Elkins Rehabilitation & Care Center

In the surveyor’s words

From the most serious findings on record at Elkins Rehabilitation & Care Center, in the surveyor’s own words.

• Actual harm, isolatedF684Aug 28, 2025

  Based on record review and staff interview the facility failed to provide care and services in accordance with current standards of practice by administering Resident #115 a Benzodiazepines that she was not ordered. The State Agency (SA) confirmed that this failed practice caused harm to Resident #115. After Resident was given the Benzodiazepines she fell, resulting in a sprained hip. The incident occurred on 07/06/24 and was corrected on 07/08/24, therefore it is cited at past non-compliance.In a addition the facility failed to ensure it followed its policy and procedure for Resident #45 on weight management. This failed practice was found true for (2) of (27) residents investigated for quality of care during the Long-Term Care Survey Process. Resident identifiers #115 and #45. […]

• No harm, potential for more than minimal, patternF585Aug 28, 2025

  Based on staff and resident interviews, and observation The Facility failed to ensure residents knew they had the right to file grievances anonymously. This deficient practice had the potential to affect more than a limited number of residents. Facility Census 103: Findings included: a) During observation and resident interview on 08/25/25 at approximately 2:40 PM Resident #88 stated she did not know how to file a grievance anonymously, that she would just talk to the social worker if she had any complaints. […]

• No harm, potential for more than minimal, patternF656Oct 25, 2023

  Based on observation, record review and staff interview the facility failed to implement a resident's comprehensive person-centered care plan. This was discovered for one (1) of 28 care plans reviewed during the Long-Term Care Survey Process in the areas of hospice scheduling, application and removal of a hand splint and nutritional interventions for weight loss. Resident Identifiers: #17, #23, #89, #49 and #91. Facility Census: #103 Findings Included: a) Resident #17 On 10/24/23 a record review found Resident #17 has hospice services through (name of Hospice organization) Hospice. On 10/25/23 at 9:00 AM record review found the care plan for Hospice services states the Hospice nurse is to visit two (2) times weekly and as needed. […]

• No harm, potential for more than minimal, patternF849Oct 25, 2023

  Based on medical record reviews and staff interviews, the facility failed to collaborate with hospice services to develop coordinated care plans for four (4) of four (4) residents reviewed for the care area of hospice during the Long-Term Care Survey Process. The care plans for Resident #18, #17, #23, and #89 did not specify when and what services were to be provided by the hospice staff. Resident identifiers: #18, #17, #23, and #89. Facility census: 103. Findings included: a) Resident #18 A medical record review on 10/25/23 revealed the person-centered care plan for Resident #18 was not developed to collaborate hospice services with the facility. […]

• No harm, potential for more than minimal, patternF880Oct 25, 2023

  Based on observation and staff interview, the facility failed to establish and maintain an effective infection prevention and control program. Staff failed to remove gloves after incontinence care contaminating the residents bed and surrounding areas. A bedpan and two triangle graduate cylinders were noted hanging on the commode with the toilet seat lifted. This is true for one of one reviewed for wound care and a random opportunity for discovery. Resident identifiers: #69, #94 and #39. Facility census: 103. Findings included: 1. Resident (R) #69 Incontinence care On 10/25/23 at 8:50 AM, Nurse Practitioner (NP) #32 and Licensed Practical Nurse (LPN) #74 were observed performing incontinence care after completing wound care on R #69. […]