ELKTON, MD. Resident #58 sat in their room on September 29 and described care plan meetings that consisted of a social worker, a copy of their care plan, and a blank grievance form.
"I only have care plan meetings at the bedside with the Social Worker," the resident told federal inspectors. "The Social Worker is unable to answer any of my questions about my medical care and business concerns, I am always told just to fill out a grievance form."
Federal inspectors found Elkton Nursing and Rehabilitation Center violated care planning requirements by conducting meetings without the required interdisciplinary team present. Two residents out of two investigated described identical experiences during the October complaint inspection.
The resident showed inspectors documentation from their September 25 meeting: a care plan invitation received two days earlier, a care plan report, and the blank grievance form they'd been handed when they asked questions.
Down the hall, Resident #14 described the same pattern. Care plan meetings happened frequently, they said, but only the social worker attended. The meetings weren't helpful. The resident couldn't discuss concerns about depression and felt unsupported.
Director of Social Services Staff #36 confirmed the practice when inspectors interviewed her October 3. Care plan meetings often occurred at residents' bedsides with only social services present, she acknowledged.
"I invite the IDT team who is required to attend, and the meetings are posted for participation, but IDT does not usually attend at the bedside with Social Services and the resident," Staff #36 told inspectors. "I meet with the resident at the bedside and give them a copy of their care plan and medication list."
When asked specifically about recent meetings for both residents, Staff #36 said no interdisciplinary team members participated.
Federal regulations require nursing homes to develop care plans within seven days of comprehensive assessments, prepared and reviewed by a team of health professionals. The interdisciplinary approach ensures residents receive input from nursing, therapy, dietary, and other specialists familiar with their conditions.
Records revealed the isolation of these meetings. Resident #58's September 25 care plan meeting included signatures from only the resident and Social Services Assistant Staff #66. No nurses, therapists, or other clinical staff signed the documentation.
Resident #14's last four care plan meetings showed the same pattern. Meetings on August 7, June 26, May 29, and April 11 included only the resident and Social Services Assistant Staff #66. Two meetings added single specialists: the recreational therapy director attended once, the physical therapy director another time.
The records painted a picture of residents trying to engage with their care while being systematically excluded from meaningful participation. Resident #58's discharge planning notes from September revealed underlying tensions, describing someone who was "alert and easily agitated" with "frustration and anger about their stay at this facility."
During a follow-up interview October 9, Staff #36 admitted no additional documentation existed to support full care plan interventions for either resident. She then offered an explanation for one resident's dissatisfaction that highlighted the facility's communication problems.
"Resident #14 is likely mad, because they had to take away the resident's weed per the DON, staff #2 request," Staff #36 told inspectors.
When inspectors asked for documentation about this confiscation, Staff #36 said none existed.
The violation affects how residents understand and influence their own care. Care plan meetings serve as the primary forum where residents learn about their treatment goals, voice concerns about their conditions, and work with clinical staff to adjust their care approach.
Without interdisciplinary participation, residents lose access to the expertise of nurses who monitor their daily health changes, therapists who understand their rehabilitation potential, and other specialists who contribute to their overall treatment strategy.
Resident #58's experience illustrated the circular frustration created by this system. They received meeting invitations, attended the meetings, received care plan copies, but couldn't get answers to medical questions from the only staff member present. When they asked questions, they received grievance forms instead of clinical expertise.
The pattern continued for months. Resident #14's four documented meetings over five months showed consistent attendance by social services staff who couldn't address the resident's depression concerns or provide the clinical support they needed.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to few residents. But the findings revealed a systematic breakdown in the care planning process that left residents unable to participate meaningfully in decisions about their own treatment.
The inspection occurred October 9 following a complaint. Records showed the problematic meetings continued through late September, just weeks before inspectors arrived to investigate.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elkton Nursing and Rehabilitation Center from 2025-10-09 including all violations, facility responses, and corrective action plans.
Additional Resources
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