Federal inspectors found that facility staff simply failed to complete laboratory work as directed by physicians, with no documentation explaining why the tests never happened.
Resident 300 arrived at the facility in January with diabetes and anemia. On January 5, the resident's physician ordered a complete blood count, comprehensive metabolic panel, and magnesium level to be drawn the following day.
The tests never happened.
Inspectors reviewing the resident's medical record on January 29 found no laboratory results from January 6. Nurses had documented nothing about why the blood work was skipped. The Director of Nursing confirmed to inspectors that staff had failed to obtain the tests as ordered.
For a diabetic patient with anemia, these laboratory values provide essential information about blood sugar control, kidney function, and red blood cell levels. The comprehensive metabolic panel would have shown whether the resident's diabetes was affecting organ function, while the blood count would have tracked the anemia's severity.
A second resident faced similar neglect. Resident 302 had been admitted with pneumonia and was being monitored through blood work. On January 7, a physician's assistant reviewed abnormal lab results and documented an order to repeat the complete blood count the next morning.
That evening, a nurse noted in the resident's record that the physician's assistant had reviewed the January 7 labs and that "resident already has order for CBC in am."
The morning blood draw never occurred.
Resident 302 was discharged from the facility on January 13 without the follow-up blood work that would have shown whether the pneumonia treatment was working. The Director of Nursing confirmed to inspectors that no CBC had been completed on January 8 as ordered.
The missed laboratory work represents a breakdown in basic medical care coordination. Physicians order blood tests to track treatment effectiveness, monitor medication side effects, and catch complications before they become serious. When nursing homes fail to complete these tests, doctors lose crucial information needed to adjust treatments.
The violations occurred during a complaint survey, suggesting someone had reported concerns about the facility's operations. Inspectors found the laboratory failures affected few residents, but classified the violations as having potential for actual harm.
Federal inspectors documented their findings under regulations requiring nursing homes to provide timely, quality laboratory services to meet residents' needs. The facility's failure to obtain ordered tests or document reasons for delays violated these standards.
For Resident 300, the missed diabetes and anemia monitoring could have delayed detection of dangerous blood sugar swings or worsening anemia. Diabetic patients in nursing homes face higher risks of complications, making regular lab monitoring essential for safe care.
Resident 302's situation was equally concerning. Pneumonia patients need follow-up blood work to ensure infection markers are improving and that treatments aren't causing dangerous side effects. Discharging the resident without completing the ordered tests left gaps in the medical record.
The Director of Nursing's acknowledgment that both residents had missed their ordered laboratory work suggests the problems weren't isolated oversights but systemic failures in the facility's lab coordination processes.
Neither resident's medical record contained any documentation explaining why the tests were skipped or rescheduled. This lack of communication between nursing staff and physicians could have led to inappropriate treatment decisions based on incomplete medical information.
The inspection findings raise questions about how many other residents may have experienced similar lapses in laboratory services, and whether the facility has adequate systems to ensure physician orders are consistently followed and completed as directed.
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.