Elkton Nursing and Rehab: Pain Crisis Ignored - MD
Those answers came from the facility's own Assistant Director of Nursing.
The inspection, completed October 9, 2025, was triggered by a complaint. Surveyors determined that the harm to Resident 179 was actual, not potential. The resident was on hospice. Hospice care carries one foundational promise above almost any other: pain will be controlled. When the surveyor asked a hospice staff member whether pain should be uncontrolled in that setting, the answer was unambiguous. No, they said. It should be controlled.
It wasn't.
On the morning of October 8, a surveyor sat down with the facility's Assistant Director of Nursing, identified in inspection records as ADON 45, to ask directly about what had happened to Resident 179. The ADON's recollection was thin. "I don't remember," she told the surveyor. "I thought that happened on an off shift, 3-11 or 11-7."
The surveyor pressed further. Had the facility done anything in response to what happened, anything to make sure it didn't happen again? The ADON's answer was a sentence that managed to acknowledge a failure and disclaim responsibility for it at the same time. "It should've been fixed," she said, "but whether it did or not, I don't know. The unit manager should have done that."
She did not know whether a hospice resident's pain crisis had ever been addressed. She pointed to someone else.
Later that same morning, at 11:45, the surveyor met with the Director of Nursing and the facility's Administrator. Both acknowledged the surveyor's concerns. Both confirmed they understood what was being communicated to them. The surveyor gave the facility an opening, asking whether there was any additional documentation, anything at all, that might show what the facility had done for Resident 179 or what steps had been taken afterward.
The Director of Nursing said there was nothing further to provide.
No documentation of follow-up. No record of corrective action. No evidence that anyone had tracked whether the pain crisis was resolved or whether the conditions that caused it had changed. The facility's own leadership, when given a direct opportunity to produce something showing they had responded, came up empty.
The inspection record lists the level of harm as actual harm and notes that few residents were affected. That phrasing, standard in CMS deficiency reports, can obscure what it describes. Resident 179 was one person. One person on hospice, in a setting where the explicit goal is comfort, who experienced a pain crisis that the facility's second-ranking nursing official could not remember and could not confirm had ever been resolved.
Elkton Nursing and Rehabilitation Center sits at 1 Price Drive in Elkton, Maryland. The facility's provider identification number is 215269.
The Director of Nursing had no further documentation to provide. Whether Resident 179's pain was ever brought under control, the inspection record does not say.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
ELKTON NURSING AND REHABILITATION CENTER in ELKTON, MD was cited for violations during a health inspection on October 9, 2025.
Those answers came from the facility's own Assistant Director of Nursing.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.