The October 9 complaint investigation revealed that staff failed to honor residents' discharge preferences and ignored requests for guardian changes, violating federal requirements that nursing homes support residents' right to make their own decisions about their care and living arrangements.
Resident 117 told staff multiple times since March that they wanted to return to the community. The resident's daughter had initially sought long-term care placement because the family could no longer provide care at home, and the resident agreed to nursing home admission in March 2025.
But the resident's preferences changed.
Staff documented that Resident 117 had "adequate decision making capacity" for all medical decisions. The facility's care plan, created in June, specifically instructed staff to "assess for the resident's preference to return to the community and refer if needed" and to "review and update discharge plans with the resident when needed."
Despite these clear instructions and the resident's repeated requests, inspectors found no evidence that staff ever followed up on discharge planning or provided any assistance.
When inspectors asked the Director of Social Services about Resident 117's case, the administrator acknowledged the resident had expressed interest in leaving but said no further assistance or documentation was offered.
Resident 65 faced a different but equally frustrating situation with guardianship. The resident told inspectors on September 30: "I have a court appointed Guardian but they are not helpful with anything. I want my granddaughter to be my POA/Guardian, but when I requested this to the Social Worker during Care Plan meetings or to the Guardian, I'm often told too much paperwork."
Medical records showed Resident 65 scored 15 on the Brief Interview for Mental Status, indicating intact cognitive function. A physician certification from 2022 confirmed the resident had "adequate decision making capacity" for all treatment decisions, including life-sustaining treatments.
The court had appointed a guardian in June 2025, but the resident clearly wanted to change that arrangement to have their granddaughter serve as power of attorney instead.
For months, the resident raised this request during care plan meetings with the social worker and discussed it with the current guardian. Each time, they received the same dismissive response about paperwork being too complicated.
Only after federal inspectors questioned staff about the situation did the Director of Social Services take action. On October 9, the administrator told inspectors: "I met with [resident 65] regarding Guardian stating too much paperwork and confirmed that resident does want granddaughter to be POA. I will assist resident 65 to get POA with the granddaughter."
The timing was telling. The resident had been requesting this change for months, but staff only offered help after inspectors discovered the problem during their investigation.
Federal nursing home regulations require facilities to support residents' rights to make decisions about their own care and living situations when they have the mental capacity to do so. Both residents clearly met this standard, with documented cognitive assessments and physician certifications confirming their decision-making abilities.
The violations reflect a broader pattern of staff dismissing residents' legitimate requests rather than providing the support required by federal law. Telling a cognitively intact resident that guardianship changes involve "too much paperwork" effectively denies their fundamental right to choose who makes decisions on their behalf.
For Resident 117, the failure was even more stark. The facility's own care plan explicitly required staff to assess discharge preferences and update plans accordingly, yet no one followed through despite multiple requests from the resident.
Both cases involved residents who had adequate mental capacity to make their own decisions but were essentially trapped by staff indifference. Resident 117 wanted to leave the facility entirely but received no help with discharge planning. Resident 65 wanted to change who had legal authority over their affairs but was repeatedly brushed off.
The inspection found the facility failed to ensure residents could exercise their rights regarding discharge planning and guardian selection. Federal regulators classified the violation as causing minimal harm but noted it affected few residents.
Both residents remained at Elkton Nursing as of the October inspection, their requests for change still largely unaddressed despite months of asking for help that never came.
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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