St. Elizabeth Rehab: PEG Tube Care Order Missing - MD
The resident, identified in inspection records only as Resident 5, had a percutaneous endoscopic gastrostomy tube, commonly called a PEG tube. The device is inserted directly through the abdominal wall into the stomach and used when a person cannot eat or swallow safely on their own. Proper care of the tube site, including how it is cleaned and monitored, requires specific medical direction.
No such direction existed in Resident 5's chart.
Inspectors reviewed the resident's Treatment Administration Record, the document nursing staff use to track and carry out ordered treatments at the bedside. The PEG tube care was not backed by a physician order.
A nurse on the third floor confirmed it. Staff identified in the report as Staff 17, the third floor nurse manager, reviewed Resident 5's medical record with inspectors during an interview at 9:53 in the morning and confirmed what they had found. There was no physician order for the PEG tube care. There should have been one.
The finding was classified at a harm level of minimal harm or potential for actual harm, a designation that means inspectors did not document that the lapse had caused injury to Resident 5 but concluded the conditions created a realistic risk that harm could occur. The inspection report notes that some residents were affected, a category that indicates the problem was not isolated to a single chart or a single moment.
At 2:00 in the afternoon on the same day, inspectors notified the facility's administrator, director of nursing, and a corporate administrator of what they had found.
PEG tubes are not routine equipment. They are placed in people who cannot maintain nutrition or hydration by mouth, often because of stroke, advanced neurological disease, or serious illness that has compromised swallowing. The tube site itself requires regular attention. Without documented physician guidance, the staff member changing a dressing or flushing a tube has no formal order defining what to do, how often to do it, or what to watch for.
The inspection was triggered by a complaint, not a routine survey cycle. That means someone, a resident, a family member, or a staff member, contacted authorities with a concern serious enough to prompt investigators to come to the facility.
St. Elizabeth Rehabilitation and Nursing Center sits on Benson Avenue in the southwestern corner of Baltimore. The facility carries the CMS provider identification number 215044.
The inspection report does not describe how long Resident 5 had been without a physician order for PEG tube care, or how many other residents may have been affected by similar gaps. It does not say whether the missing order was an isolated documentation failure or part of a broader pattern in how the facility managed treatment records. Those questions were not answered in the pages made available.
What the record does show is that on the morning of August 29, a nurse manager sat with inspectors, looked at a resident's chart, and confirmed that the care being delivered to a person dependent on a surgically placed feeding tube was not backed by a doctor's order. The administrator and director of nursing were told that afternoon.
Resident 5 remained in the facility.
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 28, 2026 · Our methodology
ST. ELIZABETH REHABILITATION & NURSING CENTER in BALTIMORE, MD was cited for violations during a health inspection on August 29, 2025.
The resident, identified in inspection records only as Resident 5, had a percutaneous endoscopic gastrostomy tube, commonly called a PEG tube.
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.