St. Elizabeth Rehab: Grievance Policy Failures - MD
The incident at St. Elizabeth Rehabilitation & Nursing Center occurred during the overnight hours of July 6 into July 7, when a certified nursing assistant identified as GNA #7 failed to provide any activities of daily living for Resident #2, according to federal inspection records.
Resident #2 had been admitted to the facility in June 2025 for therapy and antibiotics. On that July night, the resident put on their call light repeatedly, asking for help to be changed. Nobody came.
The resident's family filed a formal grievance on July 9, three days after the incident. The grievance documented that GNA #7 had failed to provide any care during the night shift.
The facility terminated the employee. But what happened next revealed a deeper problem with how St. Elizabeth handles resident complaints.
When federal inspectors interviewed Resident #2 on August 28, nearly two months after the incident, the resident became tearful. The resident revealed they were still very upset and scared because, according to the resident, there had been no follow-up communication about what happened that night.
The resident didn't know if the nursing assistant who had neglected them was coming back.
"S/he did not know if the GNA that neglected him/her that night was coming back," inspectors wrote in their report.
The facility's Director of Nursing and Nursing Home Administrator told inspectors on August 28 that the DON had followed up with the resident regarding the July 6 incident. But when asked for documentation of that follow-up, she was unable to provide any.
The facility's own grievance policy requires specific steps that weren't followed. According to policy section 10.e, "The grievance official will keep the residents appropriately appraised of progress towards resolution of the grievances."
Section 10.f requires that "the Grievance official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation."
The inspection found no evidence these requirements were met.
Federal regulations require nursing homes to honor residents' right to voice grievances without discrimination or reprisal. Facilities must establish a grievance policy and make prompt efforts to resolve complaints.
But resolving a grievance means more than just firing the offending employee. It means communicating with the resident and family about what happened, what was done, and ensuring the resident feels safe.
The case illustrates how nursing homes can technically address a problem while still failing residents. The facility fired GNA #7 for neglecting Resident #2 during that July night shift. From an administrative perspective, the problem was solved.
From the resident's perspective, nothing was solved. Nearly two months later, the resident remained tearful and frightened, not knowing what had happened to the staff member who had ignored their repeated calls for help.
The resident's fear was reasonable. Without proper communication from the facility, how could they know the neglectful employee was gone? How could they trust that pressing the call light would bring help?
The inspection occurred following a complaint to state health authorities. Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
But for Resident #2, the harm extended far beyond that single night in July. The facility's failure to properly handle the grievance left the resident living in fear of experiencing the same neglect again.
The grievance process exists to give residents and families a formal way to address problems in nursing homes. When facilities fail to properly implement that process, they violate not just federal regulations but residents' fundamental right to feel heard and safe.
St. Elizabeth's handling of this case demonstrates how a facility can take the right administrative action - firing a neglectful employee - while still failing the resident through poor communication and inadequate follow-up.
The resident's tears during the August interview, nearly two months after filing the original grievance, showed the lasting impact of the facility's inadequate response. Fear and uncertainty had replaced what should have been reassurance and resolution.
Federal regulations recognize that nursing home residents are particularly vulnerable. Many depend entirely on staff for basic needs like being changed when soiled. When that care fails, and when the facility's grievance process fails to provide proper resolution, residents are left doubly vulnerable.
Resident #2's experience illustrates why proper grievance handling matters as much as the underlying care. The facility addressed the immediate problem by terminating the neglectful employee. But by failing to properly communicate with the resident about the resolution, they created a new problem - ongoing fear and uncertainty.
The inspection found that St. Elizabeth failed to give adequate responses to grievances, specifically regarding this allegation of neglect. The facility's inability to provide documentation of follow-up with the resident further demonstrated the inadequacy of their grievance process.
For nursing home residents like Resident #2, who depend on staff for basic dignity and care, knowing that problems will be properly addressed and communicated is essential to feeling safe. When that communication fails, residents remain vulnerable long after the original problem has been solved.
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.
Resident #2 had been admitted to the facility in June 2025 for therapy and antibiotics.
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.