St. Elizabeth Rehab: Care Plan Failures Flagged - MD
The inspection, completed August 29, 2025, was triggered by a complaint. What inspectors found when they arrived were two residents whose care plans had failed them in different ways, both pointing to the same underlying problem: the documents meant to direct their daily care did not reflect what those residents actually needed.
The first resident, identified in the report as Resident 5, was on NPO status, a clinical designation meaning nothing by mouth. The designation exists for a reason. Patients placed on NPO restrictions typically face serious swallowing disorders or other conditions that make eating or drinking dangerous, sometimes fatally so. The restriction is not a minor notation. It is a safety boundary.
But the care plan for Resident 5 did not say that.
What it did say, under the section for Activities of Daily Living, was that the resident was "totally dependent on staff for eating." That entry, read by a staff member unfamiliar with the resident's condition, could reasonably be understood as an instruction to assist with feeding. The care plan also noted, under personal hygiene, that the resident "requires assistance by staff with personal hygiene and oral care." It did not specify what kind of oral care was appropriate for someone who could not safely have anything introduced into their mouth. It did not reference Speech Therapy, which was apparently involved in managing the resident's oral status. It did not draw any line between the care a typical resident might receive and the care this specific resident required.
A staff member following that care plan as written would have no way of knowing the difference.
The care plan for a resident on NPO status is supposed to be the safeguard that bridges the gap between what a physician or therapist has ordered and what the aide or nurse actually does at the bedside. When that document is incomplete, the safeguard disappears. What remains is whatever a staff member happens to know, or happens to remember, or happens to ask about on a given shift. That is not a system. That is chance.
Inspectors raised these concerns with the facility's Administrator, Corporate Administrator, and Director of Nursing on August 29, 2025, at 2:00 in the afternoon.
The second finding emerged from a separate thread of the same inspection. On August 27, 2025, inspectors were reviewing an allegation of abuse involving a resident identified as Resident 2. The abuse allegation itself is not detailed in the portion of the report available, but what the review uncovered alongside it was notable on its own terms: Resident 2 had no care plan addressing their psychiatric diagnoses or the interventions needed to manage them.
The report does not specify what those diagnoses were. It does not describe what interventions were missing. What it states plainly is that no care plan had been established for the resident's psychiatric needs, and that this gap was discovered in the context of an abuse investigation.
That context matters. Residents with psychiatric diagnoses in nursing home settings are among the most vulnerable to mistreatment, both because of the nature of their conditions and because of how those conditions can affect their ability to report what happens to them or to be believed when they do. A care plan that identifies a resident's psychiatric diagnoses, documents their behavioral patterns, and outlines specific staff interventions is a tool for protecting that resident. It tells staff what to expect, how to respond, and what approaches are most likely to keep the resident safe and stable. Without it, staff are left to improvise.
The findings were reviewed with the facility's Director of Nursing and Nursing Home Administrator on August 29.
St. Elizabeth Rehabilitation and Nursing Center is located at 3320 Benson Avenue in Baltimore. The inspection was conducted under CMS survey event ID 215044.
Both deficiencies were cited under F0656, which covers the requirement that facilities develop and implement comprehensive, person-centered care plans for each resident. The level of harm was assessed as minimal harm or potential for actual harm, the lower end of the harm scale used by CMS. That designation reflects what inspectors could document, not necessarily what was risked on every shift between the time these care plans were written and the day the inspectors walked in.
Care plan failures of this kind are not dramatic in the way that physical abuse or medication overdoses are dramatic. They do not produce a single, identifiable moment of harm that can be pointed to and described. What they produce instead is a sustained period during which the protections that are supposed to exist simply do not, and during which any staff member relying on those documents to do their job correctly is working without the information they need.
For Resident 5, that meant a document that described them as needing help with eating and oral care, with no indication that the nature of that help was fundamentally different from what any other resident might receive. It meant that Speech Therapy's role in managing the resident's oral status existed somewhere in the facility's records but not in the document that follows the resident from shift to shift.
For Resident 2, it meant that whatever psychiatric history, behavioral patterns, and clinical needs they brought to that facility had not been translated into the written plan that staff are supposed to consult when they do not know what else to do.
The administrator, corporate administrator, and director of nursing were all present when these findings were shared. All three were made aware at the same time, in the same meeting, on the same afternoon. The care plans had not been corrected before that conversation happened.
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 inspection, completed August 29, 2025, was triggered by 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.