In his prime, Ellsworth Johnson-Bey was one of Baltimore’s strongest voices for criminal justice reform.

People remember him speaking out – at City Hall and the Statehouse, at academic conferences, public school meetings and on his AM radio show – about how best to support marginalized youth and those who, like him, had once been incarcerated.

“He changed his life, and he helped hundreds of ex-felons do the same. They really looked up to him,” said former Baltimore Mayor Jack Young. “He was like their Martin Luther King.”

The founder of the Fraternal Order of Ex-Offenders (FOXO), “Brother Bey,” as he was universally known, could be blunt and forceful, according to Young.

“He’d tell us elected officials we need to do more and actually spend some money to help these people he cared so much about.”

“He was smart,” Young remembered, “and he had a way with words.”

But his daughter recalls hearing only distress in his voice when she got a call last year from a staffer at the post-acute care facility in northeast Baltimore where Johnson-Bey was living.

Her father had fallen down, and they were taking him to the emergency room.

“I heard him in the background, saying, ‘Get off me! What’s going on?’ He was upset. I could tell he was in bad pain,” the daughter said. “That’s the last time I ever heard him speak.”

“How did this happen?’” she asked the staffer about his injury. “They didn’t have an answer.”

When she got to the hospital and saw her father suffering with a broken hip, she was devastated. “I felt so hurt for him, I was in tears.”

Caught on Video

It was not until days later that the facility’s acting director of nursing and an administrator called to say Johnson-Bey had been pushed down by a geriatric nursing assistant (GNA) in an incident caught on video.

It started as a tussle over a box of rubber gloves and ended with him dropping to the floor.

Brother Bey never walked again and, after a prolonged hospital stay following the fall, was unable to speak coherently.

He no longer prowled the halls, made phone calls or played chess. He soon couldn’t recognize family members or hold a spoon and eat on his own.

Johnson-Bey died about four months later in the emergency room at another hospital. He was 75.

His daughter was reluctant to talk to The Brew about what happened to her father at Autumn Lake Post Acute Care Center, at 5009 Frankford Avenue, in part because the case is now a criminal matter:

Last January, Baltimore Police arrested Obiageriaku Jane Iheanacho, 36, and charged her with causing Johnson-Bey’s fall on May 15, 2022 and his later death.

Police had in hand a ruling, made days earlier by the Office of the Chief Medical Examiner, that Johnson-Bey’s death was a homicide caused by “blunt force trauma.”

Iheanacho remains at Central Booking on charges of second-degree murder, first-degree assault and vulnerable adult abuse leading to physical injury.

Her case is set for a preliminary hearing today.

UPDATE 8/21/23 – Lawyers in the case told Circuit Court Judge Melissa M. Phinn today that they were working on a resolution. They were scheduled to come back to court on September 18 at 9:30 a.m. in Room 203 before Judge Jennifer B. Schiffer.

UPDATE – On 9/18/23, Care facility staffer pleads guilty to first-degree assault in death of Ellsworth Johnson-Bey

“I trusted them”

Autumn Lake Healthcare, a New Jersey-based company that operates the care facility and 53 other nursing homes and long-term care facilities, most of them in Maryland, was asked for comment on the case.

The company’s position is that it is not to blame for what happened to Johnson-Bey.

“The geriatric nurses’ aide involved was an agency employee who covered a small number of shifts at Autumn Lake Healthcare Post Acute Care Center,” the company’s local spokesman, Rick Abbruzzese, said in an email.

“This individual was licensed through the Maryland Board of Nursing and had a clean background check and received employee training,” Abbruzzese wrote.

“The geriatric nurses’ aide involved was an agency employee who covered a small number of shifts”  – Rick Abbruzzese, spokesman for Autumn Lake Healthcare.

Johnson-Bey’s daughter, who has retained a lawyer, disagrees.

While she and other family members are waiting to see how the criminal case plays out, she had a quick answer when asked if the company that runs the facility where her father was injured bears some responsibility.

“I entrusted my father to Autumn Lake. I trusted them to take care of him,” she said, speaking to The Brew from her lawyer’s downtown office.

“Whatever internal process is needed in order to do that, it’s on them,” she continued. “Regardless of what they say, it happened under their care on their watch.”

The company’s stance is untenable, John R. Roche, her attorney, says.

“It sounds like they are attempting to wash their hands and step away,” Roche said. “But there are legal doctrines that will, as the facts play out, make that not really possible for them to do.”

“Striking him repeatedly”

Iheanacho’s lawyer, Gabriel Christian, has not returned the Brew’s calls requesting comment. Her employer at the time, Eshyft Nursing agency of Howell N.J. also has not returned a request for comment.

However the case plays out – in a civil suit, a criminal proceeding or both – the video taken by a security camera at the Autumn Lake facility will likely be a central piece of evidence.

It was viewed by the police officer who responded three days later when the facility alerted BPD to what had happened.

And it was viewed earlier this year by the Maryland Office of Health Care Quality (OHCQ), which monitors health care facilities and community-based programs.

The office conducts certification surveys and investigates complaints on behalf of the Centers for Medicare and Medicaid Services (CMS) to determine compliance with state and federal standards.

This is how the office’s surveyors, in a March 21, 2023 report, described what they saw on the video:

“GNA was observed walking toward Resident with several other residents in the hallway. GNA walked toward Resident and attempted to take plastic gloves from Resident’s hands. Resident moved away from GNA as she attempted to remove the plastic gloves from the resident’s hands.

GNA then moved aggressively toward Resident, pushing and striking him repeatedly. Resident tried to avoid GNA punches by backing up toward a wall. But as resident hits the wall, he falls on their left side, while the jacket he was wearing fell from his shoulders.

GNA continued to repeatedly strike Resident while the resident fell. GNA then picked up Resident’s jacket, throws it at him and walks away from the incident location.

Iheanacho described the incident very differently, according to the self-reporting form Autumn Lake submitted to the state.

Iheanacho told her employer that Johnson-Bey “was attempting to hit her when he lost his balance and fell.” The report also noted that the “resident has care plan addressing physical aggression toward staff.”

Iheanacho was placed on the “do not return” list, and the nursing agency and the Maryland Board of Nursing were notified, along with police, Autumn Lake said.

Johnson-Bey had been admitted to the facility in October 2021 with a diagnosis of dementia, liver disease and other conditions, but was able to walk.

“Immediate jeopardy”

In March 2023, Maryland Health Department officials who reviewed Johnson-Bey’s fall and injury determined that the facility had “failed to protect a resident from physical abuse from facility staff members, which resulted in an Immediate Jeopardy.”

After going through documents and interviewing staff, the OHCQ officials also determined that Autumn Lake had quickly come into compliance – within weeks of the May 2022 mishap – by instituting a “plan of correction” related to abuse.

A number of measures were to be instituted. For example, current staff were to be educated “on residents’ rights” and new staff “provided education upon hire.”

“The OHCQ reviewed and accepted the nursing home’s plan to correct these practices,” spokesman Chase Cook told The Brew.

A $23,989 penalty was imposed on Autumn Lake. By the time of the March 21, 2023 report, Johnson-Bey’s fall was classified as “past non-compliance.”

During February and March visits leading up to that report, however, the state surveyors found continued deficiencies related to abuse at Autumn Lake, the very issue the plan was designed to address.

“The facility fails to monitor its practices around abuse. . . and had repeat deficiencies for abuse prevention, abuse reporting and abuse investigation after submitting a plan of correction,” the report said.

It cited specific incidents, including a resident who was pushed from a wheelchair by a GNA and suffered a hematoma to the forehead.

In another case, a resident “threatened staff and hit another resident.”

“You really have to be trained that you don’t beat people? It’s pretty egregious what happened there”  – Attorney Toby Edelman, Center for Medicare Advocacy.

Toby S. Edelman, senior policy attorney with the Center for Medicare Advocacy, was asked by The Brew to review the report and another completed after a June 2023 revisit.

“Yes, they called it ‘immediate jeopardy,’ but it was also called ‘past non-compliance,’ which means there’s no requirement to do anything specifically about that,” she said, noting that the surveyors found subsequent abuse-related deficiencies, essentially “the same issue.”

“You really have to be trained that you don’t beat people? It’s pretty egregious what happened there,” she stated.

Problems Persist

Attorney Edelman flatly rejected the idea that Autumn Lake is not accountable for what happened to Johnson-Bey.

“The facilities’ answer to everything is ‘we fired the aide, we fired that person,’ but that’s not really sufficient,” she continued. “They’re certainly responsible for anybody in the facility who is providing care. Absolutely.”

Edelman, who has been representing older people in long-term care facilities since 1977, said she was struck by how the fall is cited as a “Level E” incident, meaning it’s “a no-harm deficiency,” in the March report.

Minimizing serious issues is a problem with regulation of care facilities nationally, she said.

“Jeopardy and harm are only cited in 4% to 6% of deficiencies, and everything else is ‘no harm.’ How can that be? Think what happened to this man and they called it no harm?” she asked.

“Dark brown stains” were noted on privacy curtains in four residents’ rooms by the March 2023 OHCQ inspection report of the Autumn Lake facility.

Other deficiencies cited in the March report involved incorrect care plans, dirt-filled cracks in the floors, broken chairs and “dark brown stains” in multiple resident rooms and bathrooms on the floors and ceiling tiles.

Many of these same problems were apparent on a June 2023 revisit. The facility “failed to provide and maintain a safe, clean and home-like environment for the residents” in “4 of 4 nursing units, and 2 of 2 elevators,” surveyors said.

Missing tiles in shower stalls, brown-stained ceiling tiles, an inaccurate care plan for a dementia patient and a missing pull cord for a bathroom call bell were among the issues identified.

As with both reports, there was a plan of correction – described as “the center’s credible allegation of compliance” – and a subsequent handwritten “completion date,” 7//5/23, was noted.

A Determined Daughter

After Johnson-Bey had been stabilized following his fall, Johns Hopkins Hospital was ready to discharge him. His daughter had to figure out where to move him next.

The family had originally placed him at the Autumn Lake facility because it had a secure dementia floor. But now in a worse condition after his broken hip, the 75-year-old needed “post acute care” even more.

After an agonizing search, they ended up sending back to the same Autumn Lake facility on Frankford Avenue where the fall had taken place.

“It was the only available post-acute care bed we could find in the city,” his daughter said. She thought it would be safer there after she had reported the incident to the state and the Maryland Board of Nursing. “I figured, all eyes would be on this place.”

At Good Samaritan Hospital, where Johnson-Bey was taken by ambulance from Autumn Lake and where he eventually died, his daughter spoke to one of the doctors.

She explained the incident with the nursing aide. The physician decided to request an autopsy.

As Edelman sees it, the existence of the video, and the daughter’s comments, leading to the autopsy, are the only reason that criminal charges were filed.

“If it hadn’t been on that video, no no one would know. They would have denied it,” she said, adding that families have been pushing in Annapolis – so far without success – for the right to put cameras in residents’ rooms.

Family members are still gathering information, some of it disturbing and unpleasant, about the care their loved one received, Johnson-Bey’s daughter said.

Meanwhile, she hopes the public can remember the positive details about her father’s life: the students he mentored, the lives he helped turn around, the policies he changed and the recognition he received.

At the 2013 NAACP Baltimore Freedom Fighter Award Breakfast, for instance, he was lauded for his work right alongside Kweisi Mfume and retired Circuit Court Judge Wanda K. Heard.

“It’s like we didn’t just lose him. The whole community lost him,” the daughter said.

• To reach a reporter: fern.shen@baltimorebrew.com

– Laura Fay also contributed to this story.