St. Elizabeth Rehab: Fall Unreported, Hip Fracture - MD
The incident at St. Elizabeth Rehabilitation & Nursing Center on August 23, 2024 went unreported until the resident was rushed to the hospital on August 26 with a broken hip that needed surgical repair.
Staff member #13 lowered Resident #21 to the floor that Friday, then assessed him and put him back to bed. She never filed an incident report or notified his family, according to federal inspection records.
The resident's daughter arrived for a visit and immediately noticed something was wrong. Her father was slumped to the left side of his wheelchair, and his left ankle was swollen.
Knowing her father had a history of blood clots, she requested that staff check for clots and X-ray his ankle. The facility ordered a venous doppler and ankle X-ray on Sunday, August 25.
The results showed the same mild degenerative changes as previous scans. But by Monday, August 26, the resident couldn't stand or put any weight on his foot.
Staff called 911 and sent him to the hospital, where doctors discovered a left hip fracture. Surgeons repaired the break, and he was returned to the nursing home.
His daughter learned about the fall only when she accompanied him to the hospital on August 26 — three full days after it happened.
The director of nursing and administrator questioned Staff #13 about what happened on August 23. She told them she had lowered the resident to the floor, so she didn't consider it a fall requiring documentation or family notification.
Federal regulations require nursing homes to immediately notify residents' families when injuries occur. The facility violated this rule by failing to report the incident that led to a hip fracture requiring surgical intervention.
Staff #13 received counseling on September 5, 2024 about the importance of reporting all incidents, according to inspection records.
The case illustrates how semantic distinctions can mask serious safety lapses in nursing homes. Whether described as "lowering to the floor" or "falling," the resident ended up on the ground and sustained an injury that required hospitalization and surgery.
Hip fractures in elderly residents often signal significant trauma and carry serious health risks. The three-day delay in proper medical evaluation potentially complicated the resident's treatment and recovery.
The daughter's medical knowledge about her father's blood clot history proved crucial in getting him appropriate care. Her insistence on diagnostic testing revealed the extent of his injuries when facility staff had missed the hip fracture.
The inspection found the facility failed to follow notification requirements for one resident during the complaint survey. Federal inspectors classified the violation as causing minimal harm or potential for actual harm to few residents.
St. Elizabeth Rehabilitation & Nursing Center operates at 3320 Benson Avenue in Baltimore. The complaint-driven inspection was completed on August 29, 2025.
The case demonstrates how reporting failures can leave families uninformed about their loved ones' medical emergencies. The resident's daughter discovered her father's serious injury through her own observation during a routine visit, not through proper facility communication.
Staff #13's distinction between "lowering" and "falling" created a dangerous gap in the facility's incident reporting system. The semantic difference had real consequences: a delayed diagnosis, emergency hospitalization, and surgical intervention that might have been avoided with immediate proper assessment.
The resident ultimately returned to St. Elizabeth after hip fracture repair, but the family's trust in the facility's communication practices had been fundamentally undermined by the three-day silence about a serious injury.
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: 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 20, 2026 · Our methodology
ST. ELIZABETH REHABILITATION & NURSING CENTER in BALTIMORE, MD was cited for violations during a health inspection on August 29, 2025.
Staff member #13 lowered Resident #21 to the floor that Friday, then assessed him and put him back to bed.
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.