Elkins Rehabilitation & Care Center

Inspectors wroteBased on staff Interview and facility documentation, the facility failed to ensure that a resident residing on the facility's Alzheimer's unit was free from physical abuse, as described by nurse aide (NA) staff members who witnessed the incident. Using the reasonable person concept it can be determined that the average person would have experienced psycho-social harm as a result of the physical abuse, since an average person would not expect to be smacked in his/her own home or in a healthcare facility. This had the potential to affect a limited number of residents. Resident Identifier: Resident #1. Facility census 104. [...]

Inspectors wroteBased on observation, staff interview, electronic medical record review, and review of the facility's Abuse, Neglect, Exploitation policy, the facility failed to correctly implement their policy for a substantiated allegation of abuse. The facility failed to provide training to staff as per their five-day follow-up of an abuse investigation. Additionally, the facility failed to report a licensed staff member to his/her licensing board. This was true of one (1) of four (4) residents reviewed for abuse during a complaint survey. Resident identifier #1. Census 104. [...]

Inspectors wroteBased on observation, staff interview, electronic medical record review, and review of the facility's Abuse, Neglect, Exploitation policy, the facility failed to take appropriate corrective action, as a result of investigation findings which substantiated physical abuse of a resident. The facility failed to provide additional training to staff as per their five-day follow-up of an abuse investigation. Additionally, the facility failed to report a licensed staff member to his/her licensing board. This was true of one (1) of four (4) residents reviewed for abuse during a complaint survey. Resident identifier #1. Census 104. [...]

Inspectors wroteBased 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. Facility Census #103. Findings Include: [...]

Inspectors wroteBased 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:

Inspectors wroteBased on observation and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This failed practice was a random opportunity for discovery. Resident identifiers: #51, #63 and #100. Facility Census: 101. a) Residents #51 and #63** On August 25, 2025, at 12:20 PM, the bathroom of Residents #51 and #63 was observed to have a very wet and slippery tile floor with standing water puddles around the toilet base. In an interview with Employee #55, she acknowledged the water puddles and slippery floor and stated she would report it to maintenance. In an interview with Maintenance #175 on 08/25/25, at 12:45 PM, he stated he had discovered the shower faucet was not completely turned off, which caused the standing water and slippery floor tiles in Residents #51 and #63's bathroom. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide sanitary environment to help prevent the development and transmission of communicable diseases and infections with regards to the personal care equipment for two (2) residents. This failed practice was a random opportunity of discovery. Resident identifiers # 66 and #9. Facility census: 101. a) Resident # 66During facility entrance observation and interview on 08/25/25 at 3:40 PM, holes and exposed padding were observed on both Resident #66's wheelchair back rest and walker belt strap. b) Resident # 9In an interview with resident # 9 on 08/26/25 at 9:05AM, it was observed that her scooter chair had rips and tears on the right side back rest exposing the inner padding. [...]

Inspectors wroteBased 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. There is no care plan in place for the number of Aide visits. The care plan is to state scheduled days the nurse and aide is to provide services. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on policy review, record review and staff interview, the facility failed to develop, promote, and implement a facility-wide system to monitor the use of antibiotics. This was true for two (2) out of three (3) residents reviewed for antibiotic use during the Long-Term Care Survey Process. Resident identifiers: #47 and #204. Facility census: 103.

Inspectors wroteBased on observation and staff interview, the facility failed to provide care and treatment in a dignified manner. Staff signed and dated a dressing after it was affixed to Resident #69's body. This is true for one (1) of one (1) reviewed for wound care. Resident identifier: # 69. Facility census: 103.

Inspectors wroteBased on medical record review and staff interview the facility failed to notify the physician and resident representative of a change in condition. This was discovered for one (1) of three (3) residents reviewed for the care area of nutrition during the Long-Term Care Survey Process. Resident # 91 had a significant weight loss and the physician and resident representative was not notified. Resident identifier: #91 Facility census:

Inspectors wroteBased on record review and staff interview the facility failed to follow Physicians order for medication administration and failed to have an order for pressure ulcer care. Resident Identifiers: #17 and #12. Facility Census:

Inspectors wroteBased on resident interview, record review, and staff interview, the facility failed to assist a resident in locating his lost hearing aide This was true for one (1) out of ( 2) residents reviewed for communication. Resident identifier #90. Facility census: 103.

Inspectors wroteBased on record review and staff interview the facility failed to provide care to a pressure ulcer injury in order to promote healing. Resident Identifiers: #17. Facility Census:

Inspectors wroteBased on medical record review, resident interview, observation and staff interview, the facility failed to ensure the residents' environment remains as free of accident hazards as is possible. Morning medications were left in Resident #37's room unsupervised and not taken until hours later. Antifungal powder was left on R #90's dresser. These were random opportunities for discovery. Resident identifiers: R #37 and R #90. Facility census: 103.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records. Resident #204's capacity status was incorrect in PointClickCare (the facility's electronic medical record software.) Resident #37's code status order was incorrect and did not match resident's Care Plan or resident's preference. This is true for two (2) of four (4) residents reviewed for Advanced Directives. Resident identifiers: Resident #204 and Resident #37. Facility census: 103.

Inspectors wrotee) Resident #47 On 07/25/22 at approximately 1:20 PM, an observation was made during incontinence care for Resident #47. Nurse Aide (NA) #72 and NA #78 were observed throwing dirty linen and a soiled brief on the floor without a barrier leaving a wet spot directly on the floor. On 07/25/22 at 1:27 PM, NA #78 stated, I forgot, when asked about using a barrier during incontinence care. NA #72 made no statement. Licensed Practical Nurse (LPN) # 77 confirmed the dirty linen and the soiled brief should not be put directly on the floor and the items were not discarded into a designated container. The facility policy entitled Perineal Care, step #11 states, Discard disposable items into designated containers . On 07/25/22 on 1:44 PM, the Director of Nursing (DON) was notified. The DON stated I'm embarrassed .I'm sorry. No further information was obtained during the survey process. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure two (2) of 28 sampled residents had a dignified dining experience. Staff stood over residents while assisting them to eat. Resident identifiers: #70 and #57. Facility census: 86.

Inspectors wroteBased on record review and staff interview, the facility failed to recognize the resident's right to formulate an advance directive. This was true for one (1) of seven (7) residents reviewed for the care area of advance directives. Resident identifier: #136. Facility census: 86.

Inspectors wroteBased on observation, staff interview and record review the facility failed to implement their abuse policy by reporting all injuries of unknown origin and thoroughly investigating all injuries of unknown origins to determine a possible cause and/or to rule out abuse and/or neglect. This was true for Resident #42 who had bruising to the left side of her head and to both sides of her neck. This was true for one (1) of one (1) resident reviewed for the care area of non pressure skin conditions. Resident Identifier: #42. Facility Census: 86.

Inspectors wroteBased on observation, record review and staff interview the facility failed to immediately report an injury of unknown origin to appropriate State agencies within the appropriate time frames. Resident #42 had a deep purple bruising to the left side of the head and to both sides of her neck. There was no indication the facility knew how this injury occurred and there was no evidence this injury was reported. This was true for one (1) of one (1) reviewed for the care area of skin conditions non -pressure related. Resident Identifier: #42. Facility Census: 86. Findings Included: a) Resident #42 Observation of Resident #42 on 07/25/22 at 1:19 PM during the first phase of the Long Term Care Survey Process (LTCSP) found a bruise to the left side of her head and on both sides of her neck. The bruises were deep purple in color. [...]

Inspectors wroteBased on observation, staff interview and record review the facility failed to ensure all injuries of unknown origin are thoroughly investigated to determine a possible cause and/or to rule out abuse and/or neglect. This was true for Resident #42 who had bruising to the left side of her head and to both sides of her neck. This was true for one (1) of one (1) residents reviewed for the care area of non pressure skin conditions. Resident Identifier: #42. Facility Census: 86.

Inspectors wroteBased on record review and staff interview the facility failed to review and revise the care plan when Resident #73 chose not to continue Hospice Care. This was true for 1 (one) of 28 sampled residents. Resident identifier: 73. Facility Census: 86. Findings Included: a) Resident #73 On 7/25/22 at 11:15 AM while reviewing medical records for Resident #73, it was noted the Resident was receiving Hospice Care. After reviewing the current orders, there was no order for the Resident to receive Hospice Care. Review of the current care plan found the resident was receiving Hospice Services. An interview on 7/26/22 at 1:14 PM, with the Administrator, confirmed Hospice Care was declined on 7/15/22 and the care plan was not revised. .

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #75 only received medications when ordered by the attending physician. Resident #75 received Tramadol on an as needed basis (PRN) from 02/13/22 through 02/20/22. Resident #75's attending physician indicated he never gave the facility an order to administer Tramadol. This was true for one (1) of one (1) resident reviewed for the care area of pain management. Resident Identifier: #75. Facility Census: 86. Findings Included: a) Resident #75 A review of Resident #75's medical record found a nursing progress note dated 01/11/22 (Resident was admitted to the facility on [DATE]) which read as follows, Received Fax from (Name of Attending physician) New orders as follows: Change Isosorbide mononitrate 10 mg tid (three times a day) to isosorbide mononitrate ER 30 mg by mouth dialy in am. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure two (2) of eight (8) residents review for the care area of pressure ulcers received care consistent with professional standards of practice to heal or prevent pressure ulcer development. Resident Identifiers: #57 and #70. Facility Census: 86.

Inspectors wroteBased on observation, record review, and staff interview the facility failed to ensure the residents environment over which it had control was as free from accident hazards as possible. This has the potential to effect more than an isolated number of residents. For Resident #70 the facility failed to investigate bruising on the Residents forearms to possibly identify any hazards/risks, implement interventions to reduce any hazards/risks and monitor for the effectiveness of any interventions. Resident #69 had medication in the room. In addition, medication was left unattended on top of the medication cart. Resident identifiers: #70 and #69. Facility census: 86.

Inspectors wroteBased on record review and staff interview the facility failed to ensure a resident with an ileostomy had physician orders for ileostomy care. This was a random opportunity for discovery. Resident Identifier: #1. Facility Census: 86.

Inspectors wroteBased on record review and staff interview the facility failed to have an accurate and completed staff posting. This failed practice had the potential to affect a limited number of residents that reside in the facility. Facility census 86.

Inspectors wroteBased on record review and staff interview the facility failed to ensure pharmaceutical services were provided to each resident to meet their needs and to ensure an accurate reconciliation of each controlled substance. Resident #75 was administered tramadol after the medication was discontinued in part because the medication was not removed from the medication cart in a timely manner after the discontinuance of the drug. In addition when the remaining tramadol were destroyed the licensed pharmacist was the only person to sign the Disposition of Drug section. This was a random opportunity for discovery and was true for Resident #75. Resident Identifier: #75. Facility Census: 86. Findings Included: [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure medication irregularities identified by the Pharmacist, and accepted by the physician were implemented. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifier: #1 Facility Census: 86. Findings Included: a) Resident #1 On 7/27/22 at 9:00 AM while reviewing medical records it was noted on the October, 2021 Consultation Report from the pharmacist, the Physician accepted the recommendation to change the timing on a medication (Bumex) from 9:00 PM to earlier in the evening due to this being a diuretic. This was not completed. On the 06/2022 Consultation Report from the pharmacist, the Physician accepted the recommendation to have the Residents Hemoglobin A1C laboratory level checked and monitored. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure foods were stored in a safe and sanitary manner. This failed practice had the potential to affect a limited number of residents. Facility census: 86.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the medical records for Resident's #136 and #42 were accurate and correct. This was true for three (3) of 28 resident records reviewed during the long term care survey. Resident identifiers: #136 and #42. Facility census: 86.