St. Elizabeth Rehabilitation & Nursing Center, Baltimore, MD

The Essentials

Summary

Across 5 inspections from October 2019 to August 2026, state surveyors documented 47 findings at St. Elizabeth Rehabilitation & Nursing Center; 43 have a recorded correction and 4 await one; CMS lists 2 enforcement actions in the window.

Inspections: 5; 2019–2026, complaint and standard
Findings: 47; Deficiencies cited by state inspectors
Corrected: 43; Of 47 findings, with a recorded correction date
Penalties: 2; 2 fines; payment not published

Findings by Year

Findings
Of which, actual harm (level G or above)

* Partial year, through October 1, 2026.

Findings by year
Year	Inspections	Findings	Of which, actual harm (level G or above)
2019	1	2	0
2020	0	0	0
2021	0	0	0
2022	0	0	0
2023	0	0	0
2024	1	20	1
2025	1	14	2
2026	2	11	0

What the Record Shows

43 of 47 findings have a recorded correction date.
CMS lists 2 enforcement actions in the window: 2 fines totaling $66,996, their payment not published.
3 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
The latest standard inspection, February 26, 2026, recorded 7 findings (most serious: Level F).

What to Ask About

Help With Daily Living, Cited in Three Inspections
Protection From Abuse and Neglect, Cited in Two Inspections
Reporting Suspected Abuse, Cited in Two Inspections
Notice Before Transfer or Discharge, Cited in Two Inspections
Accurate Assessments, Cited in Two Inspections
Quality of Care, Cited in Two Inspections
Accident Hazards and Supervision, Cited in Two Inspections
Kitchen and Food Safety, Cited in Two Inspections
Investigating Alleged Violations, No Recorded Correction
Professional Standards, No Recorded Correction
Medical Records, No Recorded Correction
Infection Control, No Recorded Correction

Report at a Glance

Facility: St. Elizabeth Rehabilitation & Nursing Center
Address: 3320 Benson Avenue, Baltimore, MD 21227
CMS Certification Number: 215044
Provider Type: Skilled nursing facility and nursing facility
Certified Beds: 162
Ownership: For profit - Limited Liability company
Record Window: October 31, 2019 to October 1, 2026

Chronology

Inspection History

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

Aug 262026
Complaint investigation
4 findings
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreDeficient, Provider has no plan of correction
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreDeficient, Provider has no plan of correction
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Feb 262026
Standard health inspection
7 findings
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Mar 31, 2026
- F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Mar 31, 2026
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level ENo actual harm, potential for moreCorrected Mar 31, 2026
- F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level DNo actual harm, potential for moreCorrected Mar 31, 2026
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Mar 31, 2026
- F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Mar 31, 2026
- F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level DNo actual harm, potential for moreCorrected Mar 31, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Aug 292025
Complaint investigation
14 findings
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level GActual harmCorrected Oct 7, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Oct 7, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Oct 7, 2025
- F578Honor 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.Level DNo actual harm, potential for moreCorrected Oct 7, 2025
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Oct 7, 2025
- F585Honor 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.Level DNo actual harm, potential for moreCorrected Oct 7, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Oct 7, 2025
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Oct 7, 2025
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Oct 7, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Oct 7, 2025
- F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level DNo actual harm, potential for moreCorrected Oct 7, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Oct 7, 2025
- F692Provide enough food/fluids to maintain a resident's health.Level DNo actual harm, potential for moreCorrected Oct 7, 2025
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Oct 7, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oct 162024
Standard health inspection
20 findings
The same visit included a complaint investigation.
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Jun 26, 2023
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Nov 13, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level ENo actual harm, potential for moreCorrected Nov 13, 2024
- F551Give the resident's representative the ability to exercise the resident's rights.Level DNo actual harm, potential for moreCorrected Nov 13, 2024
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Nov 13, 2024
- F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Level DNo actual harm, potential for moreCorrected Nov 13, 2024
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Nov 13, 2024
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Nov 13, 2024
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Nov 13, 2024
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Nov 13, 2024
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Nov 13, 2024
- F660Plan the resident's discharge to meet the resident's goals and needs.Level DNo actual harm, potential for moreCorrected Nov 13, 2024
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Nov 13, 2024
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Nov 13, 2024
- F732Post nurse staffing information every day.Level DNo actual harm, potential for moreCorrected Nov 13, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Nov 13, 2024
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Nov 13, 2024
- F772Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.Level DNo actual harm, potential for moreCorrected Nov 13, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level DNo actual harm, potential for moreCorrected Nov 13, 2024
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Nov 13, 2024
Enforcement Action
Civil money penalty, $16,341 imposed October 16, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 16, 2024, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $50,655 imposed August 29, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 16, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oct 312019
Standard health inspection
2 findings
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Dec 14, 2019
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Dec 14, 2019
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

Context

Patterns Worth Examining

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1
Help With Daily Living, Cited in Three Inspections
Inspectors cited F677 in October 2019, October 2024 and August 2025. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
1924252626F677 across all 5 inspections, oldest to newest
2
Protection From Abuse and Neglect, Cited in Two Inspections
Inspectors cited F600 in October 2024 and August 2025. This citation covers whether residents are protected from abuse and neglect by anyone. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
1924252626F600 across all 5 inspections, oldest to newest
3
Reporting Suspected Abuse, Cited in Two Inspections
Inspectors cited F609 in October 2024 and August 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
1924252626F609 across all 5 inspections, oldest to newest
4
Notice Before Transfer or Discharge, Cited in Two Inspections
Inspectors cited F623 in October 2019 and October 2024. This citation covers notice to the resident, their representative and the ombudsman before a transfer or discharge, including appeal rights. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
1924252626F623 across all 5 inspections, oldest to newest
5
Accurate Assessments, Cited in Two Inspections
Inspectors cited F641 in October 2024 and August 2025. This citation covers whether each resident’s assessment correctly records their condition. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
1924252626F641 across all 5 inspections, oldest to newest
6
Quality of Care, Cited in Two Inspections
Inspectors cited F684 in October 2024 and August 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
1924252626F684 across all 5 inspections, oldest to newest
7
Accident Hazards and Supervision, Cited in Two Inspections
Inspectors cited F689 in October 2024 and August 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
1924252626F689 across all 5 inspections, oldest to newest
8
Kitchen and Food Safety, Cited in Two Inspections
Inspectors cited F812 in October 2024 and February 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
1924252626F812 across all 5 inspections, oldest to newest
9
Investigating Alleged Violations, No Recorded Correction
F610 was cited in October 2024, August 2025 and August 2026. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
1924252626F610 across all 5 inspections, oldest to newest
10
Professional Standards, No Recorded Correction
F658 was cited in August 2026. This citation covers whether the home’s services meet professional standards of quality. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
1924252626F658 across all 5 inspections, oldest to newest
11
Medical Records, No Recorded Correction
F842 was cited in August 2025 and August 2026. This citation covers whether resident records are complete, accurate and kept confidential. The most serious was level D (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
1924252626F842 across all 5 inspections, oldest to newest
12
Infection Control, No Recorded Correction
F880 was cited in October 2024 and August 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. The most serious was level E (no actual harm, potential for more). The August 2026 citation has no recorded correction date; its status reads “Deficient, Provider has no plan of correction.” The record does not show whether the problem was fixed.
1924252626F880 across all 5 inspections, oldest to newest

For Your Next Visit

Questions to Ask on Your Visit

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

01
How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?
Help With Daily Living: cited in three inspections, most seriously at level D.
02
What happened after the abuse or neglect citation, and what changed in training or supervision?
Protection From Abuse and Neglect: cited in two inspections, most seriously at level G.
03
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in two inspections, most seriously at level E.
04
When do you transfer or discharge a resident, and how much notice do families get?
Notice Before Transfer or Discharge: cited in two inspections, most seriously at level D.
05
Who completes resident assessments, and how are they checked for accuracy?
Accurate Assessments: cited in two inspections, most seriously at level D.
06
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in two inspections, most seriously at level E.
07
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in two inspections, most seriously at level J.
08
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in two inspections, most seriously at level F.
09
When an allegation is made, who investigates it, and how are residents protected in the meantime?
Investigating Alleged Violations: cited in three inspections, most seriously at level D. The August 26, 2026 citation has no recorded correction date.
10
How do you check that nurses and aides follow professional standards, and what happens when they do not?
Professional Standards: cited in one inspections, most seriously at level D. The August 26, 2026 citation has no recorded correction date.
11
How can a family request a resident’s records, and how are they kept accurate?
Medical Records: cited in two inspections, most seriously at level D. The August 26, 2026 citation has no recorded correction date.
12
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level E. The August 26, 2026 citation has no recorded correction date.
13
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
14
What led to the 2025 fine, and has it been paid?
A $50,655 civil money penalty was imposed August 29, 2025. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.

The Evidence

Sources and Coverage

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Maryland state survey agency.

Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Maryland state survey agency
Inspection Oct 31, 2019 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Maryland state survey agency
Inspection Oct 16, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Maryland state survey agency
Inspection Aug 29, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Maryland state survey agency
Inspection Feb 26, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Maryland state survey agency
Inspection Aug 26, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Penalties, Provider Data Catalog
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗
Provider Information, Provider Data Catalog
Centers for Medicare & Medicaid Services · 215044
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗

Coverage

Record windowOctober 31, 2019 – October 1, 2026

CMS publishes about three inspection cycles; inspections before October 2019 are not in this release.
CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.

What This Report Cannot Tell You

Complaints not investigated onsite: Allegations screened out by the state before an onsite visit are not published.
Complaint allegations: CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
Facility-reported incidents: Self-reported incidents appear only if they led to an inspection.
Follow-up visits: CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
Fire safety inspections: Published by CMS separately and not included in this record yet.
Staffing levels and ownership history: Published by CMS separately and not included in this record.
Whether fines were paid: CMS publishes the fines imposed, not whether or when they were paid.

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.