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Deficiency Records for Elkton Nursing and Rehabilitation Center
A list of the most recent deficiencies for Elkton Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Elkton Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-11-20 | 2024-01-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-20 | 2024-01-17 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-11-20 | 2024-01-17 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-11-20 | 2024-01-17 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-11-20 | 2024-01-17 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-11-20 | 2024-01-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-20 | 2024-01-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-20 | 2024-01-17 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-11-20 | 2024-01-17 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-11-20 | 2024-01-17 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-11-20 | 2024-01-17 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-11-20 | 2024-01-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-11-20 | 2024-01-17 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-11-20 | 2024-01-17 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-11-20 | 2024-01-17 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-11-20 | 2024-01-17 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-11-20 | 2024-01-17 | N |
| Post nurse staffing information every day. | Health | 2023-11-20 | 2024-01-17 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2023-11-20 | 2024-01-17 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-11-20 | 2024-01-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-20 | 2024-01-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-11-20 | 2024-01-17 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-11-20 | 2024-01-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-20 | 2024-01-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-20 | 2024-01-17 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-11-20 | 2024-01-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-20 | 2024-01-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-20 | 2024-01-17 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-11-20 | 2024-01-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-20 | 2024-01-17 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-11-20 | 2024-01-17 | N |
| Keep all essential equipment working safely. | Health | 2023-11-20 | 2024-01-17 | N |
| Respond appropriately to all alleged violations. | Health | 2023-11-20 | 2024-01-17 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-11-20 | 2024-01-17 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-20 | 2024-01-17 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-11-20 | 2024-01-17 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-11-20 | 2024-01-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-20 | 2024-01-17 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-20 | 2024-01-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-20 | 2024-01-17 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-20 | 2024-01-17 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-20 | 2024-01-17 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-20 | 2024-01-17 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-11-20 | 2024-01-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-20 | 2024-01-17 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-11-20 | 2024-01-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-20 | 2024-01-17 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-11-20 | 2024-01-17 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-11-20 | 2024-01-17 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-11-20 | 2024-01-17 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Ensure gas and vacuum piping is labeled. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-07 | 2023-12-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-25 | 2023-08-25 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-06-26 | 2023-08-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-26 | 2023-08-01 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-06-26 | 2023-08-01 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-06-26 | 2023-08-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-06-26 | 2023-08-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-26 | 2023-08-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-26 | 2023-08-01 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-06-26 | 2023-08-01 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-26 | 2023-08-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-26 | 2023-08-01 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-26 | 2023-08-01 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-06-26 | 2023-08-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-26 | 2023-08-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-26 | 2023-08-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-26 | 2023-08-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-26 | 2023-08-01 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-26 | 2023-08-01 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-06-26 | 2023-08-01 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-06-26 | 2023-08-01 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-06-26 | 2023-08-01 | Y |
| Post nurse staffing information every day. | Health | 2023-06-26 | 2023-08-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-26 | 2023-08-01 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-06-26 | 2023-08-01 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-06-26 | 2023-08-01 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-06-26 | 2023-08-01 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-06-26 | 2023-08-01 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-06-26 | 2023-08-01 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-06-26 | 2023-08-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-26 | 2023-08-01 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-06-26 | 2023-08-01 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-06-26 | 2023-08-01 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2021-08-05 | 2021-11-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-05 | 2021-11-04 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-08-05 | 2021-11-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-05 | 2021-11-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-13 | 2021-09-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-13 | 2021-09-17 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-08-13 | 2021-09-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-08-13 | 2021-09-17 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-08-13 | 2021-09-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-13 | 2021-09-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-08-13 | 2021-09-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-13 | 2021-09-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-13 | 2021-09-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-13 | 2021-09-17 | N |
| Provide appropriate foot care. | Health | 2021-08-13 | 2021-09-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-13 | 2021-09-17 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-08-13 | 2021-09-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-13 | 2021-09-17 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-08-13 | 2021-09-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-13 | 2021-09-17 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2021-08-13 | 2021-09-17 | N |
| Provide or obtain dental services for each resident. | Health | 2021-08-13 | 2021-09-17 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-08-13 | 2021-09-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-13 | 2021-09-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-13 | 2021-09-17 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2021-08-13 | 2021-09-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-13 | 2021-09-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-13 | 2021-09-17 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-08-13 | 2021-09-17 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-08-05 | 2021-09-17 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-08-05 | 2021-09-17 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-08-05 | 2021-09-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-08-05 | 2021-09-17 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-08-05 | 2021-09-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-05 | 2021-09-17 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-08-05 | 2021-09-17 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-09-26 | 2018-10-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-26 | 2018-10-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-09-26 | 2018-10-30 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2018-09-26 | 2018-10-30 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-09-26 | 2018-10-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-09-11 | 2018-10-19 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-09-11 | 2018-10-19 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-09-11 | 2018-10-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-11 | 2018-10-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-11 | 2018-10-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-11 | 2018-10-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-09-11 | 2018-10-19 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-09-11 | 2018-10-19 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-09-11 | 2018-10-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-09-11 | 2018-10-19 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-09-11 | 2018-10-19 | N |
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