Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elkins Rehabilitation & Care Center during CMS and state inspections, most recent first.
A resident on an Alzheimer’s unit was physically abused when an LPN smacked the resident’s hand after the resident attempted to hit another resident and then asked how it felt to be smacked. Staff who reviewed video footage confirmed the hand-smacking, and slight discoloration of the resident’s hand was observed. The facility’s abuse policy required use of trained staff, protective staffing or room changes, analysis of the incident, changes to care provisions, staff training, and reporting of licensed staff suspected of abuse to their licensing board. Despite the abuse being substantiated, the LPN was later reinstated to work on the Alzheimer’s unit without having received required abuse training and was not reported to the licensing board, reflecting a failure to protect the resident from abuse and to follow the facility’s abuse policy.
A substantiated incident of physical abuse occurred when an LPN smacked a resident’s hand after the resident attempted to hit another resident, causing temporary discoloration. The facility’s abuse policy required analysis of the event, changes to care provisions, staff training with demonstrated competency, and reporting any licensed staff suspected of abuse to their licensing board. Despite documenting the allegation as substantiated and planning mandatory nurse training, the LPN remained employed and was reinstated to work without receiving abuse training, and was not reported to the licensing board, in direct conflict with the facility’s written policy.
A resident on an Alzheimer’s unit was physically abused when an LPN smacked the resident’s hand and made a remark about how it felt to be smacked, with staff observing temporary discoloration of the hand and video evidence confirming the event. The facility’s investigation substantiated the abuse and its policy required analysis of the incident, staff training on abuse/neglect, and reporting licensed staff suspected of abuse to their licensing board. However, the facility did not provide the mandated abuse training before allowing the LPN to return to work and did not report the LPN to the licensing board, while the LPN remained employed on the unit.
A nurse administered a benzodiazepine without a physician's order to a resident, using another resident's medication and disguising it in a milkshake, which was followed by a fall resulting in a sprained hip. Additionally, the facility did not follow its weight management policy for another resident by failing to re-weigh after a significant weight loss.
Residents were not informed how to file grievances anonymously. Cognitively intact residents stated they did not know the anonymous complaint process and would only talk to staff or the social worker if they had concerns. The facility’s grievance policy said residents could file complaints verbally, in writing, or anonymously, and the SW confirmed a locked complaint box was placed on a shelf in a hallway location that residents in wheelchairs could not reach without staff help.
The facility failed to keep resident areas free of accident hazards and did not ensure adequate supervision. Two residents shared a bathroom with a very wet, slippery tile floor and standing water around the toilet base after a shower faucet was left partially on. In a separate observation, a resident was found with a large pair of nail clippers in her hand, and staff stated she was not supposed to have them in her room.
The facility failed to maintain an infection prevention and control program for two residents when personal care equipment was observed with holes, rips, tears, and exposed padding. A resident's wheelchair back rest and walker belt strap were damaged, and another resident's scooter chair had exposed inner padding; the IP acknowledged the damaged wheelchair, walker, and scooter chair during a walk-through.
Failure to Protect Resident From Physical Abuse and Corporal Punishment by LPN
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident on the Alzheimer’s unit from physical abuse and corporal punishment by an LPN. According to staff interviews and facility documentation, an LPN smacked the resident’s hand after the resident attempted to smack another resident and then asked the resident how it felt to be smacked. Multiple staff, including a social worker, another LPN, and a nurse aide, reported that they viewed video footage of the incident and confirmed that the LPN did in fact smack the resident’s hand. One LPN and the initial abuse report noted discoloration to the resident’s hand following the incident. The incident occurred on the facility’s Reflections Hall, identified as the Alzheimer’s unit, and the reasonable person concept was applied to determine that an average person would experience psychosocial harm from being smacked in a healthcare setting. The facility’s own Abuse, Neglect, Exploitation policy required deployment of trained and qualified staff, room or staffing changes as needed to protect residents from alleged perpetrators, analysis of why abuse occurred, changes to care provisions to protect residents, staff training on changes made, and reporting of licensed staff suspected of abuse to their licensing board. Despite the policy and the substantiated finding of abuse and use of corporal punishment, the LPN involved in the incident was later found to be reinstated and working again on the Alzheimer’s unit. The DON confirmed that the LPN had not been reported to the LPN licensing board for the substantiated abuse and that required abuse training had not been provided prior to the LPN’s return to work. These actions and inactions demonstrate the facility’s failure to ensure the resident was free from physical abuse and to follow its own abuse prevention and response policies.
Failure to Implement Abuse Policy and Report LPN After Substantiated Abuse
Penalty
Summary
The deficiency involves the facility’s failure to correctly implement its Abuse, Neglect, Exploitation policy following a substantiated allegation of physical abuse toward a resident. According to staff statements and video review, an LPN smacked a resident’s hand after the resident attempted to smack another resident and then asked the resident how it felt to be smacked. Staff reported that there was slight discoloration to the resident’s hand, which later resolved. The facility’s policy required analyzing the occurrence, defining how care provisions would be changed to protect residents, training staff on changes made, and demonstrating staff competency, as well as reporting a licensed staff member suspected of abuse to his or her licensing board. Surveyors found that the facility substantiated the allegation of abuse and documented that the incident was captured on security camera footage and that witnesses provided statements. The five-day follow-up investigation report indicated that the perpetrator was to be terminated and that mandatory nurse training on abuse and neglect would be scheduled. However, the LPN involved remained employed and was reinstated to work on the Alzheimer’s unit. The DON and Administrator confirmed that no abuse training was provided to the LPN prior to returning to work, and the DON acknowledged that the LPN was not reported to the appropriate licensing board despite the substantiated abuse and use of corporal punishment, contrary to the facility’s written policy.
Failure to Implement Corrective Actions After Substantiated Abuse
Penalty
Summary
The deficiency involves the facility’s failure to take appropriate corrective action following a substantiated incident of physical abuse of Resident #1 by a licensed nurse. According to staff statements and video review, LPN #200 smacked Resident #1’s hand after the resident attempted to smack another resident and then asked the resident how it felt to be smacked. Staff noted slight discoloration to Resident #1’s hand that later resolved. The facility’s five-day follow-up investigation documented that the allegation of abuse was substantiated, that the incident was captured on security camera footage, and that witnesses provided statements. The facility’s Abuse, Neglect, Exploitation policy required analyzing the occurrence, defining how care provisions would be changed to protect residents, training staff on changes made, and reporting a licensed staff member suspected of abuse to his/her licensing board. Despite the substantiated finding of abuse and the policy requirements, the facility did not provide the mandatory abuse and neglect training to staff as indicated in the five-day follow-up investigation report. The DON and Administrator verified that no abuse training was given prior to LPN #200 returning to work. Additionally, contrary to the facility’s policy that a licensed staff member suspected of abuse will be reported to his/her licensing board, LPN #200 was not reported to the LPN licensing board for the substantiated abuse and use of corporal punishment. A review of the staff roster showed that LPN #200 remained employed at the facility and continued to work on the Alzheimer’s unit following the incident.
Unauthorized Medication Administration and Failure to Follow Weight Management Policy
Penalty
Summary
A nurse administered a benzodiazepine (Ativan) to a resident without a physician's order, using medication that belonged to another resident. The nurse attempted to control the resident's behaviors by disguising the medication in a milkshake. Shortly after receiving the unauthorized medication, the resident fell while moving to allow another resident to pass, resulting in a sprained hip and requiring evaluation at a local emergency room. The incident was later substantiated through review of video footage and staff interviews, confirming the medication error and the subsequent fall. Additionally, the facility failed to follow its own weight management policy for another resident. The policy required that if a resident experienced a weight difference of 5 pounds, a re-weigh should occur the following day to verify the change. However, after a resident lost five pounds between two weigh-ins, the required next-day re-weigh was not performed, as confirmed by record review and staff interview.
Residents Not Informed How to File Anonymous Grievances
Penalty
Summary
The facility failed to ensure residents knew they had the right to file grievances anonymously. During interviews, Resident #88 stated she did not know how to file a grievance anonymously and said she would just talk to the social worker if she had any complaints. Resident #41 also stated she did not know how to file a grievance or complaint anonymously and would just talk to staff. Review of the most recent MDS showed both residents had capacity and were cognitively intact. The facility’s grievance policy stated residents have the right to file grievances without discrimination or reprisal and that residents would be notified individually and through postings of the right to file grievances verbally, in writing, or anonymously. During a resident council meeting, Residents #26, #36, and #44, who also had capacity and were cognitively intact per MDS review, stated they did not know how to file a grievance form anonymously and said they were never told how or where to file it. The social worker confirmed the facility had a locked complaint box located on a shelf in the conference room hallway and acknowledged that residents in wheelchairs would not be able to reach it without staff assistance.
Unsafe Resident Environment and Unsupervised Access to Nail Clippers
Penalty
Summary
The facility failed to keep the resident environment free from accident hazards as possible and did not provide adequate supervision to prevent accidents. Residents #51 and #63 shared a bathroom that was observed to have a very wet, slippery tile floor with standing water puddles around the toilet base. An employee acknowledged the water and slippery floor and said it would be reported to maintenance. Maintenance later stated the shower faucet had not been completely turned off, which caused the standing water and slippery tiles in the bathroom used by the two residents. In a separate observation, Resident #101 was found holding a large pair of pink nail clippers with nail clippings in her lap, and an employee stated she did not know where the clippers came from or whether the resident was permitted to have them. An LPN later stated Resident #101 was not supposed to have the nail clippers in her room.
Infection Control Deficiency Involving Damaged Personal Care Equipment
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a sanitary environment and help prevent the development and transmission of communicable diseases and infections related to personal care equipment for two residents. During an entrance observation, Resident #66 was found to have holes and exposed padding on both the wheelchair back rest and walker belt strap. In a separate interview, Resident #9 was observed with a scooter chair that had rips and tears on the right side back rest exposing the inner padding. During a later walk-through with the Infection Preventionist, both Resident #9's wheelchair and walker and Resident #66's scooter chair were acknowledged to have exposed inner padding, and the Infection Preventionist stated they would be removed and repaired.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 19 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Elkins
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nella's At Autumn Lake Healthcare | 4.6 mi | ★★★★★ | 4 | 0 |
| Autumn Lake Healthcare At Crystal Springs | 4.7 mi | ★★★★★ | 3 | 0 |
| Tygart Valley Health & Rehabilitation | 11.4 mi | ★★★★★ | 12 | 0 |
| Holbrook Healthcare Center | 21.1 mi | ★★★★★ | 0 | 0 |
| Mansfield Place | 21.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Elkins Rehabilitation & Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.