Staff member 47 admitted during a December 30 interview that she knew Resident 1 had recently eloped from the facility.
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The most serious lapses involved Xifaxan, an expensive medication used to treat bacterial infections and hepatic encephalopathy.
Resident #7 had lived at the Baltimore facility since October 2025 with a diagnosis of dementia with behavioral disturbance.
The December 17 incident involving Resident #25 was reported to the administrator the same day.
Resident 6 entered the facility with Parkinson's disease, dementia, and major depressive disorder.
The resident left the facility at 5:36 PM on December 27, according to security video.
This classification suggests the documentation failures affected a limited number of residents rather than representing a systemic facility-wide problem.
The December 31 incident involved Resident 20, who has spastic movements he cannot control.
The resident arrived at the facility on December 10.
Investigators assigned a severity rating of Level G, indicating isolated instances that caused actual harm to residents.
This classification signals to regulators that the problems were widespread enough to affect multiple residents or multiple aspects of the protective system.
Resident #1 consistently refused care from S8CNA, his assigned nursing assistant, because of their prior relationship outside the facility.