St. Elizabeth Rehab: Resident Left Unchanged for Days - MD
The resident, who requires assistance with bowel and bladder incontinence, went unchanged on consecutive days throughout June, July, and August 2025, according to the facility's own documentation reviewed by federal inspectors on August 29.
In June alone, nursing staff failed to change the resident during 22 separate shifts. Day shift workers missed changing the resident on June 2, 7, 8, 9, 16, and 22. Evening shift staff failed to provide care on 15 different days, including five consecutive days from June 1 through 5. Night shift workers left the resident unchanged on 10 occasions, including consecutive nights.
The pattern continued into July. Day shift staff missed four days, including July 4, 14, 25, and 28. Evening shift workers failed to change the resident on July 2, 5, 14, and 30.
August brought no improvement. Documentation showed day shift staff failed to change the resident on August 5, 6, 7, and 27.
The facility tracks this basic care through what it calls a "GNA Kardex," a record of what nursing assistants are supposed to do for each resident. The Kardex showed a clear pattern of missed care spanning multiple shifts and months.
When inspectors toured the third floor at 10:30 AM on August 27, they found the hallway area smelled of urine. The resident in one room complained directly to inspectors about not being changed and having to wait long periods for someone to help.
Federal inspectors interviewed the Director of Nursing and the Administrator together on August 27. The Director of Nursing blamed agency nursing assistants, claiming they "were not aware of where to sign off on the record that care was completed."
The Administrator remained silent during the interview.
The inspection began after the facility received a complaint about the resident not being changed regularly. Federal investigators found the complaint was substantiated when they reviewed three months of nursing documentation.
Basic hygiene care represents one of the most fundamental responsibilities in nursing home care. Residents who cannot change themselves depend entirely on staff to maintain their dignity and prevent health complications from prolonged exposure to waste.
The facility's own records painted a picture of systematic neglect. The documentation showed not isolated incidents, but a sustained pattern where an incontinent resident was left in soiled conditions across multiple shifts and months.
During the June period alone, evening shift staff failed to change the resident on nearly half the days of the month. The consecutive days without changes suggest the resident endured extended periods in soiled conditions.
Federal regulations require nursing homes to ensure residents don't lose their ability to perform activities of daily living unless there's a medical reason. For residents who already cannot manage their own hygiene, facilities must provide that care consistently.
The inspection found the facility failed this basic standard. The resident's complaint about irregular changes was supported by the facility's own documentation showing dozens of missed care instances.
The Director of Nursing's explanation that agency staff didn't know where to document care suggests a training failure. But the documentation system was working well enough to record when care wasn't provided, indicating staff knew how to use the records.
The smell of urine in the hallway during the inspector's tour suggested the problem extended beyond documentation. Physical evidence supported the resident complaints and record review findings.
The Administrator's silence during the interview with federal inspectors offered no explanation for how the facility planned to address the documented care failures.
St. Elizabeth Rehabilitation & Nursing Center received a citation for failing to ensure residents maintain their ability to perform activities of daily living. The violation was classified as causing minimal harm or potential for actual harm.
The resident who complained about not being changed regularly had medical records confirming incontinence of both bowel and bladder, making regular changes essential for health and dignity.
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.
In June alone, nursing staff failed to change the resident during 22 separate shifts.
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.