Elkton Nursing and Rehab: Fall Risk Failures Cited - MD
That was January 29, 2026. The resident, identified in inspection records as Resident 300, was a documented fall risk. The care plan listed it plainly: ensure the urinal is within reach, keep the bed in its lowest position, place common items where the resident can get to them, and remind the resident to use the call light before trying to get up. None of those things were happening.
The urinal was hooked on the handle of the nightstand drawer. The resident could not reach it. The bed was raised to a medium-high position. The call bell was on the floor, underneath the bed frame.
When the Director of Nursing arrived at 11:08 that morning, she confirmed the bed was not in the low position and used the bed remote to lower it herself. Asked whether the resident should have fall mats beside the bed, the DON said it depended on what therapy had assessed, noting the resident had just returned from the hospital.
The occupational therapist who saw the resident that morning had already formed her own view. She described the resident as more sedated than the day before. Before the hospital stay, the resident had dealt with a urinary tract infection, behavioral changes, altered mental status, and previous falls. "I feel like fall mats are a good idea," she told inspectors. She also noted that the resident was impulsive, and that if items were out of reach, the resident would attempt to get out of bed, something the resident knew was not safe to do.
The fall precautions were not the only failure documented during the visit.
Resident 300's physician had ordered Midodrine, a medication used to treat low blood pressure, to be given three times a day with a specific condition attached: if the systolic blood pressure, the top number, was above 120, the dose should be held. On January 28, at 2 in the afternoon, staff gave the medication anyway. The blood pressure reading at the time was 128 over 74, eight points above the threshold that required withholding the dose.
The Director of Nursing, when told about the medication error during the inspection, said she had just seen it when the inspector asked about it. The medical director, interviewed later that afternoon, confirmed the Midodrine should have been held.
Midodrine raises blood pressure. Giving it to a resident whose blood pressure already exceeded the physician's limit for the drug carries a direct risk of pushing that pressure higher, in a resident already prone to falls, already impulsive, and already observed to be more sedated than usual that morning.
The licensed practical nurse who had been assigned to the resident's care that day, LPN 23, held the call bell in her hand during the inspection and said she didn't know who was supposed to place it on the bed.
Nobody had.
The inspection was conducted as a complaint investigation. Inspectors cited the facility for failing to provide adequate supervision and assistive devices to prevent accidents, and separately flagged the medication administration error. The care plan had the right instructions. The problem was that none of them were followed, and no one on staff appeared to have noticed before an inspector walked through the door.
The occupational therapist's words stayed in the record. When the resident's underlying medical conditions flare up, she said, the fall risk gets worse. The resident knew getting out of bed alone was not safe. What the resident needed, and what the care plan required, was to have the tools to call for help within arm's reach.
They were under the bed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elkton Nursing and Rehabilitation Center from 2026-01-29 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 19, 2026 · Our methodology
ELKTON NURSING AND REHABILITATION CENTER in ELKTON, MD was cited for violations during a health inspection on January 29, 2026.
The resident, identified in inspection records as Resident 300, was a documented fall risk.
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.