Elkton Nursing And Rehabilitation Center

money on Friday.

Sometimes the facility runs out of money to dispense to the residents.

resident's funds are distributed by the day receptionist Monday through Friday, from about 9AM to

distribute resident funds during office hours, Monday through Friday, from 10AM to 4:30PM, if the receptionist is not available.

There is no money distributed after business hours or on weekends. If a resident needs money for the weekend, they must request it on Friday.

The Surveyor expressed the concern that the facility does not provide ongoing access to their funds and that the facility cannot restrict the resident's access based on the time of day.

In addition, BOM #51 stated that the facility recently ran out of petty cash one day in October to dispense to the residents.

Residents seemed to be taking out more money than in past months. BOM #51 informed the Surveyor that the business office will ensure there is enough petty cash available to accommodate the resident monetary needs.

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Elkton Nursing and Rehabilitation Center 1 Price Drive Elkton, MD 21921

punishment, and neglect by anybody.

the review of medical records, administrative records, interviews, and observations it was determined

was evident for 1 (#143) out of 8 residents reviewed for abuse during the recertification survey.The findings include:On 09/28/2025 at 09:30 AM the surveyor observed the Resident #143 in the hallway of the second floor in a wheelchair.

The resident denied any remembrance of an employee being physically abusive towards him/her. On 09/28/2025 at 1:00 PM the surveyor reviewed intake #2578157 and the complaint #2578168 related to resident #143.

The facility report was directly related to the complaint.On 10/07/25 at 08:15 AM the surveyor continued the review of the resident's hard copy facility incident report.

The review revealed that the facility had found the perpetrator (GNA #40) physical abused Resident # 143.

The physical abuse consisted of the GNA #40 being observed slapping the resident on the right cheek while attempting to get Resident #143 off the elevator. A staff #41, from the laundry department witnessed the encounter between Resident #143 and GNA # 40.

The resident was struck on the right side of the face.

However, the hospital staff stated the resident #143 reported being hit on left side of the face by a staff member while at the nursing home facility.

The resident was ordered to be taken to the hospital for CT scan of the head on the same evening of the incident.

The CT scan completed on 08/01/25 was negative. Resident #143 returned to the facility on [DATE]. On 10/07/2025 at 09:40 AM the hard copy of the entire facility incident report was provided to the surveyor.

The initial report stated: Allegation: physical abuse and stated the facility became aware of the incident on 07/31/2025 at 08:15 PM the assistant administrator was notified at 8:27 PM on 07/31/2025.

The alleged perpetrator was GNA #40.

The individual who made the witnessed allegation was laundry assistant #41.

The laundry assistant #41 was contacted by the surveyor by telephone and verified/confirmed the physical assault incident described in the facility report.

The final investigation of the facility incident report confirmed that resident #143 had been physically assaulted by GNA #40. GNA#40 was terminated on 08/07/25 and reported to the Maryland Board of Nursing. On 10/07/2025 the surveyor reviewed the results of the facility report investigation and the complaint with the DON.On 10/09/2025 the facility administrator and DON were advised of the deficiency related to resident abuse during the exit conference.

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reviewed, and revised by a team of health professionals.

ensure residents right to participate in the development, review and revision of his/her care plan.

This

include: On 09/29/2025 at 12:35 PM during observation and interview with Resident #58, resident stated I only have care plan meetings at the bedside with the Social Worker, the most recent was 09/25/25, I receive a copy of my latest care plan and a grievance form and that is it Resident further stated, the Social Worker is unable to answer any of my questions about my medical care and business concerns, I am always told just to fill out a grievance form.

The resident shared with Surveyor the copies of the Care Plan related documents they have received from the Social Worker, the items consisted of the Care Plan meeting invitation for 9/25/25-the resident documented on the letter it was received 9/23/25 at 2:56 PM; a Care Plan Report with admission Date: 6/4/25 and Revision Date: 9/15/25; and a blank Grievance form.On 09/29/2025 at 1:04 PM during observation and interview with Resident #14, resident stated, care plan meetings occur frequently, but are only attended by social worker (Staff #36) and stated the meeting is not very helpful, unable to discuss concerns regarding depression, and they do not feel supported.On 10/03/2025 at 12:45 PM during an interview with the Director of Social Services, Staff #36, surveyor shared resident expressed concerns of bedside care plan meetings with only Social Services in attendance and no support from an Interdisciplinary Team (IDT).

Staff #36 confirmed Care Plan meetings are often at the residents' bedside and attended by Social Services alone.

Surveyor asked what the Care Plan meeting process is, the expectation based on facility Policies & Procedures, and what is provided to the resident.

Staff #36 stated I invite the IDT team who is required to attend, and the meetings are posted for participation, but IDT does not usually attend at the bedside with Social Services and the resident. I meet with the resident at the bedside and give them a copy of their care plan and medication list.

Surveyor asked, of the recent meetings for Residents #58 and #14, if the IDT team participated at the bedside Care Plan meetings; staff #36 stated No.On 10/07/2025 at 8:53 AM during record review of Resident #58, it revealed 2 identical Discharge Planning notes, dated 9/1/25 and 9/8/25 both indicating Resident was alert and easily agitated. [They] has frustration and anger about [their] stay at this facility.

Surveyor also reviewed the Care Plan Report Sign-In sheet, which revealed a facility signature, the Social Services Assistant, Staff #66, dated 9/25/25 at 1:10 PM and Resident #58 signature only.On 10/08/2025 at 2:17 PM a record review of Resident #14 revealed sign-in sheets for the last 4 Care Plan meetings were held 8/7/25, 6/26/25, 5/29/25, and 4/11/25 and attended only by the resident and the Social Services Assistant, Staff #66, except for the addition of the Director of Recreational Therapy, staff #10 on 8/7/25 and Physical Therapy Director, staff #30 on 5/29/25.On 10/09/2025 at 9:19 AM during follow-up interview with Director of Social Services, staff #36, regarding record review for both residents.

Staff #36 stated no further documentation existed to support full Care Plan meeting interventions.

Staff #36 informed this surveyor that Resident #14 is likely mad, because they had to take away the resident's weed per the DON, staff #2 request.

Surveyor requested documentation and timeframe regarding this interaction and stated confiscation; staff #36, states no, there was no documentation.

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Elkton Nursing and Rehabilitation Center 1 Price Drive Elkton, MD 21921

Review of Facility Reported Incident Investigation on 10/02/2025 at 2:00 PM revealed that that the facility had verified Resident #156 having a witnessed fall while transferring to bed from a wheelchair sustaining a right acute fracture of the distal femur on 09/15/2025 due to Geriatric Nursing Assistant (GNA) staff #28 failing to identify transfer status of Resident #156 to be a mechanical lift assist of 2 persons for all transfers.

The facility interviewed Geriatric Nursing Assistant (GNA) #28 on 09/17/2025 and GNA #28 statement stated that on 09/15/2025 at 10:50 AM therapy had gotten Resident #156 out of bed into a wheelchair, and he/she requested to go back to bed. GNA #28 stated to Resident #156 that he/she was going to put him/her in bed but Resident #156 stated, No I do not need help, stood to take a step and went down on his/her right knee, turned to his/her buttocks leaning back toward the bedside table.

The facility interviewed resident #156 on 09/15/2025 and resident statement stated that he/she was trying to transfer from the wheelchair to his/her bed and that the bed was lowered for him/her to get in, he/she had been working with therapy for stand and pivot and did a car transfer the other day with therapy. He/she stated he/she stood, his/her feet would not move almost like glue to the floor, and he/she fell on to the right knee, then his/her buttocks then fell back and hit their head on the floor.

The resident stated that the caregiver was at the foot of the bed near the window and the resident stated that he/she was trying to get into bed on the side closest to the door.

Further review revealed that GNA #28 was terminated by the facility on 09/24/2025 for violation of company policy.

During interview with 10/02/2025 at 2:10 PM Director of Nursing staff #2 stated that, [GNA #28] attempted to assist [Resident #156] with a transfer without a Hoyer Lift or a second person, did not try and stop resident from transferring, did not try and get help or clarification from the resident medical chart or ask a nurse regarding [Resident #156] transfer status. He/she should have known and did not.

Director of Nursing staff #2 further stated, [GNA #28] was reported to the Maryland Board of Nursing.

During an interview on 10/02/2025 at 4:31 PM Director of Rehabilitation staff #30 stated, [Resident #156] was a 2 person transfer with a Hoyer lift at the time of injury/fracture on 09/15/2025.

Staff #30 also provided a PT Recert, Progress Report and Updated Therapy Plan Current dated 8/21/2025 revealing that Resident #156 was Substantial/ maximal assistance for chair/bed transfers.

Staff #30 further stated, staff should have used a Hoyer lift with 2 persons assist with [Resident #156] on the day that he/she was transferred and sustained a fracture.

Review of facility staff education on 10/03/2025 at 11:20 AM revealed that the facility completed all facility nursing staff, including agency staff, education as of 09/22/2025 regarding transferring a resident safely, checking Kardex for transfer status prior to transfer, and notifying nurse if resident insists on transferring in a manner inconsistent with safe transfer status.

During an interview on 10/07/2025 at approximately 8:05 AM Director of Nursing stated that, audits were started on 09/29/2025 to ensure staff are able to demonstrate where the transfer status is found in the clinical record and that the residents that require a mechanical lift for transfer are transferred appropriately.

During review of facility documentation on 10/07/2025 at 8:10 AM the facility audit sheets revealed a start date of 09/29/2025.

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Elkton Nursing and Rehabilitation Center 1 Price Drive Elkton, MD 21921

hospice services, they stated: No, it (pain) should be controlled. On 10/8/25 at 9:08AM the surveyor

#45 reported I don't remember, I thought that happened on an off shift, 3-11 or 11-7.

When the

#179's situation to prevent further occurrence, they stated the following: It should've been fixed, but whether it did or not I don't know, the unit manager should have done that. On 10/8/25 at 11:45AM the surveyor shared the harm level concern with the facility's Director of Nursing and the facility's Administrator who both acknowledged and confirmed understanding of the surveyor's concerns. At this time the surveyor additionally provided an opportunity for any and all further documentation to be provided by the facility for surveyor review.

The Director of Nursing stated to surveyors that there was no further documentation to be provided.

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Elkton Nursing and Rehabilitation Center 1 Price Drive Elkton, MD 21921

plans with the resident when needed. Of note, this Surveyor was unable to locate any follow-up

#65 shared with this Surveyor, that I have a court appointed Guardian but they are not helpful with

Worker during Care Plan meetings or to the Guardian, I'm often told too much paperwork.On 10/08/2025 at 10:27 AM during record review it revealed Resident #65's court appointed Guardian dated 6/9/25; a BIMS Score of 15 dated 11/21/24; and the Physician Certification Related to Medical Condition, Decision Making, and Treatment Limitations, states resident has adequate decision making capacity (including decisions about life-sustaining treatments), dated 1/17/22.

These findings and Resident #65's concerns were shared with the Director of Social Services staff #36.On 10/09/2025 at 4:36 PM during interview with Director of Social Services staff #36, stated I met with [resident #65] regarding Guardian stating too much paperwork and confirmed that resident does want granddaughter to be POA.

Staff #36 stated I will assist resident #65 to get POA with the granddaughter.

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Elkton Nursing and Rehabilitation Center 1 Price Drive Elkton, MD 21921

resident #58 next appointment schedule for 10-23-25.

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Elkton Nursing and Rehabilitation Center 1 Price Drive Elkton, MD 21921

According to the updated list Resident #55 is still an independent smoker.

sustained an unwitnessed fall with no injuries, on 08/20/2025 at 19:55 PM.

Progress note Type:

08/20/2025 at 12:00 AM.

Progress note Type: 72-hour Post Fall Documentation dated 08/27/2025 stated resident fall occurred on 08/20/2025 at 12:00 AM, Progress note Type: 72-hour Post Fall Documentation Effective dated 08/31/2025 stated resident fall occurred on 08/26/2025 at 12:00 AM.

During interview on 10/07/2025 at 11:20 AM the Director of Nursing staff #2 was notified and shown the progress notes reflecting different time frames related to the when Resident #105 sustained a fall on 08/20/2025.

Staff #2 stated Yes and agreed that the progress notes reflected different times of when the fall occurred.

Staff #2 also stated Resident #105 had only 1 fall since his/her admission to the facility which was on 08/20/2025.

During interview on 10/07/2025 at 11:51 AM the Director of Rehabilitation Services staff #30 stated, Resident #105 had 1 fall since his/her admission, that the department has documented on 08/20/2025.

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Elkton Nursing and Rehabilitation Center 1 Price Drive Elkton, MD 21921

During observation rounds of Unit 1 on 09/28/2025 at 8:55 AM resident #16 room was observed to have 11 black insects flying around near and on resident #16 head, bed and privacy curtain.

During an interview on 09/28/2025 at 8:56 AM resident #16 stated, there are flies flying around my head, landing on my food, all over my bed and just everywhere.

During an interview on 09/28/2025 at approximately 11:00 AM the Nursing Home Administrator staff #1 was made aware of the observation of insects in resident #16 room.

Staff #1 stated that the problem would be addressed.

During observation rounds of Unit 1 on 09/30/2025 at 10:00 AM resident #16 room was noted to have 5 black insects flying around near and on resident #16 bed and privacy curtain.

During an interview on 09/30/2025 at approximately 10:20 AM staff #16 was made aware of the observation of insects in resident #16's room and stated, the pest control company can come in and if the flies are still a problem, then they can come in and spray the room.

On 9/28/2025 at 7:50AM, during a tour of Unit 2, the Surveyor observed flies and gnats in the hallway.

On 9/28/2025 at 9:55AM, during an interview with resident #155 on Unit 1, the Surveyor was informed that the facility issues with flies and gnats in the building.

On 9/28/2025 at 10:08AM, during a continued tour of Unit 1, the Surveyor observed flies in room [ROOM NUMBER].

During a tour of the shower room on Unit 1 on 9/29/2025 at 10:45AM, the Surveyor observed flies inside the bathroom.

On 9/29/2025 at 12:30PM, during an observation of room [ROOM NUMBER] on Unit 2, the Surveyor observed a trail of ants crawling from the baseboard underneath the window to a yellow food like particle on the ground by the bed.

Geriatric Nursing Assistant (GNA) #68 and Unit Manager (UM) #23 confirmed the Surveyor findings. UM #23 stated that she would let the maintenance department know about the ants in room [ROOM NUMBER].

During environmental rounds with the Director of Maintenance (DOM) #16, Director of Housekeeping (DOH) #15, the Nursing Home Administrator (NHA), and Administrator in Training (AIT) #3 on 10/2/2025 at 10:30AM, the Surveyor expressed the concerns regarding gnats, flies, and ants within the facility. DOM #16 stated that a pest control company visits the facility weekly and will make sure they look into the pest concerns.