St. Elizabeth Rehab: Medical Record Failures - MD
That was the finding when federal inspectors arrived at the facility on August 29, 2025, following a complaint. A review of the electronic medical record for Resident 7 turned up a physician order, dated December 2, 2024, directing physical therapy staff to evaluate the resident's wheelchair and positioning. What the record did not contain was any documentation that the evaluation had been completed.
When inspectors sat down with the Director of Physical Therapy on August 26, he could not confirm or deny that the evaluation had occurred. The information, he said, was not available in the electronic medical record.
That answer, on its own, is the problem.
A rehabilitation and nursing center exists, in part, to manage exactly these kinds of needs. Wheelchair fit and positioning are not minor concerns for a nursing home resident. Poor positioning contributes to pressure injuries, contractures, pain, and reduced mobility. A physician ordered an evaluation because someone believed one was necessary. Whether that evaluation happened, and what it found, and whether anything was done in response, are questions the medical record is supposed to answer. At St. Elizabeth, it answered none of them.
The Director of Nursing confirmed the failure in an interview on August 28. Staff had not maintained Resident 7's medical record in its most complete form. That confirmation came not as a discovery but as an acknowledgment of something inspectors had already documented themselves.
Inspectors cited the facility under F0842, which covers the obligation to safeguard resident-identifiable information and maintain medical records that meet accepted professional standards. The deficiency was tagged at a level of minimal harm or potential for actual harm, affecting few residents. In the formal language of federal inspection reports, that is among the lower tiers of severity.
But the category of harm assessed by inspectors addresses what they could document, not the full range of what the gap might have meant for Resident 7. A physician believed this resident needed a wheelchair and positioning evaluation badly enough to write an order for one. That order sat in the record for more than eight months before anyone outside the facility reviewed it and asked what had happened next. The answer was that no one inside the facility could say.
Medical records in nursing homes serve multiple purposes at once. They guide the clinical team making decisions about a resident's daily care. They document what was ordered, what was done, and what changed over time. They are the mechanism by which a physician's order becomes a completed intervention with a recorded outcome. When that chain breaks, a resident can go months without a needed evaluation, and the people responsible for their care may not know it.
At St. Elizabeth, the chain broke somewhere between the physician's order in December and the inspectors' arrival in August. The Director of Physical Therapy could not locate documentation of the evaluation. The Director of Nursing confirmed the record was incomplete. Neither interview produced an explanation for how an order written by a physician went unresolved, undocumented, or both, for the better part of a year.
The inspection covered two residents selected for medical record review. The documentation failure was identified for one of them.
Resident 7 remains identified only by number in the inspection report. What is known is that their physician believed a wheelchair and positioning evaluation was warranted in December 2024, and that as of late August 2025, there was no documentation in the electronic medical record to show the evaluation had ever been completed, or that anyone had followed up on the order in the months between.
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 26, 2026 · Our methodology
ST. ELIZABETH REHABILITATION & NURSING CENTER in BALTIMORE, MD was cited for violations during a health inspection on August 29, 2025.
That was the finding when federal inspectors arrived at the facility on August 29, 2025, following 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.