the facility on 11/13/25 at 7:49AM a medication cart was observed with the metal button protruding outward which indicated the cart was unlocked, and was unattended in the resident hallway. Upon further surveyor observation, all drawers of the cart, containing various medications, was able to be opened by the surveyor. Surveyors attempted to find facility staff to inform of the concern.

Upon informing staff at the nurse's station, Registered Nurse (RN) #3 responded to the surveyor's concern.

At this time surveyors conducted an interview and shared concerns with RN #3 who confirmed they were responsible for the medication cart.

On 11/13/25 at 7:55AM the concern was shared by surveyors with the facility's Director of Nursing who acknowledged understanding of the concern.

On 11/18/25 at 2:23PM the concern was shared with the facility Administrator.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Levindale Hebrew Ger Ctr & Hsp

2434 West Belvedere Avenue Baltimore, MD 21215

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interview with staff, it was determined that the facility failed to maintain medical records

in accordance with accepted professional standards and practices related to residents wander risk status and required assessments. This was evident for 2 (Resident #5 and Resident #7) out of 16 residents reviewed for wandering/elopement during the complaint survey.The findings include:

1. 1. On 11/14/25 at 11:12 AM, review of the electronic medical record for Resident #5 documented a high

wander risk score of 13 from an assessment completed 6/27/25; however, the resident was not included on

the facility's wander list, and there was no quarterly assessment documented after 6/27/25. Review of Resident #5's care plan, documented on 4/3/25 and revised 5/1/25, noted wandering behaviors related to adjustment to the nursing home. The incomplete and inaccurate documentation failed to represent the resident's current risk status and need for monitoring.

At 1:14 PM, the Director of Nursing and the administrator acknowledged that the quarterly wander assessment had been missed and that the resident's risk status was not reflected on the wander list.

On 11/17/25 at 8:29 AM, further review confirmed the wander assessment was completed on 11/14/25,

after surveyor intervention.

2. 2. On 11/13/2025 at 10:00AM, during a review of Resident #7's electronic medical record, the Surveyor

discovered a nursing progress note dated 1/23/2025 at 7:04PM which stated the resident was busy seeking exit and wanted to go to floor 2 and go home.

On 11/13/2025 at 10:25AM, during a review of Facility Reported Incident #329725 and the facility's investigative file on, the Surveyor discovered that on 3/6/2025 at 3:04PM Resident #7 eloped.

A review of Resident #7's Wandering Risk assessment dated [DATE REDACTED] revealed an incomplete assessment with a score of 0. A review of Resident #7's readmission Wandering Risk assessment dated [DATE REDACTED] revealed an incomplete assessment with a score of 0. Scores 0-8 indicate a low risk to wander. According to the Wandering Risk Assessment instructions, the assessment should be completed on admission and readmission, with a change of condition, and annually on all residents.

On 11/13/2025 at 1:15PM, the Surveyor reviewed the Identifying Risk for Patient Wandering and Use of the WanderGuard System policy with an effective date of 11/13/2025. According to the policy, residents will be screened upon admission, whenever there is a change regarding wandering, and quarterly. The facility failed to complete an updated Wandering Risk Assessment that recognized Resident #7's exit seeking behaviors on 1/23/2025 and failed to complete an accurate Wandering Risk Assessment on 4/11/2025 that recognized the resident's elopement on 3/6/2025.

During an interview with the Administrator and the Director of Nursing (DON) on 11/14/2025 at 1:30PM, the Surveyor was informed that all resident will be screened for wandering risk upon admission, quarterly, and as needed. The Surveyor expressed the concern with the accuracy and timeliness of the Wandering Risk Assessments.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet