Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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.
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.
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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.
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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 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.