Federal inspectors found the violations during a January 29 complaint investigation at Elkton Nursing and Rehabilitation Center on Price Drive.
Resident #300 told inspectors he had trouble standing up and had fallen, breaking his pelvis and sternum. He said he had two cracks in his skull from a fall that left him unconscious.
When inspectors arrived at 8:50 AM, they found the resident's call bell under his bed. Licensed Practical Nurse #23 picked up the call bell and said, "I don't know who was supposed to put it on the bed." The urinal was positioned where the resident could not reach it.
The resident's care plan identified him as at risk for falls due to weakness, diabetes, orthostatic hypotension, left hip pain, anemia, and use of cardiovascular and psychotropic medications. Required interventions included ensuring the urinal stayed within reach, keeping the bed in the lowest position, placing common items within reach, and reminding the resident to use the call light for assistance.
None of these safeguards were in place when inspectors arrived.
The medication error involved Midodrine, prescribed three times daily for hypotension. The doctor's order specified the medication should be held if systolic blood pressure exceeded 120. On January 28 at 2 PM, staff administered the Midodrine despite the resident's blood pressure reading of 128/74 - eight points above the threshold.
When the Director of Nursing arrived at 11:08 AM the next day, the resident's bed was in medium-high position rather than the required low position. The DON lowered the bed using the remote control and confirmed it had not been in the proper position.
Inspectors asked whether Resident #300 should have fall mats beside the bed. The DON said it depended on therapy assessment since the resident had just returned from the hospital. When informed about the medication error, the DON responded, "I just saw that when you asked about it."
Occupational Therapist #21 confirmed the resident was a fall risk during an 11:37 AM interview. She said Resident #300 appeared more sedated that morning than the previous day. Before the hospital stay, the resident had experienced a urinary tract infection, behavioral changes, altered mental status, and previous falls.
"I feel like fall mats are a good idea," the therapist said. She explained that when the resident's underlying medical conditions flared up, fall risk increased significantly.
The therapist described Resident #300 as impulsive, noting that if the resident couldn't reach needed items, he would attempt to get out of bed despite knowing it wasn't safe.
The medical director confirmed during a 1:15 PM interview that the Midodrine should have been withheld given the blood pressure reading.
The facility's care plan specifically required staff to ensure the urinal remained within reach and remind the resident to use the call light for assistance. Yet inspectors found both safety devices positioned where the resident could not access them.
The violations occurred despite the resident's documented history of serious fall injuries and multiple risk factors. His care plan acknowledged the dangers posed by his medical conditions and medications, but staff failed to implement basic safety measures.
Federal inspectors classified the deficiency as causing minimal harm or potential for actual harm to few residents. The facility must submit a plan of correction addressing how staff will ensure fall-risk residents have access to call bells and urinals, and how medication administration will follow physician parameters.
For a resident who had already suffered skull fractures, a broken pelvis, and sternum damage from falls, the combination of improper medication administration and inaccessible safety equipment represented a dangerous breakdown in basic care protocols.
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.