St. Elizabeth Rehabilitation & Nursing Center

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Based on record review and interview it was determined the facility staff 1) failed to determine on admission if a resident had an advance directive and provide information about the right to formulate an advance directive; and 2) failed to identify a primary decision-maker for a resident determined not to have decision-making capacity. This was evident for 1 (Resident #5) of 17 residents reviewed for Quality of Care and Treatment during the complaint survey. The findings include:1) Resident #5's medical record was reviewed on 8/25/25 at 12:30 PM. An admission BIMS (Brief Interview of Mental Status) cognitive screening tool dated 5/25/25 revealed Resident #5 score was 14. A score of 13-15 is categorized as cognitively intact.

The admission Record revealed the resident was his/her own Responsible Party. The section of the admission record titled, Advance Directive was blank.No documentation was found in the resident's medical

record to indicate the facility staff determined if Resident #5 had an Advance Directive on admission, that

they informed the resident of his/her right to establish an Advance Directive and provided him/her assistance if he/she wished to establish one.2) The record review also revealed that Resident #5 experienced changes in his/her condition including but not limited to increased confusion. On 8/5/25 2 physicians assessed Resident #5 and certified that s/he lacked the capacity to make informed medical decisions. Further review of the medical record failed to reveal who was responsible for making decisions

on Resident #5's behalf nor how they identified Resident #5's decision maker.On 9/29/25 at 9:20 AM the Surveyor requested all documentation related to Resident #5's Advance Directives and determination of decision maker.On 9/29/25 at 11:10 AM the Administrator indicated that the resident did not bring Advance Directives with him/her on admission. He was made aware of the above concerns and asked to provide evidence that the facility offered the resident an opportunity and assistance to develop advanced directives upon admission and documentation reflecting the determination of a surrogate decision maker for Resident #5.He returned at 1:48 PM on 8/29/25 and indicated that he was unable to find any additional documentation and added that the facility's Social Worker at that time no longer worked in the facility.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Elizabeth Rehabilitation & Nursing Center

3320 Benson Avenue Baltimore, MD 21227

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on medical record and statement from Staff # 13, the facility failed to notify Responsible party after

the Resident fell on 8/23/24. This was evident for 1 (Resident # 21) out of 1 resident reviewed during the complaint survey. Findings include:On 8/23/24 Resident #21 was lowered to the floor by Staff # 13.

Resident #21 was assessed and put back to bed. The Resident's daughter came to visit and noticed he/she was slumped to the left side of wheelchair and left ankle was swollen. Resident # 21 had a history of blood clots and asked that resident be checked for blood clots and have his/her left lower ankle be x-rayed. On 8/25/24 Lower left ankle was x-rayed and venous doppler was done. Results were the same as before, mild degeneration changes done on 8/26/24. On 8/26/24 Resident #21 could not stand or put pressure on his/her foot. The Resident was sent out 911 to hospital on 8/26/24 and noted to have a left hip fracture. The Resident had it repaired and was sent back to facility.The Responsible party was not notified of the fall that occurred until 8/26/24 when she went to the hospital. DON and administrator aware and stated they spoke with Staff # 13 asking about a fall that resident had on 8/23/24. Staff #13 stated she lowered resident to the floor so she did not consider this a fall so she never reported this. Staff was counselled on 9/5/24 on importance of reporting all incidents.

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Elizabeth Rehabilitation & Nursing Center

3320 Benson Avenue Baltimore, MD 21227

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Based on interviews with resident, staff and review of the grievance process it was determined that the facility failed to give adequate responses to grievances presented by a resident/family regarding an allegation of neglect. This was found evident in the review a facility reported incident of neglect that was also a reported grievance from Resident #2 reviewed during the complaint survey.The findings include:A

review of the medical record for Resident #2 on 8/28/25 at 8:25 AM revealed admission to the facility in June of 2025 for therapy and antibiotics. On the nightshift of 7/6/25 into 7/7/25 Resident #2 put on their call-light repeatedly asking for help to be changed out of a soiled brief. According to a grievance form completed by Resident # 2's family on 7/9/25, GNA #7 failed to provide any activities of daily living on the night shift for Resident #2. According to the response and resolution on the form the employee was terminated, however, there is nothing noted that there was follow up with the family or the resident.

Resident #2 was interviewed on 8/28/25 at 8:42 AM. Resident #2 was very tearful and revealed that at that moment s/he was still very upset and scared as according to the resident there was no follow up and s/he did not know if the GNA that neglected him/her that night was coming back. Interview with the facility DON and NHA on 8/28/25, the DON stated that she had followed up with the resident regarding the incident that occurred on 7/6/25 however, she was unable to provide any documentation that there was follow-up.According to the facility grievance policy 10. e. The grievance official will keep the residents appropriately appraised of progress towards resolution of the grievances. f.the Grievance official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Elizabeth Rehabilitation & Nursing Center

3320 Benson Avenue Baltimore, MD 21227

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the morning.' S/he stated that s/he was scared as he would just stand there and not do anything and is still scared as the facility has yet to follow up directly with him/her about the status of the employee and if he is ever coming back and if he will ever care for him/her again. S/he further stated that the excoriation on his/her buttocks has gotten worse and is painful. The DON and NHA were interviewed on 8/28/25 regarding

this after the interview with Resident #2. The DON stated that she had followed up and met with the resident, however, could not verify what she told the resident or when she followed up with the resident.2.

Record review of Resident #29 on 8/27/25 at 11:21 AM revealed MDS assessments showing on 7/7/25; a BIMS of 15 and according to section ‘GG' that assesses functional abilities, Resident #29 was documented as always incontinent of bowel and occasionally incontinent of urine and requires supervision assistance with the wheelchair/walker. Review of an interview with Resident #29 documented in the facility investigation noted that s/he was ‘ignored on purpose and given the silent treatment' according to question #3 on the psychological abuse questionnaire that was given out on 7/10/25 after the abuse allegations reported on 7/7/25 from Resident #2. Resident #29 further reported that on the 11-7 shift that [s/he] was not offered toileting or incontinent care. The Resident stated that [s/he] can go to the bathroom but was not offered help. According to the documentation survey report for Resident #29, GNA #7 documented that s/he was ‘NA' for bowel and bladder, meaning that s/he was unavailable. However, reviews of the progress notes revealed that the resident was in the facility at that time. 3. Review on 8/28/25 of GNA #7's documentation for the remainder of the residents on his assignment from the night of 7/6/25 revealed the following: GNA #7 documented the same thing for-Resident # 33, 39 and #40 as was documented for Resident #2; 1, M, 1 for bowel, NA for bladder. This coding meant that he changed the resident, s/he was dependent for care, incontinent of bowel and no urine in the brief when he changed the resident also documented at 6:59 AM. The following residents were documented as ‘RU,' (not available) for 7/6/25 or ‘NA' (not applicable): Resident #30, 31, 32, 34, 35, 36, 37, 38 all signed off on the documentation survey report between 6:50 AM and 6:59 AM. Further review revealed that GNA #7 worked the 11-7 AM shift on 7/4, 7/5 and 7/6 and that this documentation and lack of care occurred over 3 consecutive days.A review of the above identified resident's progress notes and statuses revealed that the residents noted as ‘NA' or unavailable were all present in the facility. The 13 identified, according to their completed MDS's surrounding the time of the incident revealed that they all required some sort of dependence and support from staff for care from partial to complete for toileting. Review of the employee file for GNA #7 on 8/27/25 at 10:30 AM revealed that GNA #7 was recently hired on 6/12/25 and completed orientation with basic abuse education and training completed on 6/14/25 with skills orientation completed on 6/18/25. The DON and NHA were interviewed regarding these concerns on 8/27/25 at 11:58 AM. They were asked about the thoroughness of the investigation, including completing a skin assessment of the residents. The DON stated that an order was put in for Resident #2 related to the excoriation. However, it was brought to their attention that there is no record or documentation of the excoriation anywhere in the medical record, only

the ordered treatment. In addition, there were no assessments of the other identified residents and their skin status from the incident. The DON and the NHA were also unaware that GNA #7 had coded residents that were in the facility as ‘NA' and ‘RU.Cross reference, F-F585, F-F609, F-F610, F-F656

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Elizabeth Rehabilitation & Nursing Center

3320 Benson Avenue Baltimore, MD 21227

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609

living.

Level of Harm - Minimal harm or potential for actual harm

4) Facility reported incident 347683 was reviewed on 8/27/25 at 1:00 PM. The report indicated that on 5/11/25 at approximately 2:45 PM Resident #4's family member reported that the resident stated “bum, bum, bum.” The facility reported an allegation abuse to the state agency, and the police were notified.

Residents Affected - Few

The facility investigation included statements from several staff members. A statement from Staff #19 a GNA (Geriatric Nursing Assistant) dated 5/11/25 7-3 indicated that on Saturday 5/10/25 she arrived at 7 AM and checked on residents. She stated: [Resident #4] was very upset, crying, and doing a hand movement gesture waving back and forth saying something happened, but I couldn’t understand him/her, and it kept making [him/her] more upset. So, I said don’t worry I’ll be back”, “but [s/he] didn’t say anything the rest of the day”. Staff #19 added “today” the resident’s family member reported Resident #4 made similar remarks to them.

There was no evidence that Staff #19 reported the resident’s distress or report that “something happened” immediately to a nurse or supervisor on 5/10/25.

On 8/29/25 at 12:32 PM Staff #3 the Corporate Administrator (former NHA of the facility) and the current NHA were made aware of these findings. The Corporate Administrator indicated that agitated and upset behavior was baseline for Resident #4 and not unusual. However, the facility’s summary from the investigation indicated - Resident #4 had “no signs of mood disturbance at this time. However, s/he does have a history per nursing staff. There have been no mood or behavior disturbance reported at this time.”

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Elizabeth Rehabilitation & Nursing Center

3320 Benson Avenue Baltimore, MD 21227

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Director of Nursing), was so concerned about that status she found Resident #2 in that she took a picture of him/her in their soiled brief prior to initiating activities of daily living and changing the resident into a new brief. When the ADON changed Resident #2 she noted that Resident # 2's sacrum was red and excoriated and immediately ordered Calmoseptine, a multipurpose moisture barrier cream to help with the excoriation.

Further record review failed to reveal any documented skin assessment showing the presence of the sacral excoriation.

Surveyor reviewed the medical records of the 12 other residents on GNA#7's assignment. The documentation survey report was reviewed and revealed that GNA #7 documented the same thing for-Resident # 33, 39 and #40 as was documented for Resident #2; 1, M, 1 for bowel, NA for bladder, even though it was established care was not provided for Resident #2. This coding meant that he changed the resident, s/he was dependent for care, incontinent of bowel and no urine was in the brief when he changed

the resident, all documented between 6:51-6:59 AM.

The remaining residents on his assignment were documented as ‘RU,’ (not available) for 7/6/25 or ‘NA’ (not applicable): Resident #30, 31, 32, 34, 35, 36, 37, 38 all were signed off on

the documentation survey report between 6:50 AM and 6:59 AM.

Further review revealed that GNA #7 worked the 11-7 AM shift on 7/4, 7/5 and 7/6 and that this documentation and lack of care occurred over 3 consecutive days.

The DON and NHA were interviewed regarding these concerns on 8/27/25 at 11:58 AM. They were asked about the thoroughness of the investigation, including completing a skin assessment of the residents and/or assessments of the other identified residents and their skin status from the incident. The DON and the NHA also verbalized that they were unaware that GNA #7 had coded 8 residents that were in the facility as ‘NA’ and ‘RU' for ADL care over 3 nights. 3) Review of facility reported incident 347683 on 8/29/25 at 12:02 PM revealed that on 5/11/25 at approximately 2:45 PM Resident #4’s family member reported that the resident stated “bum, bum, bum.” The facility reported an allegation of abuse to the state agency and the police and conducted an investigation.

The facility’s investigation included 11 statements from staff. Staff did not identify the date or shift to which their statement pertained in 9 of the 11 statements.

Review of the nursing staffing schedule for Sarah’s Circle where Resident #4 resided revealed there were no statements from 7 staff who worked on the unit on 5/9/25 and 5/10/25.

The census on Sara’s Circle on 5/9/25 and 5/10/25 was 32 – 33 residents. Physical Abuse interviews were conducted with only 4 of the 32/33 residents. There were no physical assessments of residents who were not interviewable.

These concerns were reviewed with the Administrator, DON & Corporate Administrator on 8/29/25 at 2:00 PM.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Elizabeth Rehabilitation & Nursing Center

3320 Benson Avenue Baltimore, MD 21227

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview it was determined that the facility failed to complete accurate assessments of a resident related to the Brief interview of mental status (BIMS) assessment completed on the minimum data set (MDS). This was evident for 1 of 5 residents (Resident #2) reviewed

during the complaint survey. The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs.

Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each resident receives the care they need. BIMS (mandatory, cognitive screening tool used in long-term care facilities to identify and monitor cognitive changes in residents upon admission and periodically thereafter)Review of the medical record for Resident #2 on 8/28/25 at 8:25 AM revealed that on admission to the facility in 2025, the resident signed the admission contract and was identified as their own representative. The facility social worker also completed a BIMS assessment on admission on [DATE REDACTED] and Resident #2 scored a 13 meaning that s/he was cognitively intact. However, further review of the medical

record for Resident #2 revealed that the submitted MDS assessments for section ‘C' cognitive status since admission all noted that the BIMS for Resident #2 was not assessed or rated and should be scored by the facility staff. The facility social worker who completed all the BIMS assessments and MDS assessments was interviewed on 8/28/25 at 11:35 AM. She stated that she was not sure and could not recall and would like to review her notes.Follow-up from the facility social worker at approximately 12:30 PM on 8/28/25 revealed that yes there was an error in documentation on the submitted MDS related to Resident #2 related to the coded BIMS and that another resident's information was entered under him/her and that it will be corrected.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Elizabeth Rehabilitation & Nursing Center

3320 Benson Avenue Baltimore, MD 21227

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm

The plan of care failed to identify Resident #5’s specific NPO oral status nor Speech Therapy interventions, specific oral care needs.

An ADL (Activities of Daily Living) plan of care interventions indicated: Eating: The resident is totally dependent on staff for eating.

Residents Affected - Few Personal Hygiene: The resident requires assistance by staff with personal hygiene and oral care. It did not identify that Resident #5 was to receive nothing by mouth except with Speech Therapy and did not identify his/her specific oral care needs considering the Resident’s NPO status.

The Administrator, Corporate Administrator and DON were made aware of these concerns on 8/29/25 at 2:00 PM. 2) During the review of an allegation of abuse on 8/27/25 at 8:45 AM, regarding Resident #2 it was revealed that there was no care plan established regarding the resident’s psychiatric diagnosis’ and needed interventions.

This was reviewed with the facility DON and NHA on 8/29/25.

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Elizabeth Rehabilitation & Nursing Center

3320 Benson Avenue Baltimore, MD 21227

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to clean and change the brief of an incontinent resident. This was evident for 1 resident (Resident # 6) out of 5 residents reviewed during the complaint survey.Findings include:On 8/26/25 at 1:58 PM an investigation was done for Resident # 6 who complained about not being changed on a regular basis. According to the medical record, the resident is incontinent of bowl and bladder. The GNA Kardex is a record of what is being done for the resident. The GNA Kardex indicated the resident had not been changed on the following days:On June 2025 documentation states the nursing staff did not change Resident on the following:Day shift 6/2/25, 6/7/25, 6/8/25, 6/9/25, 6/16/25, 6/22/25Evening shift 6/1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 16, 17, and 29Night shift 6/1, 3, 4, 6, 8, 9, 10, 11, 12, 15.July 2025 documentation states the nursing staff did not change Resident on the following:Day shift: 7/4, 14, 25, 28Evening shift: 7/2, 5, 14, 30August 2025 documentation states the nursing staff did not change Resident

on the following:Day shift: 8/5, 6, 7, 27On 8/27/25 at 1:10PM an interview was held with the Director of Nursing and Administrator who was in the room at the time of the interview, and stated the agency GNA's were not aware of where to sign off on the record that care was completed. A tour of the 3rd floor at 10:30 AM indicated [NAME] Circle smelled of urine and the resident in room [ROOM NUMBER]-1 complained of not being changed and having to wait a long period of time for someone to come in. The Administrator said nothing.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Elizabeth Rehabilitation & Nursing Center

3320 Benson Avenue Baltimore, MD 21227

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

Based on medical record review and staff interviews it was determined the facility staff failed to ensure that Resident #25's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 1 (Resident # 25) of 4 residents reviewed during the survey process. The findings include:On 8/28/25 9:30 AM review of complaint 347660 alleged that Resident #25's did not receive showers in the month of December 2024.The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need.Review of Resident #25's most recent MDS completed on 1/30/25, revealed that s/he is maximal assistance for bathing. The Brief Interview for Mental Status (BIMS) revealed a score of 13 indicating adequate cognitive ability.Further review of Resident #25's shower schedule which is every Wednesday and Saturday, as well as the Geriatric Nursing Assistant (GNA) task documentation of Activity of Daily Living (ADL) revealed that from 12/5/25 until 1/30/25, Resident #25 received showers on 1/16/25, and 1/19/25. Resident # 25 did not have any showers in the month of December.On 8/28/25 at 9:45 AM the DON stated that she could not find shower sheets.The Director of Nursing (DON) was made aware of this concern on 8/28/25 at at 11 AM.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Elizabeth Rehabilitation & Nursing Center

3320 Benson Avenue Baltimore, MD 21227

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm

the TAR. She confirmed that if a Resident had a PEG tube there should be a physician order for PEG tube care. During an interview on 8/29/23 at 9:53 AM, Staff #17 the 3rd floor Nurse Manager was made aware, reviewed Resident #5's medical record, and confirmed the above findings.The Administrator, DON and Corporate Administrator were made aware of these findings on 8/29/25 at 2:00 PM.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Elizabeth Rehabilitation & Nursing Center

3320 Benson Avenue Baltimore, MD 21227

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm

Nursing the concern that the fall resulted in harm to Resident #7.On 8/28/25 at 12:30 PM at the time of exit conference the Administrator handed the surveyor a plan of correction that was incomplete and the Wheelchair leg rest policy which stated; when residents are transported by staff (pushed in wheelchair): leg rest and footplates shall be in place with both feet supported to prevent dragging, injury, or entrapment.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Elizabeth Rehabilitation & Nursing Center

3320 Benson Avenue Baltimore, MD 21227

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692

Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or potential for actual harm

Based on medical record review and interview, the facility failed to monitor a resident's hydration and nutrition status resulting in the resident's change in condition that led to the resident being transferred to the local hospital to be treated for dehydration. This was evident for 1 (Resident #17) of 3 residents reviewed for neglect during a complaint survey. The findings include:On 8/25/25, the surveyor reviewed complaint 347682/MD00215742 which alleged that facility staff members failed to offer water to Resident #17 leading to the resident being transferred to the local hospital for emergency services. Review of Resident #17's medical record on 8/25/25 at 12:39pm revealed that the resident had a change in condition on 3/6/25. The resident was unable to speak, and his/her eyes were unfocused. Facility nursing staff assessed the resident, treated the resident with supplemental oxygen, and received orders to start an IV with a saline solution. Facility nursing staff were unable to establish the IV and the resident was transferred to the local hospital for treatment. Continued review of resident #17's medical record on 8/25/25 at 1:00pm revealed that the resident's last nutritional assessment was completed on 9/9/24. The assessment stated that the resident was dependent on facility staff for feeding. The resident was also assessed as having adequate fluid intake. Further review of resident #17's medical record on 8/25/25 at 1:10pm revealed a discharge summary from a local hospital dated 3/8/25. The discharge summary stated that facility staff told the hospital that the resident had decreased oral intake prior to the resident's change of condition on 3/6/25.

The hospital records stated that the resident was diagnosed with dehydration and the resident was treated with IV fluids. Additional review of Resident #17's medical record on 8/25/25 at 8:00am revealed the resident had reduced oral intake on 3/1/25 - 3/5/25. The resident was documented as normally eating 75-100% of meals. From 3/1/25 - 3/5/25, the resident was documented as eating nothing for lunch on 3/1/25, no dinner on 3/4/25, and no meals at all on 3/5/25. On 8/26/25 at 9:08am, the surveyor interviewed Dietitian #15 regarding the hydration/nutritional management of residents in the facility. Dietitian #15 stated that all residents have a nutritional assessment quarterly. Any residents that are identified as being at risk would be monitored more frequently in daily and weekly clinical meetings. Dietitian #15 also stated that resident intake percentages are monitored regularly and reduced resident intake percentages should trigger an alert to the dietitian. The surveyor pointed out that Resident #17 had reduced intake percentages from 3/1/25 - 3/5/25 and there was no documentation that the resident was assessed by the dietitian. The surveyor also pointed out that resident #17's last nutritional assessment prior to the change in condition was on 9/9/24. Dietitian #15 confirmed that the resident should have had another nutritional assessment prior to the resident's change in status on 3/6/25. Also, the resident's reduced intake should have alerted

the Dietitian in 3/2025.On 8/26/25 at 11:54am, the surveyor informed the Director of Nursing (DON) of the facility's failure to monitor the resident's reduced intake from 3/1/25 - 3/5/25 and provide interventions to prevent dehydration.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

St. Elizabeth Rehabilitation & Nursing Center

3320 Benson Avenue Baltimore, MD 21227

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on medical record review and interview it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for a Resident. This was evident for 1 (Resident #7) of 2 residents selected for review during the survey process.The findings include:A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.On 8/21/ 25 at 10 AM a review of Resident # 7's electronic medical record revealed a physician order for PT to evaluate wheelchair and positioning on 12/2/24.On 8/26/25 at 10 AM an interview with the Director of Physical Therapy (PT) revealed that he could not confirm or deny that the evaluations occurred. The information was not available

in the electronic medical record.On 8/28/25 at 1:30PM , in an interview with the Director of Nursing confirmed the facility staff failed to maintain the medical record in the most complete form for Resident #7.

Event ID:

Facility ID:

If continuation sheet