Elkton Nursing and Rehab: Transfer Failure Broke Resident's Leg - MD
The resident, identified in inspection records as Resident 156, had a care plan in place since July that was unambiguous: Hoyer lift, two-person assist, for all transfers. Ambulation was listed as impossible. A therapy progress report from August 21 described the resident as requiring substantial to maximal assistance for any chair or bed movement. None of that information reached the nursing assistant who was in the room that morning.
According to the facility's own investigation, Geriatric Nursing Assistant 28 was present when the resident, who had been brought out of bed by therapy earlier that day, asked to go back to bed. The nursing assistant told the resident they would help. What happened next is documented in the resident's own words, given to facility staff the same day as the fall.
The resident said the bed had been lowered for them to get in. They had been working with therapy on stand-and-pivot transfers and had done a car transfer with a therapist recently. They believed they could do it. They stood. Their feet, the resident said, felt almost like they were glued to the floor. They fell onto their right knee, then their buttocks, then hit their head on the floor. The nursing assistant, the resident recalled, was at the foot of the bed near the window.
The nursing assistant's account, given to the facility two days later, described standing nearby while the resident declared they did not need help, stood, took a step, and went down. The nursing assistant did not attempt to stop the resident, did not call for a second person, did not consult the medical chart, and did not ask a nurse about the resident's transfer status before any of this unfolded.
An X-ray taken that same day told the rest of the story. The radiology report documented a grossly displaced fracture of the distal femur, extending into the hardware from a prior knee replacement.
The Director of Nursing, interviewed by inspectors on October 2, was direct about what went wrong. The nursing assistant, she said, attempted to assist with a transfer without a Hoyer lift or a second person, did not try to stop the resident from transferring, did not seek help, and did not check the chart or ask a nurse about transfer status. "He/she should have known and did not," she said.
The Director of Rehabilitation confirmed that on the day of the fracture, the resident required a two-person Hoyer lift transfer. Full stop.
The nursing assistant was terminated on September 24, nine days after the fall. The facility also reported the nursing assistant to the Maryland Board of Nursing.
By September 22, the facility had put all nursing staff, including agency workers, through education on safe transfers, checking the Kardex for transfer status before moving a resident, and what to do when a resident insists on transferring in a way that contradicts their care plan. Audits began September 29, intended to confirm that staff could locate transfer status in the clinical record and that residents requiring mechanical lifts were actually receiving them.
Federal inspectors, who completed their review on October 9, 2025, cited the facility for causing actual harm to Resident 156.
The resident had scored a perfect 15 out of 15 on a mental status assessment in July, meaning they were fully cognitively intact. They understood what therapy had been working on with them. They believed, not unreasonably given recent sessions, that they could manage a short transfer on their own. What they could not have known was that the person in the room with them had never looked at the care plan.
A fractured femur at the site of a knee replacement, in an elderly resident who could not walk, is not a minor injury. The inspection record does not describe what came next for Resident 156. It does not say whether they returned to rehabilitation, whether the fracture required surgery, or whether they ever transferred to a bed again without a mechanical lift and two sets of hands steadying them.
The record ends with the audit sheets, dated September 29, and the question of whether any of it was enough.
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
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 10, 2026 · Our methodology
ELKTON NURSING AND REHABILITATION CENTER in ELKTON, MD was cited for violations during a health inspection on October 9, 2025.
Ambulation was listed as impossible.
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.