Elkton Nursing And Rehabilitation Center

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Elkton Nursing and Rehabilitation Center

1 Price Drive Elkton, MD 21921

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Elkton Nursing and Rehabilitation Center

1 Price Drive Elkton, MD 21921

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

01/29/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Elkton Nursing and Rehabilitation Center

1 Price Drive Elkton, MD 21921

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID: