St. Elizabeth Rehabilitation & Nursing Center

In the surveyor’s words

From the most serious findings on record at St. Elizabeth Rehabilitation & Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 16, 2024

  Based on observation, medical record review, review of the facility's investigation reports, and interviews with staff, it was determined that the facility failed to supervise and provide a secure environment for a resident residing in a secure unit. These failures contributed to the resident eloping and placed the resident at increased risk for serious harm. This was evident for 1 (Residents #374) of 3 residents reviewed for elopement. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy Past Non-compliance. The findings include: On 10/4/24 at 9:18 AM, the surveyor reviewed the medical record for Resident #374. […]

• Actual harm, isolatedF600Aug 29, 2025

  Based on medical record review and interview with staff and resident it was determined that the facility staff neglected his assigned patients and failed to provide care to them causing identified harm to a resident when the care was refused to be administered. This resulted in psychosocial harm to Resident #2 and was evident during the review of a facility reported incident reviewing documented neglected care of 13 (Residents #2, #29, #33, #39 #40 #30, # 31, #32, #34, #35, #36,# 37, and # 38 ) of 13 residents reviewed during the complaint survey. The findings include: 1. […]

• Actual harm, isolatedF689Aug 29, 2025

  Based on review of medical records and other pertinent documentation, observations, and interviews, it was determined that the facility failed to prevent avoidable falls. This was found to be evident for 1 (Resident #7) out of 2 residents reviewed for accidents during the survey. The fall resulted in actual harm to Resident #7. The findings include:On 8/21/25 at 10 AM, review of Resident #7's medical record revealed the resident was admitted to the facility with diagnosis that included but not limited to dementia, polyarthritis, and contracture of muscle. […]

• No harm, potential for more than minimal, widespreadF812Feb 26, 2026

  Based on observation and staff interview, it was determined that the facility failed to ensure that refrigerated food items were consistently labeled and dated with preparation and expiration dates to maintain sanitary storage conditions and prevent the potential for serving unsafe food. This deficient practice was identified during the initial and follow-up tours of the kitchen during the recertification survey. The findings include: On 02/19/2026 at 7:52 AM, during the initial tour of the kitchen, the surveyor met with Dietary Technician (Staff #32). […]

• No harm, potential for more than minimal, patternF880Aug 26, 2026

  Based on observations and interview it was determined that the facility staff failed to maintain infection control practices. This deficient practice was evidenced in 20 of 24 PPE carts observed outside of residents' rooms and 1 (#1) of 2 residents with urinary drainage bags assessed during the complaint survey.The findings include:1. On 08/20/26 at 10:15 am during observation rounds the surveyor observed PPE carts outside of the residents' room on the second and third floors.On 08/21/26 at 11:42 am the surveyor observed PPE carts on the floor outside of room [ROOM NUMBER] on the first floor. On the second floor there was a PPE cart on the floor outside Rooms 218, 219, 224, 225, 228, 230, and 232. […]