St. Elizabeth Rehab: Fall Causes Actual Harm - MD
The inspection, completed August 29, 2025, was triggered by a complaint. Inspectors cited the facility for failing to protect Resident 7 from a fall that caused actual harm, the most serious category of harm short of immediate jeopardy on the federal scale. CMS uses that designation when an injury has already occurred, not merely when one was possible.
The fall happened on or before August 28. What inspectors found when they dug into the facility's own paperwork made the lapse harder to explain away.
St. Elizabeth had a written policy on wheelchair transport. It was specific. When staff pushed a resident in a wheelchair, leg rests and footplates were to be in place, with both feet supported. The stated purpose was to prevent dragging, injury, or entrapment. The policy existed. Staff knew it existed. Resident 7 was hurt anyway.
At the exit conference on August 28 at 12:30 in the afternoon, the administrator handed the surveyor two documents: the wheelchair leg rest policy and a plan of correction. The policy was clear. The plan of correction was incomplete.
That detail, buried near the end of the inspection report, carries weight. A plan of correction is the facility's formal written response to a cited deficiency. It is supposed to identify what went wrong, what will be done to fix it, and when. Handing inspectors an unfinished one at the close of an investigation into a resident injury is not a paperwork problem. It is a signal about how seriously the facility took what happened.
The inspection report does not describe the nature of Resident 7's injuries beyond the finding of actual harm. It does not say whether the resident's feet were dragging at the time of the fall, whether a footplate was missing or simply not secured, or whether the staff member pushing the wheelchair was trained on the policy. Those details were not disclosed in the portion of the report available.
What the report does establish is the sequence: a resident was transported in a wheelchair, something went wrong, the resident was hurt, and the facility's own written safety standard was not followed.
Wheelchair-related falls and injuries in nursing homes are among the more preventable categories of resident harm. Footplates and leg rests exist precisely because unsupported feet can catch on flooring, drag, or become trapped during movement. A facility that writes a policy acknowledging those risks and then fails to enforce it has documented its own awareness of the danger.
The deficiency was cited under F0689, the federal tag covering the requirement that facilities keep residents free from accidents that could reasonably be prevented. The level of harm was marked actual, meaning inspectors concluded the fall caused Resident 7 real injury, not a near-miss.
St. Elizabeth Rehabilitation & Nursing Center operates at 3320 Benson Avenue in Baltimore. The complaint inspection was completed August 29, 2025.
Resident 7 was described only as one of a few residents affected by the deficiency. The report does not give an age, a diagnosis, or a name. It does not say whether Resident 7 was at the facility for short-term rehabilitation or long-term care, or whether the injury required hospitalization.
What it says is that the resident was harmed, that the harm was real, and that when inspectors sat down with the administrator at the end of the inspection day, the paperwork meant to show the facility understood what happened and intended to fix it was not complete.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St. Elizabeth Rehabilitation & Nursing Center from 2025-08-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 27, 2026 · Our methodology
ST. ELIZABETH REHABILITATION & NURSING CENTER in BALTIMORE, MD was cited for violations during a health inspection on August 29, 2025.
The inspection, completed August 29, 2025, was triggered by a complaint.
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.