Elkton Nursing And Rehabilitation Center

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

Based on medical record review and staff interview, it was determined that the facility staff failed to administer medications as ordered by the physician (Resident #302). This was evident for 1 of 5 residents reviewed during a complaint survey.The findings include:Review of Resident #302's medical record on 1/29/26 revealed the Resident was admitted to the facility with a diagnosis to include pneumonia.Review of Resident #302's January 2026 Medication Administration Record with the Director of Nursing on 1/29/26 revealed no documentation the following medications and treatments were administered to the Resident per physician's orders:PICC (peripherally inserted central catheter) line flush every shift on 1/7/26 night shift and 1/10/26 day shiftAcetylcysteine Solution 10 ml inhale orally every 6 hours on 1/8, 1/9 and 1/10/26 at 6 AM, 1/11/26 at 12 PM and 6 PM and 1/12/26 at 6 PMAlbuterol Sulfate Inhalation 3 ml via nebulizer every 6 hours on 1/8, 1/9 and 1/10/26 at 6 AMPiperacillin 4.5 gram intravenously every 6 hours for pneumonia on 1/8, 1/9 and 1/10/26 at 6 AMInterview with the Director of Nursing on 1/29/26 at 10:28 AM confirmed the Surveyor's findings.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Elkton Nursing and Rehabilitation Center

1 Price Drive Elkton, MD 21921

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined the facility failed to provide treatment/services to prevent/heal pressures ulcers. This was evident for 1 (#300) of 3 residents reviewed for pressure ulcers

during a complaint survey.The findings include: A pressure ulcer, also known as pressure sore or decubitus ulcer, is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed). On 1/29/26 at 8:35 AM a

review of Resident #300's medical revealed the resident was admitted to the facility on [DATE REDACTED] with diagnoses that included a fracture of the left pubis, type 2 diabetes mellitus with diabetic neuropathy and hyperglycemia, and severe protein-calorie malnutrition. Review of a 1/6/26 nursing admission note documented Resident #300 was admitted with a pressure ulcer on the right heel. A 1/6/26 medical progress note documented that Resident #300 had an active right heel pressure injury and staff were to, offload right heel continuously with boots and pillows and avoid pressure on affected area. A 1/8/26 skin and wound note documented the right heel pressure ulcer was stage 3 and the assessment/plan was, float heels while

in bed with use of the facility's preferred equipment, pillows/boots, etc. Recommend ongoing pressure reduction and turning/repositioning precautions per protocol, including pressure reduction to the heels.

Review of Resident #300's January 2026 Treatment Administration Record (TAR) documented the physician's order, offload heels with green boots as tolerated every shift. On 1/28/26 the boots were signed off as worn each shift. On 1/29/26 at 8:50 AM Resident #300 was observed in bed lying on his/her back eating breakfast. Resident #300's feet were observed lying directly on the mattress of the bed and the heels were not elevated. Resident #300 was wearing gray slipper socks and did not have heel boots on their feet.

Resident #300 was asked if the staff ever elevated his/her feet off the mattress and the response was, sometimes but there is nothing there now. On 1/29/26 at 9:30 AM a second observation was made of Resident #300, and his/her heels were still lying directly on the mattress. On 1/29/26 at 11:04 AM a third

observation was made of the resident, and a pillow was under the bottom of his/her legs. Resident #300 was wearing gray slipper socks. The Director of Nursing (DON) came to the room with the surveyor and observed the resident's feet. The DON was informed of the previous observations and was informed that nursing staff had been signing off that heel boots were being worn, however there were no heel boots in the resident's room. The DON confirmed the finding and stated she would have someone get heel boots on the resident.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Elkton Nursing and Rehabilitation Center

1 Price Drive Elkton, MD 21921

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

1/29/26 at 8:50 AM an interview was conducted with Resident #300. Resident #300 stated that he/she had trouble standing up. Resident #300 stated he/she had fallen and broke his/her pelvis and sternum. Resident #300 stated he/she had 2 cracks in his/her skull because he/she fell and went unconscious. On 1/29/26 at 8:50 AM Licensed Practical Nurse (LPN) #23 was asked to come into Resident #300's room. At that time

the surveyor showed LPN #23 where the call bell was located. LPN #23 stated, what is it doing under there.

LPN #23 picked up the call bell and was holding the end of it and said, I don't know who was supposed to put it on the bed. At that time the surveyor showed LPN #23 where the urinal was and that the resident could not reach it.Continued review of Resident #300's medical record revealed a care plan, the resident is at risk for falls and fall related injury r/t weakness, diabetes, orthostatic hypotension, pain in left hip, anemia, use of cardiovascular and psychotropic medications. Interventions on the care plan included, Ensure urinal is within reach, place bed in lowest position while resident is in bed, place common items within reach of

the resident, and remind the resident to use their call light to ask for assistance with ADLS.Review of physician's orders revealed the order for Midodrine 10 mg. to be given 3 times a day for hypotension. The order stated if the systolic blood pressure (SBP) (top number of blood pressure) is greater than 120, the medication should be held. Review of Resident #300's January 2026 Medication Administration Record (MAR) documented the Midodrine was given on 1/28/26 at 1400 (2 PM) for a blood pressure of 128/74. The Midodrine should have been held because it was outside of physician ordered parameters. Cross Reference F-F757.On 1/29/26 at 11:08 AM with the Director of Nursing (DON), Resident #300 was observed with the bed in medium high position. The DON confirmed the bed was not in low position. The DON via bed remote lowered the resident's bed. The DON was asked if Resident #300 should have fall mats next to

the bed. The DON stated it depended on what therapy assessed as the resident just came back from the hospital. The DON was informed at that time about the Midodrine being given outside of parameters. The DON stated, I just saw that when you asked about it. The DON was also informed of the morning's

observations of the urinal on the night stand drawer handle and the call bell under the bed.On 1/29/26 at 11:37 AM an interview was conducted with Occupational Therapist (OT) #21. OT #21 stated that Resident #300 was a fall's risk. OT #21 stated that when she saw Resident #300 this morning that Resident #300 was a little more sedated than yesterday. Prior to going out to the hospital the resident had a urinary tract infection and then had the behaviors and altered mental status and had previous falls. I feel like fall mats are a good idea. OT #21 stated that she felt that when the resident's underlying medical conditions arise then it places the resident at more of a risk for falls. OT #21 stated that Resident #300 was also impulsive, so if Resident #300 could not reach things the resident would try to get out of bed which the resident knew was not safe to do.On 1/29/26 at 1:15 PM an interview conducted with the medical director confirmed that

the Midodrine should have been held.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Elkton Nursing and Rehabilitation Center

1 Price Drive Elkton, MD 21921

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

record revealed a physician's order for Midodrine 5 mg., give 1 tablet by mouth 3 times a day for hypotension. Hold for SBP greater than 110. Review of Resident #303's December 2025 MAR documented

the Midodrine was given on the following days when outside of physician ordered parameters:12/04/25: 121/62 at 12 PM12/04/25: 119/72 at 6 PM12/09/25: 132/77 at 6 PM12/13/25: 126/72 at 6 AM12/14/25: 118/60 at 6 AM12/14/25: 112/70 at 6 PM12/15/25: 118/68 at 12 PM12/16/25: 120/61 at 6 PM12/28/25: 118/73 at 2 PM12/31/25: 126/78 at 6 AM12/31/25: 119/78 at 8 PM Review of Resident #303's January 2026 MAR documented the Midodrine was given on the following days when outside of physician ordered parameters:1/04/26: 125/74 at 6 AM1/09/26: 122/74 at 6 AM1/06/26: 118/74 at 2 PM1/06/26: 121/77 at 8 PM1/11/26: 115/72 at 8 PM1/25/26: 113/65 at 6 AM1/25/26: 119/741/27/26: 118/70 at 6 AM On 1/4/26 at 8 PM the resident's blood pressure was 97/58 and staff did not administer the Midodrine when they should have administered as the SBP was below 110. On 1/29/26 at 1:15 PM an interview was conducted with the medical director who confirmed that facility staff failed to follow the physician's ordered parameters. The medical director stated that he had concerns when the medication was administered outside of parameters.On 1/29/26 at 1:30 PM the concern was discussed with the DON who stated that she would begin in-servicing staff.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Elkton Nursing and Rehabilitation Center

1 Price Drive Elkton, MD 21921

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770

Provide timely, quality laboratory services/tests to meet the needs of residents.

Level of Harm - Minimal harm or potential for actual harm

Based on medical record review and staff interview, it was determined that the facility staff failed to obtain laboratory tests as ordered by the physician for residents (#300 and #302). This was evident for 2 of 3 residents reviewed for laboratory services during a complaint survey.The findings include: 1. Review of Resident #300's medical record on 1/29/26 revealed the Resident was admitted to the facility in January 2026 with diagnosis to include diabetes and anemia. Review of Resident #300's physician orders revealed

the Resident was ordered a CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) and Magnesium level on 1/5/26 to be completed on 1/6/26. Further review of Resident #300's medical record on 1/29/26 revealed the Resident did not have any laboratory results on 1/6/26. Review of the Resident's nurses' notes revealed no documentation on why the laboratory tests were not completed. Interview with

the Director of Nursing on 1/29/26 at 1:45 PM confirmed the facility staff failed to obtain laboratory tests ordered by the physician on 1/5/26 for Resident #300. 2. Review of Resident #302's medical record on 1/29/26 revealed the Resident was admitted to the facility with a diagnosis to include pneumonia. Further

review of Resident #302's medical record revealed the Resident was seen by the Physician's Assistant (Staff #24) on 1/7/26 for abnormal laboratory results. At that time Staff #24 documented to repeat CBC (Complete Blood Count) in the AM. Further review of Resident #302's medical record revealed a nurse's note by Staff #25 on 1/7/26 at 10:57 PM that stated: Labs from 1/7/26 reviewed by PA (Staff #25) resident already has order for CBC in am. Review of Resident #302's laboratory results revealed no lab tests were drawn on 1/8/26. The Resident was discharged from the facility on 1/13/26 without the lab tests completed.

Interview with the Director of Nursing on 1/29/26 at 10:28 AM confirmed Resident #302 did not have a CBC laboratory test on 1/8/26 as ordered by the physician.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet