Deficiencies (last 4 years)
Deficiencies (over 4 years)
33.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
160% worse than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Deficiencies: 10
Oct 9, 2025
Visit Reason
The inspection was conducted as part of the annual recertification survey of Elkton Nursing and Rehabilitation Center to assess compliance with regulatory requirements including resident rights, care planning, abuse prevention, financial management, pain management, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to dignified existence and self-determination, inadequate management of resident funds and financial affairs, failure to prevent physical abuse, improper care planning participation, unsafe transfer practices resulting in resident injury, inadequate pain management, insufficient medically-related social services, failure to assist with transportation needs, inaccurate medical records, and ineffective pest control program.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Level of Harm - Actual harm: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to ensure residents' right to a dignified existence, self-determination, communication, and access to persons and services inside and outside the facility. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the resident's right to manage his or her financial affairs and failed to obtain written authorization for facility to act as fiduciary of resident's funds. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect a resident from physical abuse perpetrated by a facility employee. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents' participation in development, review, and revision of care plans. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident who required a Hoyer lift for transfer was transferred with a Hoyer lift, resulting in fracture injury. | Level of Harm - Actual harm |
| Failed to provide safe, appropriate pain management for a resident resulting in unmanaged pain crisis. | Level of Harm - Actual harm |
| Failed to provide medically-related social services to help residents achieve highest practicable physical, mental, and psychosocial well-being. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assist a resident in making transportation arrangements to and from the source of service when needed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain accurate medical records for residents, including documentation of dressing changes, smoking status, and fall documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an effective pest control program to keep the facility free of pests including flies, gnats, and ants. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Outstanding unpaid bill: 42559.12
Missed appointments: 3
BIMS score: 15
Fall count: 1
Number of residents investigated for personal funds management: 2
Number of residents reviewed for abuse: 8
Number of residents reviewed for pain management: 9
Number of residents investigated for medically related social services: 9
Number of residents investigated for missed appointments due to transportation: 1
Number of residents reviewed for medical record accuracy: 38
Number of nursing units observed for pest control: 3
Number of black insects observed in resident #16 room: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Physician #30 | Physician | Completed decision-making capacity certifications and signed SSA-787 form for Resident #58. |
| Staff #30 | Director of Rehabilitation Services | Provided information about Resident #58's wheelchair and power wheelchair billing. |
| Staff #51 | Business Office Manager | Discussed Resident #58's financial management and Resident Payee process. |
| Staff #36 | Director of Social Services | Interviewed regarding Resident #58's concerns and social services. |
| GNA #40 | Geriatric Nursing Assistant | Perpetrator of physical abuse against Resident #143. |
| Laundry Assistant #41 | Laundry Assistant | Witnessed physical abuse incident involving Resident #143. |
| Staff #2 | Director of Nursing | Interviewed regarding Resident #58's funds and Resident #156 transfer incident. |
| Staff #28 | Geriatric Nursing Assistant | Failed to use Hoyer lift for Resident #156 resulting in fracture. |
| Staff #47 | Nurse | Reported Resident #179's pain crisis and narcotic medication issues. |
| Physician #48 | Physician | Witness to Resident #179's pain crisis. |
| CRNP #49 | Certified Registered Nurse Practitioner | Documented medical progress note regarding Resident #179's pain crisis. |
| Unit Manager #50 | Unit Manager | Witness to Resident #179's pain crisis. |
| LPN Charge Nurse #46 | Licensed Practical Nurse | Witness to Resident #179's pain crisis and interviewed about medication administration. |
| Staff #66 | Social Services Assistant | Attended care plan meetings with Residents #58 and #14. |
| Staff #10 | Director of Recreational Therapy | Attended care plan meeting for Resident #14 on 8/7/25. |
| Staff #76 | Unit Clerk | Discussed transportation scheduling limitations for Resident #58. |
| Staff #1 | Nursing Home Administrator | Interviewed regarding Resident #58's financial concerns and pest control. |
| Staff #15 | Director of Housekeeping | Reported laundry staffing shortages affecting residents' clothing availability. |
| Staff #16 | Director of Maintenance | Addressed pest control concerns. |
| Staff #62 | Regional Director of Operations | Discussed billing and payment delays for Resident #58's power wheelchair. |
| Staff #61 | Regional VP of Operations | Discussed Resident #58's wheelchair and transportation issues. |
| Staff #3 | Administrator in Training | Interviewed regarding Resident #58's financial concerns and care planning. |
| Staff #52 | Physician | Certified Resident #58's decision-making capacity and signed SSA-787 form. |
| Staff #39 | Resident | Reported staff not knocking before entering rooms. |
| Staff #4 | Geriatric Nursing Assistant | Observed entering resident rooms without knocking. |
| Staff #53 | Geriatric Nursing Assistant | Observed entering resident rooms without knocking. |
| Staff #66 | Social Services Assistant | Attended care plan meetings with residents. |
| Staff #67 | Unit Manager | Discussed smoking assessments and care plans. |
Inspection Report
Complaint Investigation
Deficiencies: 24
Jul 2, 2025
Visit Reason
The inspection was conducted as a complaint survey reviewing multiple allegations including resident dignity, notification failures, privacy breaches, environmental concerns, misappropriation of property, medication administration, and other care and safety issues.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to notify representatives of medication changes, failure to maintain resident privacy, inadequate housekeeping and maintenance, misappropriation of resident property, inaccurate resident assessments, failure to provide scheduled care such as showers, failure to provide timely hospital transfers, inadequate neuro checks after falls, failure to provide respiratory care, failure to post staffing information, medication management issues, failure to maintain complete medical records, failure to obtain outside professional services timely, and ineffective pest control.
Complaint Details
The complaint survey included allegations of dignity violations, failure to notify representatives, privacy breaches, environmental and maintenance issues, misappropriation of property, inaccurate assessments, failure to provide scheduled care, inadequate hospital transfers, failure to conduct neuro checks, respiratory care deficiencies, staffing posting failures, medication management issues, incomplete medical records, failure to obtain outside services, and pest control problems.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 23
Level of Harm - Potential for minimal harm: 1
Deficiencies (24)
| Description | Severity |
|---|---|
| Facility staff failed to treat residents in a dignified manner by standing over a resident while feeding and not placing a urinary catheter bag in a dignity bag. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to notify a resident's representative of a medication order change. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to ensure resident medical records remained private and confidential. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, comfortable interior. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide an environment free of misappropriation of property related to a missing PlayStation 5. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to timely report suspected abuse, neglect, or theft to the proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to conduct a complete investigation for allegations of misappropriation of property. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide residents or responsible parties a copy of their baseline care plan and admission medications within 48 hours of admission. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide needed activities of daily living for a resident totally dependent on bathing assistance. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure residents received treatment and care according to orders, preferences, and goals, including safe transport to hospital and timely hospital transfers after falls. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to assist a resident in gaining access to vision services by not providing glasses. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure fall mats were properly in place for a resident with a history of falls. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide appropriate care to prevent urinary tract infections including proper catheter care. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide safe and appropriate respiratory care for a resident with a tracheostomy. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to post resident census and nurse staffing information daily. | Level of Harm - Potential for minimal harm |
| Facility failed to provide timely medications to meet the needs of residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to monitor vital signs prior to medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to keep treatment and medication carts locked when unattended and failed to date and discard expired medications. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to keep signed and dated reports of EKGs and other diagnostic services in the resident's medical record. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to obtain outside professional services in a timely manner including gynecology, stroke clinic, and orthopedic follow-up appointments. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to have an effective pest control program as evidenced by numerous flies and gnats throughout the facility. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 57
Deficiencies with minimal harm severity: 23
Deficiencies with potential for minimal harm severity: 1
Medication expiration days: 28
Dates of pest control invoices: Array
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #17 | Unit Manager | Mentioned in relation to baseline care plan and missing EKG documentation |
| LPN #38 | Licensed Practical Nurse | Mentioned in relation to unlocked medication cart and medication cups |
| Staff #5 | Maintenance Director | Interviewed regarding ceiling tile stains and maintenance issues |
| Staff #34 | Unit Manager | Confirmed fall mat placement and transport procedures |
| LPN #22 | Licensed Practical Nurse | Interviewed regarding fall documentation and assessments |
| LPN #6 | Licensed Practical Nurse | Interviewed regarding unlocked treatment cart and expired ointments |
| LPN #31 | Licensed Practical Nurse | MDS coordinator confirming inaccurate assessments |
| LPN #32 | Licensed Practical Nurse | MDS coordinator confirming inaccurate assessments |
| LPN #33 | Licensed Practical Nurse | Interviewed regarding medication delays |
| LPN #21 | Licensed Practical Nurse | Interviewed regarding medication administration |
| Staff #26 | Unit Secretary | Interviewed regarding transport procedures |
| Physician #25 | Physician | Interviewed regarding transport procedures |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding medication issues and neuro checks |
| Director of Nursing | Director of Nursing | Multiple interviews confirming findings and deficiencies |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding missing PlayStation and pest control |
Inspection Report
Annual Inspection
Deficiencies: 12
Nov 20, 2023
Visit Reason
The inspection was conducted as part of the annual recertification survey and complaint investigations related to allegations of abuse, resident transfers, care planning, medication administration, respiratory care, and other compliance issues.
Findings
The facility was found to have multiple deficiencies including incomplete investigations of abuse allegations, failure to document and communicate resident transfers properly, inadequate care planning and care plan meetings, medication administration errors including narcotic reconciliation and delayed administration, failure to provide appropriate respiratory care, lack of coordination with hospice services, inadequate staff training on abuse and dementia care, and failure to monitor antibiotic use effectively.
Complaint Details
The inspection included complaint investigations related to abuse allegations involving multiple residents and staff, medication administration concerns, and failure to follow care plans and transfer protocols.
Deficiencies (12)
| Description |
|---|
| Facility failed to ensure thorough investigations of abuse allegations including interviews with residents, witnesses, and documentation of prevention measures. |
| Facility failed to document basis for resident transfers, notify residents or representatives in writing, and prepare residents adequately for transfers. |
| Facility failed to develop and implement comprehensive, person-centered care plans including for trauma/PTSD, oxygen therapy, elopement risk, communication needs, hospice care, and occupational therapy recommendations. |
| Facility failed to hold care plan meetings quarterly or as required and failed to document care plan meetings in medical records. |
| Facility failed to administer medications according to orders and professional standards including leaving medications unattended, failure to follow transfer care plans, and delayed medication administration. |
| Facility failed to maintain accurate medication records and reconcile controlled substances properly. |
| Facility failed to provide safe and appropriate respiratory care including failure to date oxygen tubing, lack of physician orders for oxygen, and failure to provide humidification for tracheostomy care. |
| Facility failed to ensure timely physician documentation of resident visits and progress notes. |
| Facility failed to ensure monthly pharmacist medication regimen reviews were completed and pharmacy recommendations were communicated to physicians. |
| Facility failed to provide adequate staff training on abuse, neglect, exploitation, dementia care, and resident abuse prevention. |
| Facility failed to monitor and track antibiotic use and resistance data as part of the antibiotic stewardship program. |
| Facility failed to safeguard resident-identifiable information and maintain accurate medical records, including errors in care plans and documentation. |
Report Facts
Facility reported incidents investigated: 12
Residents reviewed for abuse: 11
Residents reviewed for care planning: 69
Residents reviewed for medication administration: 5
Residents reviewed for respiratory care: 6
Residents reviewed for nutrition: 9
Residents reviewed for hospice care: 1
Residents reviewed for antibiotic use: 3
Employees training records reviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #49 | Registered Nurse | Named in medication administration observation with Resident #21. |
| Staff #24 | Licensed Practical Nurse | Named in multiple interviews regarding resident transfers and hospital transfer form completion. |
| Staff #25 | Licensed Practical Nurse, Unit Manager | Named in interviews regarding oxygen care and medication side effect monitoring. |
| Staff #6 | Social Worker | Named in interviews regarding care plan meetings and PASARR documentation. |
| Staff #10 | Speech Language Pathologist | Named in interview regarding Resident #108 swallowing precautions. |
| Staff #21 | Registered Dietician | Named in interviews regarding weight monitoring and nutrition concerns. |
| Staff #29 | Hospice Nurse | Named in telephone interview regarding hospice care coordination. |
| Staff #45 | Geriatric Nursing Assistant | Named in interview regarding fall incident with Resident #50. |
| Staff #46 | Geriatric Nursing Assistant | Named in interview regarding transfer assistance for Resident #50. |
| Staff #47 | Geriatric Nursing Assistant | Named in abuse allegation and training record review. |
| Staff #50 | Activities Assistant | Named in interview regarding communication boards for Resident #108. |
| Staff #51 | Named in hospital transfer documentation but identity unclear. | |
| Staff #52 | Licensed Practical Nurse | Named in interview regarding thickened liquids and straw use for Resident #108. |
| Staff #53 | Named in interview regarding straw found in Resident #108's drink. | |
| Staff #74 | Licensed Practical Nurse | Named in interview regarding controlled medication documentation. |
| Staff #3 | Licensed Practical Nurse | Named in interview regarding reporting weight loss to dietitian and physician. |
| Staff #1 | Licensed Practical Nurse | Named in interview regarding medication administration timing. |
| Staff #16 | Medical Director | Named in interview regarding physician note timeliness and pharmacy recommendations. |
| Staff #17 | Attending Physician | Named in medical record review for Resident #217. |
| Staff #18 | Attending Physician | Named in medical record review for Resident #219. |
| Staff #70 | Geriatric Nurse Assistant | Named in training record review. |
Inspection Report
Annual Inspection
Deficiencies: 28
Nov 20, 2023
Visit Reason
The inspection was conducted as part of the annual recertification survey and complaint investigation of Elkton Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, resident council responsiveness, advance directives, environmental maintenance, personal property management, staffing adequacy, medication administration, care planning, infection control, food service, and staff training. Specific deficiencies included failure to ensure staff treated residents with dignity, inadequate response to resident grievances, incomplete advance directive documentation, poor environmental maintenance, missing resident clothing, insufficient staffing levels, medication errors, incomplete care plans, lack of infection preventionist, and failure to maintain proper food safety and staff competency documentation.
Complaint Details
Complaint investigations revealed issues with staffing shortages, medication administration delays, missing resident clothing, and inadequate grievance processes. Specific complaints included staff sleeping on duty, delayed medication administration, and poor response to resident grievances.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 28
Level of Harm - Potential for minimal harm: 1
Deficiencies (28)
| Description | Severity |
|---|---|
| Failed to ensure all residents were treated with respect and dignity; staff observed using phones during care and not following rules. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure concerns and suggestions from resident council were reviewed and responded to in writing. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were informed of their rights to formulate advance directives and failed to document advance directives in medical records. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a safe, clean, comfortable, and homelike environment; multiple maintenance and housekeeping deficiencies noted including dirty vents, damaged walls, and insufficient linen supply. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have an effective grievance process; missing grievance logs and unresolved resident complaints. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to report allegations of abuse immediately and conduct thorough investigations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document basis for resident transfer and ensure appropriate communication with receiving facility. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify residents or representatives in writing of transfers and bed-hold policies. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to orient, prepare, and document resident preparation for hospital transfer. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement comprehensive person-centered care plans addressing residents' needs including trauma-informed care, oxygen therapy, elopement risk, hospice care, communication aids, and therapy recommendations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer medications safely and timely, follow medical orders, and ensure residents received care and treatment as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate care for residents with indwelling catheters including timely emptying of urinary drainage bags and catheter care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide culturally competent, trauma-informed care for residents with PTSD and failed to provide staff training on trauma-informed care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct competency evaluations for Geriatric Nursing Assistants (GNAs). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have a licensed nurse as unit manager for unit 3 responsible for supervision and resident care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to post nurse staffing information daily by unit and shift. | Level of Harm - Potential for minimal harm |
| Failed to ensure medication labeling, removal of expired medications, and monitoring of medication storage temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide sufficient qualified nutrition professional for oversight of food preparation and kitchen operation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to serve food that was palatable, attractive, and at a safe and appetizing temperature; food complaints included cold food, poor quality, and inadequate portions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain accurate resident medical records including care plans, medication documentation, and advance directive information. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate respiratory care including oxygen therapy orders, monitoring, and humidification. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate care for residents with feeding tubes including flushing and evaluation for discontinuation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure safe use of bed rails including assessment, informed consent, and physician orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide sufficient nursing staff to meet residents' needs; staffing shortages noted on weekends and multiple shifts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct yearly performance reviews for nurse aides. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain infection control precautions including isolation signage, PPE use, and prevention of contamination of ice and respiratory equipment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to monitor and track antibiotic usage and resistance data; incomplete antibiotic stewardship program. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document and provide education on COVID-19 vaccination for residents and staff. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 12.9
Staffing shifts below goal: 59
Staffing shifts below goal: 44
Missing grievance logs: 8
Weight change: 49
Weight change: 48.8
Weight change: 28.8
Weight change: 20.4
Weight change: 11.4
Missing plate bottom insulators: 30
Missing dishwashing temperature records: 4
Medication doses not documented: 3
Medication doses given late: 6
Medication doses given late: 12
Medication doses given late: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #61 | Director of Admissions | Interviewed about advance directives and grievance process |
| Staff #6 | Assistant Director of Social Services | Interviewed about advance directives and care plan meetings |
| Staff #25 | Licensed Practical Nurse, Unit Manager | Interviewed about wound care documentation and infection control |
| Staff #49 | Registered Nurse | Observed medication administration and infection control practices |
| Staff #64 | Director of Laundry | Interviewed about missing resident clothing and lost and found process |
| Staff #70 | Geriatric Nurse Assistant | Competency records missing |
| Staff #71 | Geriatric Nurse Assistant | Competency records missing |
| Staff #47 | Geriatric Nursing Assistant | Alleged abuse incident and training records |
| Staff #19 | Dietary Manager | Interviewed about food quality and kitchen observations |
| Staff #21 | Registered Dietitian | Interviewed about food quality and resident weight monitoring |
| Staff #15 | Director of Rehabilitation | Interviewed about therapy recommendations and resident care plans |
| Staff #4 | Licensed Practical Nurse | Interviewed about bed hold policy and oxygen therapy |
| Staff #2 | Licensed Practical Nurse | Interviewed about staffing and infection control |
| Staff #37 | Geriatric Nursing Assistant | Observed infection control practices |
| Staff #54 | Maintenance Assistant | Interviewed about maintenance of scales and lifts |
| Staff #58 | Geriatric Nursing Assistant | Interviewed about scales and competency records |
| Staff #33 | Nurse | Interviewed about COVID-19 vaccination documentation |
| Staff #30 | Nurse | Interviewed about COVID-19 vaccination documentation |
| Staff #31 | Nurse | Interviewed about COVID-19 vaccination documentation |
| Staff #32 | Nurse | Interviewed about COVID-19 vaccination documentation |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Aug 24, 2023
Visit Reason
The inspection was conducted due to complaints and observations that Resident #2 was smoking inside the facility in unauthorized areas, posing immediate jeopardy to resident health and safety.
Findings
The facility failed to ensure that residents only smoked outside in designated areas. Resident #2 was found smoking inside the building multiple times, including in bathrooms and dining rooms, despite facility policy prohibiting indoor smoking. Immediate jeopardy was declared and later abated after corrective actions were implemented.
Complaint Details
The investigation was complaint-related, focusing on Resident #2's unsafe smoking behavior inside the facility. Immediate jeopardy was declared on 8/24/23 and abated on 8/25/23 after corrective actions including continuous observation and re-education were implemented.
Severity Breakdown
Level of Harm - Immediate jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents only smoked outside in designated areas, resulting in immediate jeopardy to resident health or safety. | Level of Harm - Immediate jeopardy |
Report Facts
Residents present: 28
Date of immediate jeopardy declaration: Aug 24, 2023
Date of immediate jeopardy abatement: Aug 25, 2023
Number of times Resident #2 smoked outside with staff assistance: 2
Date of smoking care plan last modification: Nov 22, 2022
BIMS score: 15
Date of smoking assessments: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff #8 | Reported knowledge of residents smoking in rooms | |
| Unit Manager #6 | Denied knowledge of residents smoking in rooms | |
| Staff #4 | Caught Resident #2 smoking in room and reported it | |
| Staff #3 | Witnessed Resident #2 smoking in dining room and reported it | |
| Licensed Practical Nurse (LPN) #9 | Licensed Practical Nurse | Received report of smoking incident from Staff #3 but denied knowledge |
| Maintenance Staff #10 | Reported clogged toilet due to cigarette filters and seeing Resident #2 with cigarette | |
| Maintenance Director | Confirmed maintenance staff reports and communication with nursing staff | |
| Administrator | Administrator | Interviewed regarding smoking incidents and facility policy enforcement |
| Director of Nursing | Director of Nursing (DON) | Involved in re-education and inspection plan |
| Assistant Director of Nursing | Assistant DON | Involved in re-education of residents who smoke |
Inspection Report
Complaint Investigation
Deficiencies: 24
Jun 26, 2023
Visit Reason
The inspection was conducted as a complaint survey to investigate multiple allegations including failure to post survey results, medication errors, failure to notify physicians and families, confidentiality breaches, inadequate housekeeping and maintenance, abuse prevention failures, incomplete investigations of abuse allegations, improper resident transfers, inaccurate assessments, incomplete care plans, failure to provide ADL care, respiratory care issues, medication administration errors, staffing deficiencies, and training deficiencies.
Findings
The facility was found deficient in multiple areas including failure to post survey results, medication administration errors, failure to notify physicians and families timely, breaches in resident confidentiality, inadequate housekeeping and maintenance, failure to prevent and investigate abuse, incomplete resident transfer documentation, inaccurate Minimum Data Set (MDS) assessments, incomplete and outdated care plans, failure to provide adequate ADL care, respiratory care deficiencies, medication regimen errors including duplicate orders and failure to monitor vital signs, failure to maintain accurate medical records, and failure to provide adequate staff training and supervision.
Complaint Details
The complaint investigation revealed multiple allegations including failure to post survey results, medication errors, failure to notify physicians and families, confidentiality breaches, inadequate housekeeping and maintenance, abuse prevention failures, incomplete investigations of abuse allegations, improper resident transfers, inaccurate assessments, incomplete care plans, failure to provide ADL care, respiratory care issues, medication administration errors, staffing deficiencies, and training deficiencies.
Severity Breakdown
Level of Harm - Potential for minimal harm: 2
Level of Harm - Minimal harm or potential for actual harm: 21
Deficiencies (24)
| Description | Severity |
|---|---|
| Facility failed to post a notice of where the results of the most recent surveys, certifications, and complaint investigations were located. | Level of Harm - Potential for minimal harm |
| Failure to notify resident's physician and family timely of changes in condition, medication availability, and room changes. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to ensure confidentiality of resident records; medication carts left unlocked with resident information visible. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to maintain sanitary, orderly, and comfortable interior; observed insect presence, stains, damaged furniture and walls. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to fully implement abuse prevention policies; no background check obtained for agency staff prior to employment. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to promptly initiate and thoroughly investigate abuse allegations and report to regulatory agency within required timeframe. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to thoroughly investigate multiple incidents of alleged abuse; incomplete staff interviews and monitoring documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to document resident discharge adequately including status, reason, and transfer documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded, missing pressure ulcers, weight loss, and falls. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to implement care plan related to resident's dependence on staff for feeding and meal set up. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to update care plans related to resident's sexual and physical aggression and discharge wishes. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide needed activities of daily living (ADL) care for residents dependent on assistance. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide respiratory services in accordance with professional standards; oxygen not administered as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure physician supervised care and failed to review significant weight loss in resident's medical record. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure physician wrote, signed, and dated progress notes at each required visit. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to post total number and actual hours worked by nursing staff categories and failed to keep accurate assignment copies. | Level of Harm - Potential for minimal harm |
| Facility failed to timely provide medication to meet resident needs; medications not delivered and signed off as given. | Level of Harm - Minimal harm or potential for actual harm |
| Facility pharmacist failed to identify and report irregularities in resident's drug regimen including failure to monitor vital signs and duplicate medication orders. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to keep medications labeled with date opened, store medications securely, monitor refrigerator temperatures, and discard medications after discharge. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to perform laboratory blood testing as ordered and had expired laboratory supplies. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to employ a full time certified dietary manager to oversee dietary operations. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide food that accommodated resident allergies, intolerances, and preferences; vegetarian diet not provided as requested. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to maintain complete and accurate medical records including documentation of elopement, change in condition, and nursing notes. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure agency nurses were educated on dementia care and abuse prevention before working with residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 57
Residents affected: 5
Residents affected: 3
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 7
Residents affected: 1
Medication administration opportunities missed: 13
Weight loss: 20
Weight loss: 45
Falls: 16
Pressure ulcer size: 4.25
Pressure ulcer size: 5.16
Expired fecal occult blood test kits: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #10 | Licensed Practical Nurse | Interviewed about admission note and oxygen order; signed off medication administration incorrectly; failed to remove sutures but signed off as done |
| Physician #26 | Physician | Interviewed about failure to be notified of weight loss and oxygen orders; failed to review weight loss |
| Nurse Practitioner | Nurse Practitioner | Interviewed about failure to be notified of weight loss and oxygen orders; no longer works at facility |
| DON | Director of Nursing | Interviewed multiple times regarding findings including failure to post survey results, medication errors, weight loss notification, respiratory care, staffing, and training |
| GNA #31 | Geriatric Nursing Assistant | Identified as perpetrator in abuse allegation; no background check or abuse training documented |
| LPN #67 | Licensed Practical Nurse | Discontinued duplicate medication order for Resident #54 |
| LPN #23 | Registered Nurse | Acknowledged leaving medication cart unlocked |
| CMA #6 | Certified Medicine Aide | Acknowledged medication cart unlocked and dated inhalers after surveyor inquiry |
| LPN #25 | Licensed Practical Nurse | Informed surveyor about unlocked medication room door |
| Staff #8 | Receptionist | Interviewed about posting survey results and staffing schedules |
| Staff #40 | Director of Maintenance | Interviewed about maintenance and room audits |
| Staff #45 | Social Services | Interviewed about care conferences and discharge planning |
| Staff #66 | MDS Nurse | Confirmed MDS assessment errors |
| Staff #22 | Licensed Practical Nurse | Observed preparing to administer IV medications; informed about unlocked medication cart |
| Staff #29 | Registered Nurse | Observed leaving medication cart unlocked |
Inspection Report
Annual Inspection
Deficiencies: 23
Aug 13, 2021
Visit Reason
The inspection was conducted as part of an annual survey and complaint investigations to assess compliance with regulatory requirements and quality of care standards.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, communication of lab results and family notifications, safe and homelike environment, accurate resident assessments, baseline and comprehensive care planning, medication administration, pressure ulcer care, foot care, respiratory care, dental services, food service and menu management, infection control, medical record maintenance, and call system functionality.
Complaint Details
Complaint investigations revealed issues with quality of care including failure to communicate lab results, failure to notify family of wound worsening, failure to develop care plans, medication administration errors, and infection control breaches.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 22
Deficiencies (23)
| Description | Severity |
|---|---|
| Facility staff failed to provide a resident with dignity and respect by improperly transporting a resident down the hall. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure laboratory test results were communicated to a resident's physician and family members were notified of a worsening wound. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide a safe, clean, comfortable homelike environment and failed to provide a dresser for a resident's personal belongings. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to accurately document resident assessments on the Minimum Data Set (MDS). | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to develop a baseline care plan addressing a resident's pain management needs following admission. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to develop and implement comprehensive care plans including oxygen use, wound care, and fall precautions. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure multidisciplinary team meetings were held timely and residents and families were invited to care plan meetings. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to provide thorough grooming and personal hygiene services for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to provide liquids at lunch, timely initiate antibiotics, administer medications as ordered, and document rationale for as-needed pain medication. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to elevate heels as ordered and failed to implement wound care recommendations. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to provide proper foot care and treatment for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to promote an environment free from accident hazards by not maintaining beds in low position and not applying leg rests to wheelchairs. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to apply catheter strap and failed to address coude catheter recommendations timely. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to obtain orders for oxygen and parameters for BiPAP use and failed to document oxygen usage and treatment accurately. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to maintain medication refrigerator temperature logs consistently. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to assist a resident in obtaining routine dental care. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to ensure residents were given opportunity to choose meals in advance and failed to provide items of choice. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to use proper sanitary practices during food handling and utensil use. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to document rehabilitation evaluation in the medical record. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to maintain medical records in the most accurate form and failed to document oxygen equipment changes accurately. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to obtain an order from primary care physician for endocrinology consult as required. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to follow infection control standards related to contact precautions for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Facility staff failed to maintain resident call system in working order for one nursing unit and one resident room. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 63
Residents affected: 58
Medication doses missed: 24
Medication doses missed: 4
Temperature log missing days: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #26 | Registered Nurse | Failed to administer Hydrochlorothiazide and observed not wearing gloves during food handling |
| Staff #23 | Dietary Aide | Observed not wearing gloves during meal service |
| Director of Nursing | Interviewed multiple times confirming failures in documentation, care planning, and infection control | |
| Unit Manager #6 | Observed medication patch delivery issues for Resident #57 | |
| Unit Manager #31 | Reported call bell system not functioning properly on Unit 3 | |
| Unit Manager #53 | Observed call bell enunciator turned off on Unit 3 | |
| Director of Physical Therapy | Provided wheelchair assessment for Resident #123 | |
| Director of Social Services | Confirmed no care plan meetings held for some residents | |
| Regional Food Service Director (CDM Staff #18) | Present during food handling observations and provided education memo | |
| Dietary Manager Staff #17 | Interviewed about menu and food preference issues | |
| Occupational Therapist | Confirmed lack of rehabilitation evaluation documentation | |
| Pharmacy Consultant | Reported documentation incompatibility and lack of record of recommendations in medical record |
Inspection Report
Annual Inspection
Deficiencies: 11
Sep 11, 2018
Visit Reason
The inspection was conducted as part of the annual survey process to assess compliance with regulatory requirements and resident care standards at Elkton Nursing and Rehabilitation Center.
Findings
The facility was found to have multiple deficiencies including failure to provide dignified care, failure to honor residents' end-of-life wishes, inadequate maintenance and cleanliness, failure to notify ombudsman of transfers, failure to follow physician orders, failure to provide prescribed diets and fluids, inadequate documentation of behaviors and medication monitoring, and ineffective pest control.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to provide residents with a dignified existence, including staff being unresponsive and disrespectful. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure criteria for advance directives and end-of-life wishes were met and honored. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain a safe, clean, comfortable, and homelike environment including medical equipment and facility maintenance. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely notification to residents, representatives, and ombudsman before transfers or discharges. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow physician's orders regarding blood pressure monitoring and notification. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide nectar thick liquids as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain fluid restriction and document supplement consumption as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to document and communicate targeted behaviors for dementia care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to identify specific targeted behaviors to monitor for continued use of anti-anxiety medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain accurate and complete medical records, including documentation of refused podiatry consultation and missed nebulizer treatment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an effective pest control program, specifically concerning fly control. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 52
Residents affected: 3
Residents affected: 1
Residents affected: 61
Residents affected: 4
Fluid restriction: 1500
Blood pressure readings: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and provided information on multiple deficiencies including staff behavior, investigation results, and training initiation | |
| Geriatric Nursing Assistant (GNA) Staff #2 | Named in deficiency for disrespectful behavior toward residents and subsequent termination | |
| Unit Manager | Confirmed environmental cleanliness issues and fly presence | |
| Social Worker (Staff #2) | Interviewed regarding MOLST completion and compliance | |
| Director of Maintenance | Observed and responded to maintenance deficiencies | |
| Administrator | Interviewed regarding notification procedures for transfers | |
| Staff #1 | Unable to administer nebulizer treatment and failed to document notification |
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