St. Elizabeth Rehab: Falsified Care Records - MD
The Assistant Director of Nursing at St. Elizabeth Rehabilitation & Nursing Center discovered Resident #2 in such deplorable condition on July 6 that she photographed the person in their soiled brief before providing care. When she finally changed the resident, she found the person's sacrum was red and excoriated, immediately ordering Calmoseptine barrier cream for treatment.
No skin assessment documenting the sacral excoriation was ever recorded in the resident's medical file.
Federal inspectors reviewing the incident found that Geriatric Nursing Assistant #7 had documented identical care for multiple residents who received no assistance. The aide recorded changing Resident #2, #33, #39, and #40 between 6:51 and 6:59 AM on July 6, using the same codes for each: "1, M, 1" for bowel movements and "NA" for bladder, indicating he had changed each resident who was incontinent of bowel with no urine present.
Investigators established that Resident #2 received no care during this timeframe.
Eight other residents assigned to GNA #7 were marked as "RU" (not available) or "NA" (not applicable) for care between 6:50 and 6:59 AM. All documentation was completed within a nine-minute window despite the aide being responsible for 12 residents total.
The falsification extended beyond a single shift. Records show GNA #7 worked three consecutive overnight shifts from July 4 through July 6, with the same pattern of fraudulent documentation occurring each night.
When federal inspectors interviewed the Director of Nursing and Nursing Home Administrator on August 27, both administrators admitted they were unaware that GNA #7 had marked eight residents as unavailable for care over three consecutive nights. Neither had conducted skin assessments of the affected residents or investigated the scope of neglected care following the incident.
The facility's investigation into the matter proved inadequate on multiple levels.
A separate abuse allegation at the facility revealed similar investigative failures. On May 11, a family member reported that Resident #4 had said "bum, bum, bum," prompting the facility to report suspected abuse to state authorities and police.
The facility collected 11 staff statements during its internal investigation. Nine of those statements failed to identify which date or shift the staff member was addressing, rendering them largely useless for determining what actually occurred.
Nursing schedules showed seven staff members worked on Sarah's Circle, where Resident #4 lived, on May 9 and May 10. None of those seven employees provided statements to investigators.
The unit housed 32 to 33 residents during the relevant timeframe. Investigators conducted abuse interviews with only four residents. No physical assessments were performed on residents who could not be interviewed, despite standard protocols requiring such examinations when abuse is suspected.
Federal inspectors presented these investigative deficiencies to the Administrator, Director of Nursing, and Corporate Administrator during a meeting on August 29.
The inspection findings highlight systemic failures in both direct patient care and administrative oversight. Residents paying for around-the-clock nursing care instead received falsified documentation while sitting in their own waste. When serious incidents occurred, facility leaders failed to conduct thorough investigations that could prevent future harm.
The case of Resident #2 demonstrates the physical consequences of such neglect. Left unchanged for hours in soiled briefs, the person developed painful skin breakdown requiring immediate medical intervention. The Assistant Director of Nursing's decision to photograph the resident's condition suggests the severity was significant enough to warrant documentation.
Yet no formal skin assessment recorded this injury in the resident's medical record, leaving no trail for tracking the wound's healing or preventing similar incidents.
The pattern of fraudulent documentation raises questions about care quality throughout the facility. If one nursing assistant could falsify records for 12 residents over three consecutive nights without detection, similar practices may be occurring with other staff members.
Overnight shifts traditionally operate with reduced supervision, making residents particularly vulnerable to neglect. When nursing assistants document care they never provided, residents may go hours without basic hygiene assistance, medication administration, or safety checks.
The facility's inadequate response to the abuse allegation compounds these concerns. Incomplete staff interviews and limited resident assessments suggest administrators lack the investigative skills necessary to protect vulnerable patients.
Family members entrusting loved ones to professional care expect thorough documentation reflects actual services provided. They rely on facility investigations to uncover problems and implement solutions. When both systems fail, residents bear the consequences through untreated medical conditions and continued exposure to potential harm.
The timing of these incidents, occurring just months apart, indicates ongoing problems with staff supervision and quality assurance. Effective nursing home management requires systems to detect falsified documentation before residents suffer physical harm.
Resident #2's skin excoriation could have been prevented with proper hygiene care. The family member's concern about Resident #4 deserved a comprehensive investigation to determine if abuse occurred. Both situations required immediate administrative attention that the facility failed to provide.
Federal inspectors classified the violations as causing minimal harm with few residents affected. However, the documented cases likely represent a fraction of actual incidents, given the facility's poor investigative practices and lack of oversight systems.
The photographs taken by the Assistant Director of Nursing serve as stark evidence of what happens when documentation systems break down. A resident sitting in waste for hours, developing painful skin breakdown, while official records claim proper care was provided.
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.
The Assistant Director of Nursing at St.
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.