Inspection Reports for Elkins Rehabilitation & Care Center

This document is a plan of correction related to a previously cited deficient practice following an investigation survey concluding on 10/25/2023.

The facility, Elkins Rehabilitation & Care Center, is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with accepted plans of correction and credible evidence in lieu of an onsite revisit.

The inspection was conducted to review facility documentation and staff interviews to determine compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.

An unannounced Annual Survey was conducted at Elkins Rehabilitation and Care Center from 10/23/23 to 10/25/23 to assess compliance with regulatory requirements based on observations, clinical record reviews, interviews, and facility documentation.

The facility was found deficient in multiple areas including inaccurate medical records related to code and capacity status, failure to provide dignified wound care, unsafe storage of medications and powders, incomplete hospice care plans, failure to notify physician and representative of significant weight loss, improper infection control practices, failure to follow wound treatment orders, incomplete antibiotic stewardship monitoring, and failure to administer medications as ordered due to residents sleeping.

The inspection was conducted to assess compliance with NFPA 99 standards regarding the proper storage and maintenance of oxygen cylinders in the facility.

The facility failed to ensure that oxygen cylinders were stored and maintained in accordance with NFPA 99, specifically that empty and full oxygen cylinders were not properly segregated at two nurse stations. This deficient practice could affect all residents, staff, and visitors.

An unannounced complaint investigation survey was conducted at Elkins Regional Convalescent Center from March 20 - 21, 2023.

The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. Complaint #27826 was unsubstantiated with no related or unrelated deficiencies cited.

Complaint #27826 was unsubstantiated with no related or unrelated deficiencies cited.

An unannounced complaint investigation survey was conducted at Elkins Regional Convalescent Center from September 6-7, 2022.

The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. Complaints #27312 and #27304 were unsubstantiated with no related or unrelated deficiencies cited.

Complaint #27312 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #27304 was unsubstantiated with no related or unrelated deficiencies cited.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility was found to be in substantial compliance with the regulatory requirements, with plans of correction and credible evidence accepted in lieu of an onsite revisit. Previously cited deficient practices were addressed.

The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2012, and Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and all applicable Federal, State, and local Emergency Preparedness requirements.

An unannounced annual recertification, annual relicensure, and complaint investigation survey was conducted at Elkins Regional Convalescent Center from July 25-27, 2022. The visit included complaint investigations for complaints #26933, #26549, and #26467.

The facility was found deficient in multiple areas including resident dignity during dining, failure to recognize residents' rights to formulate advance directives, failure to report and investigate injuries of unknown origin, medication management errors including administration of discontinued medications, delayed wound care treatment, inaccurate nurse staffing postings, improper food storage, inaccurate medical records, and infection control breaches.

Complaint #26933 was substantiated with related deficiencies cited at F550, F684, F689 and F755. Complaint #26549 was substantiated with related deficiencies cited at F550, F689 and F880. Complaint #26467 was unsubstantiated with no related or unrelated deficiencies.

A review of the plans of correction and credible evidence was accepted in lieu of an onsite revisit for the survey concluding on 02/02/2022.

Elkins Regional Convalescent Center is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. The facility is in substantial compliance with the previously cited deficient practices.

An unannounced complaint investigation and focused infection control survey was conducted at Elkins Regional Convalescent Center from February 1-2, 2022, triggered by complaints #26442 and #26242.

The facility failed to ensure all residents received proper foot care treatment to maintain mobility and good foot health. Five residents (#13, #19, #51, #86, and #88) were found with long, thick, and improperly maintained toenails, some with debris and curling toes. Consent issues and inconsistent podiatry visits were noted.

Complaint #26442 was substantiated with one related deficiency cited. Complaint #26242 was unsubstantiated with no related or unrelated deficiencies cited.

An unannounced complaint investigation and focused infection control survey was conducted at Elkins Regional Convalescent Center from November 15-16, 2021.

The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. Two complaints were unsubstantiated with no related or unrelated deficiencies cited.

Complaint # WV00026016 was unsubstantiated with no related or unrelated deficiencies cited. Complaint # WV00026096 was unsubstantiated with no related or unrelated deficiencies cited.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility was found to be in substantial compliance with the regulatory requirements, with the review of plans of correction and credible evidence accepted in lieu of an onsite revisit. The facility was in substantial compliance with previously cited deficient practices.

An unannounced complaint survey was conducted at Elkins Regional Convalescent Center on August 31 - September 1, 2021, based on observations, clinical record reviews, interviews, and other documentation.

The facility failed to utilize appropriate personal protective equipment (PPE) in a Resident COVID-19 isolation room, specifically an LPN was observed without goggles and with an untied gown, potentially exposing residents to infection. The complaint was substantiated but no related deficiencies were cited.

Complaint #25455 was substantiated with no related deficiencies cited.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility was found to be in substantial compliance with the regulatory requirements. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit, confirming compliance with previously cited deficient practices.

An unannounced annual re-certification and annual re-licensure survey was conducted at Elkins Rehabilitation & Care Center from 04/26/21 through 04/28/21.

The survey identified multiple deficiencies including failure to ensure a dignified dining experience, inaccurate Minimum Data Set (MDS) assessments, improper respiratory care, food safety violations related to refrigerator temperature logs, and infection control issues including improper use of PPE, catheter bag placement, and CPAP equipment storage.

Routine inspection of Elkins Rehabilitation & Care Center to assess compliance with NFPA standards and emergency preparedness requirements.

The facility was found deficient in maintaining and testing fire alarm systems, HVAC installations, electrical systems, emergency generator maintenance, electrical equipment testing, emergency preparedness exercises, and fire door maintenance in accordance with NFPA standards. Deficiencies could affect all residents, staff, and visitors.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on June 30, 2020.

The facility was found in compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to E-0024 (b)(6), and the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The inspection was conducted as a complaint investigation survey related to complaint reference #23233, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, Elkins Rehabilitation & Care Center, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

Complaint reference #23233; the facility was in substantial compliance with previously cited deficient practices based on review of plans of correction and credible evidence.

An unannounced complaint survey was conducted at Elkins Regional Convalescent Center from 10/07/19 to 10/08/19 based on complaint 23233 which was substantiated with related deficiencies cited.

The facility failed to report an allegation of neglect involving Resident #54 who was left unattended in his wheelchair for two hours resulting in a fall. Additionally, the facility failed to ensure adequate supervision and assistance devices, as Resident #54 was observed without ordered leg rests and chair alarms on his wheelchair.

Complaint 23233 was substantiated. The allegation involved Resident #54 being left unattended in his wheelchair for two hours after a family member requested he be put to bed, resulting in a fall. The facility failed to report this allegation of neglect to the state survey agency and protective services as required.

An unannounced complaint investigation was conducted at Elkins Regional Convalescent Center on 09/03/19 to 09/04/19.

The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with applicable regulations.

Complaint #23085 was unsubstantiated with no related or unrelated deficiencies cited.

An unannounced complaint investigation was conducted at Elkins Regional Convalescent Center from 06/10/19 through 06/11/19.

The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. Complaint #22597 and Complaint #22544 were both unsubstantiated with no related or unrelated deficiencies cited.

Complaint #22597 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #22544 was unsubstantiated with no related or unrelated deficiencies cited.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility was found to be in substantial compliance with the applicable federal and state regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2012, and Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and all applicable Federal, State, and local Emergency Preparedness requirements.

The inspection was conducted as a complaint investigation survey related to complaint reference #21002, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, Elkins Regional Convalescent Center, was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

Complaint reference #21002; the facility was in substantial compliance with previously cited deficient practices based on review of plans of correction and credible evidence.

An unannounced annual re-certification and annual re-licensure survey was conducted at Elkins Regional Convalescent Center from 04/01/19 through 04/03/19.

The facility was found deficient in multiple areas including failure to ensure dignity during medication administration, failure to keep call light accessible, failure to implement and revise care plans, delayed medication administration, failure to provide proper perineal care, failure to label insulin vials properly, failure to obtain and notify physicians of lab results timely, failure to maintain medical records legibly, failure to maintain infection control practices, and failure to ensure food was served at safe temperature.

An unannounced complaint survey was conducted at Elkins Regional Convalescent Center from 02/26/19 to 02/28/19 based on complaint #21002.

The facility failed to maintain a complete and accurate medical record for Resident #8, including omissions and inaccuracies in progress notes, medication administration records, transcription of physician's orders, and controlled substance reconciliation records. The complaint was unsubstantiated with one unrelated deficiency cited.

Complaint #21002 was unsubstantiated with one unrelated deficiency cited.

The inspection was conducted as a complaint investigation, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

Complaint investigation concluded on 06/12/18 with facility in substantial compliance; Complaint Reference: 19965.

An unannounced complaint survey was conducted at Elkins Regional Convalescent Center on June 11-12, 2018, in response to Complaint #19965, which was not substantiated. The survey included observations, clinical record reviews, interviews, and documentation review.

The facility failed to discard two vials of insulin after being opened for more than 28 days and failed to label one vial with the date of initial opening, affecting Residents #17 and #57. The facility provided training and implemented corrective actions to ensure compliance with insulin storage and labeling guidelines.

Complaint #19965 was not substantiated, and no related deficiencies were recommended. The deficiency cited was unrelated to the complaint.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility was found to be in substantial compliance with the regulatory requirements. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit, confirming compliance with previously cited deficient practices.

An unannounced annual recertification and relicensure survey was conducted at Elkins Regional Convalescent Center from April 23, 2018 through April 25, 2018.

The survey identified deficiencies including failure to follow physician's orders for ear irrigation, failure to maintain acceptable nutritional status for multiple residents, and failure to conduct gradual dose reductions for psychotropic drugs in an effort to discontinue them.

The inspection was conducted to assess compliance with National Fire Protection Association (NFPA) 101 standards related to emergency lighting, fire drills, electrical systems maintenance and testing, and essential electric system alarm annunciator.

The facility failed to maintain emergency lighting, conduct fire drills properly, maintain and test electrical receptacles at patient bed locations, and maintain the essential electric system alarm annunciator as required by NFPA 101. The director of maintenance acknowledged these deficiencies and corrective actions were planned.

The inspection was conducted as a complaint investigation, reviewing plans of correction and credible evidence in lieu of an onsite revisit for complaint reference #19739.

The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

Complaint investigation concluded on 02/16/18 with substantial compliance found; complaint reference #19739.

An unannounced Complaint Investigation was conducted at Elkins Regional Convalescent Center from February 12, 2018 through February 14, 2018 based on observations, clinical record reviews, and interviews.

The facility failed to develop comprehensive person-centered care plans for four residents with anxiety, failed to provide behavioral health care and services to assist Resident #49 in maintaining her highest practicable mental and psychosocial well-being, and failed to ensure psychotropic drugs were used appropriately with documentation of non-pharmacological interventions and resident responses.

Complaint Reference #19739 was substantiated with related deficiencies.

An unannounced complaint investigation was conducted at Elkins Regional Convalescent Center from January 16, 2018 through January 17, 2018 for Complaint Reference #18605.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.

Complaint Reference #18605 was unsubstantiated with no related or unrelated deficient practices identified.

A review of the plans of correction and credible evidence was accepted in lieu of an onsite revisit for the Quality Indicator and Licensure Surveys concluding on 04/20/17.

The facility is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule, and is in substantial compliance with the previously cited deficient practices.

The inspection was a routine facility inspection to assess compliance with NFPA 101 fire safety codes and other regulatory requirements.

The facility failed to maintain smoke barrier construction, had unsafe electrical and gas utility conditions, failed to conduct fire drills at varied times, did not perform a formal risk assessment of building systems, failed to categorize essential electrical systems, and lacked evidence of required electrical equipment testing.

An unannounced annual Quality Indicator Survey, State Licensure Survey, and Complaint Investigation Survey #17373 were conducted at Elkins Regional Convalescent Center from 04/17/2017 through 04/20/2017.

The facility failed to conduct an accurate comprehensive minimum data set (MDS) assessment for one resident (#152) regarding anticoagulant medication, and failed to provide a means of communication allowing residents to call for staff assistance in three bathrooms. The complaint investigation was unsubstantiated with no related or unrelated deficiencies.

Complaint Investigation #17373 was unsubstantiated with no related or unrelated deficiencies.

This document is a plan of correction related to a Quality Indicator Survey for Elkins Rehabilitation & Care Center, accepted in lieu of an onsite revisit.

The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, with previously cited deficient practices addressed through plans of correction and credible evidence.

An unannounced annual Quality Indicator Survey was conducted at Elkins Regional Convalescent Center from January 26, 2016 through January 28, 2016 to assess compliance with regulatory requirements.

The facility was found deficient in maintaining resident privacy during wound care, providing comfortable temperature levels in rehabilitation unit bathrooms, preventing pressure ulcers, ensuring sanitary food storage and preparation, and maintaining an effective infection control program including proper medication administration and wound care techniques.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, including smoke barrier integrity, sprinkler system maintenance, and emergency generator upkeep.

The facility failed to maintain smoke barrier walls with the required fire resistance rating due to unsealed openings, failed to maintain the sprinkler system in reliable operating condition with wiring draped across sprinkler piping, and did not properly monitor the emergency generator battery electrolyte fluid as required.

An unannounced revisit was conducted at Elkins Regional Convalescent Center from 03/09/15 to 03/11/15 for the Quality Indicator and State Licensure Surveys concluding on 01/07/15.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

The inspection was conducted to review the facility's compliance with the provisions of NFPA 101, Life Safety Code, 2000, based on documentation review, staff interview, observations, and performance testing.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted at Elkins Regional Convalescent Center from December 29, 2014 to January 7, 2015.

The facility had multiple deficiencies including failure to act on resident council grievances, failure to report and investigate allegations of verbal abuse, failure to provide effective housekeeping and maintenance, failure to provide care according to plan of care, failure to ensure drug regimen was free from unnecessary drugs, failure to maintain sanitary food storage, failure to maintain infection control, and failure to maintain an effective quality assurance program.

An unannounced complaint survey was conducted at Elkins Regional Convalescent Center from August 25, 2014 to August 28, 2014. The survey investigated complaints #11913 (unsubstantiated) and #11855 (substantiated with related deficiency cited).

The facility failed to seek health care decisions from and properly inform both equally appointed health care decision makers for a resident who had been determined by a physician to lack the capacity to manage her medical care herself. This deficiency was found for one of seven residents reviewed (Resident #95).

Complaint #11913 was unsubstantiated with no unrelated deficiencies. Complaint #11855 was substantiated with a related deficiency cited involving failure to properly involve co-appointed health care decision makers for Resident #95.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Elkins Rehabilitation & Care Center.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Elkins Rehabilitation & Care Center.

The document includes a deficiency related to the facility's failure to properly inform residents of their rights, rules, services, and charges as required by regulation.

The inspection was conducted as a complaint investigation based on complaint reference 13255 / 8979.

The complaint was found to be unsubstantiated with no citations issued.

Complaint reference 13255 / 8979 was investigated and found to be unsubstantiated with no citations.

The inspection was conducted as a substantiated complaint investigation from 10/16/13 to 10/21/13 regarding care and services provided to residents.

The facility failed to provide timely care for a skin condition for Resident #101, who had a skin disruption on admission but did not receive treatment until 10/04/13. Additionally, the facility failed to recognize and address severe weight loss in Resident #101, with a 10% weight loss over nine days unaddressed and no proper interventions documented.

Complaint Reference: 13235 / 8908. Substantiated complaint record with citations related to failure to provide timely skin care and failure to maintain nutritional status.

Quality Indicator and Licensure Surveys conducted from 09/23/13 to 10/01/13 to assess compliance with federal regulations for nursing facilities.

The facility was cited for multiple deficiencies including inaccurate resident assessments, failure to maintain dignity during dining, inaccurate care plans, failure to provide necessary dental services, medication errors, failure to implement physician orders, and infection control issues.

The inspection was conducted to review the facility's compliance with the NFPA 101, Life Safety Code, 2000, based on documentation review, staff interview, observations, and performance testing.

The facility was found to be without waivers and in compliance with the provisions of the NFPA 101, Life Safety Code, 2000.

The inspection was conducted in response to a complaint referenced as 13200 / 8674.

The complaint investigation was unsubstantiated and no citations were issued during the inspection.

Complaint Reference: 13200 / 8674. The complaint was unsubstantiated with no citations.

This document is a Plan of Correction submitted by Elkins Rehabilitation & Care Center in response to deficiencies cited during a prior inspection.

The report includes a deficiency related to the facility's failure to properly inform residents of their rights, rules, services, and charges as required by regulation.

The inspection was conducted as a complaint investigation related to safety hazards and clinical record accuracy at the facility.

The facility failed to ensure resident safety by leaving an unlocked laundry room door with harmful chemicals accessible to residents and failing to post oxygen usage signs for some residents. Additionally, the facility failed to maintain complete and accurate clinical records by not documenting a resident's refusal of 'as needed' medication and oxygen therapy.

Complaint Reference: 13089 / 7981. The complaint was unsubstantiated but resulted in unrelated citations.

An onsite revisit was conducted to verify compliance following a previous inspection.

The facility was found to be in substantial compliance during the revisit.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance of Elkins Rehabilitation & Care Center.

The report includes a deficiency related to the facility's failure to properly inform residents of their rights, rules, services, and charges in writing and orally in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was conducted as a complaint investigation involving substantiated and unsubstantiated complaints regarding resident care and facility compliance.

The facility failed to immediately notify the physician and family of significant changes in a resident's health status, failed to develop an interim care plan after a resident's fall with potential head injury, and failed to provide adequate hydration resulting in hospitalization for dehydration.

Complaint Reference: State 12079 / ACTS - Unsubstantiated complaint record with unrelated citations. Complaint Reference: State 12063 - Substantiated complaint record with citations.

Quality Indicator and Licensure Surveys conducted from 04/30/12 to 05/03/12 to assess compliance with federal regulations for nursing facilities.

The facility was cited for multiple deficiencies including failure to prominently display Medicare and Medicaid benefit information, incomplete criminal background checks for employees, inaccurate resident assessments, failure to develop or revise comprehensive care plans addressing residents' needs, failure to provide necessary care and services to maintain residents' highest practicable well-being, and failure to address mental or psychosocial adjustment difficulties.

The inspection was conducted to review the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Elkins Rehabilitation & Care Center.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, including Medicaid-related information.

The inspection was conducted as a substantiated complaint investigation (State #12032 / ACTS #6956) from 03/22/12 to 03/23/12.

The facility failed to dispense ice water to residents in a sanitary manner according to facility policy, creating potential for the spread of infectious microorganisms. Observations revealed staff did not wash or sanitize hands before handling residents' water pitchers, lids, and straws, and multiple pitchers were filled simultaneously contrary to policy.

Substantiated complaint record with citation related to infection control practices during ice water dispensing.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of Elkins Rehabilitation & Care Center.

The document references a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, including Medicaid-related information.

The inspection was conducted in response to two complaints: Complaint #11348, which was unsubstantiated with unrelated deficiencies, and Complaint #11352, which was substantiated but had no deficiencies.

The facility failed to revise the care plan for one resident readmitted with a new tracheotomy, resulting in inadequate documentation and monitoring of tracheotomy care. Additionally, the facility failed to transfer physician's orders for tracheotomy care and humidified oxygen from prescription forms to the official physician's order forms, risking failure to provide ordered care.

Complaint #11348 was unsubstantiated with unrelated deficiencies. Complaint #11352 was substantiated but no deficiencies were cited related to it.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance of the Elkins Rehabilitation & Care Center.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, including Medicaid-related information and legal rights.

The inspection was conducted in response to complaint reference #11311 regarding concerns about the care of Resident #58, specifically failure to notify the physician timely of a change in condition and inadequate treatment of a boil.

The facility failed to notify the physician in a timely manner about a significant change in Resident #58's condition involving a hard raised area (boil) on the left upper thigh near the buttock. The resident was treated with pain medication and warm compresses without physician orders, and was later hospitalized with a urinary tract infection and dehydration. The complaint was unsubstantiated but unrelated deficiencies were cited.

Complaint reference #11311 was unsubstantiated with unrelated deficiencies cited. The complaint involved allegations by Resident #58's spouse that the resident was 'not right' since 10/20/11, was 'talking out of his head' on 10/22/11, and had a boil that was inadequately treated with warm compresses only one day. The facility failed to notify the physician timely and delayed medical intervention.

The inspection was conducted as an annual survey to assess compliance with federal regulations related to resident care, infection control, medical record accuracy, and quality assurance.

The facility was found deficient in developing comprehensive care plans for residents with pressure ulcers, providing physician-ordered treatments, maintaining an effective infection control program, ensuring complete and accurate medical records, and fully implementing the quality assessment and assurance committee's plans of correction.

Complaint investigation related to concerns about the assessment, monitoring, and care planning for pressure ulcers at the facility.

The facility failed to accurately assess, monitor, and document a pressure ulcer on Resident #103, which worsened from a Stage II to a Stage III ulcer during the stay. The wound was not measured or documented as ordered, the care plan did not reflect the wound's presence or changes, and the resident's MDS assessments were inconsistent with the wound status. Physician orders for wound care were not consistently followed.

Complaint reference #11085 was unsubstantiated but unrelated deficiencies were cited.

The inspection was conducted in response to complaint reference #10041.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #10041 was investigated and found to be unsubstantiated with no deficiencies cited.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Elkins Rehabilitation & Care Center.

The report includes a deficiency related to the facility's failure to properly inform residents of their rights, rules, services, and charges in accordance with regulatory requirements.

The inspection was conducted to review the facility's compliance with the provisions of NFPA 101, Life Safety Code, 2000, based on documentation review, staff interview, observations, and performance testing.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.

This complaint investigation was conducted concurrently with the facility's annual Federal Medicare / Medicaid certification resurvey and State licensure inspection.

The facility was found to have multiple deficiencies including failure to validate health care surrogate appointments, failure to notify Medicaid residents of account limits, failure to ensure privacy during care, failure to report abuse allegations timely, failure to respond to resident council concerns, failure to provide reasonable accommodations, unclean environment, medication administration errors, failure to meet physician visit frequency requirements, failure to monitor drug regimens and report irregularities, and infection control lapses.

Complaint reference #9295. Substantiated complaint record with deficiencies cited. The facility failed to report two (2) of ten (10) complaints containing allegations of resident abuse/neglect to the State survey and certification agency as required. The facility also failed to ensure three (3) of one hundred fifty-eight (158) employees reported allegations of abuse immediately to supervisory staff as required.

The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to comprehensive care plans and resident rights, including assessment of nursing interventions for residents receiving psychoactive medications and infection control measures.

The facility failed to adequately address potential problems for residents receiving psychoactive medications by not including detailed nursing interventions or adverse consequences in care plans for 11 of 13 sampled residents. Additionally, the care plan for one resident with MRSA infection did not include nursing interventions for contact isolation despite isolation precautions being in place.

The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident rights, comprehensive care plans, quality of care, and clinical records.

The facility was found deficient in multiple areas including failure to address all identified problems in care plans, delayed physician intervention for aspirational pneumonia, incomplete adherence to physician orders for impaction checks, and inaccuracies in clinical records such as drug allergy documentation and bowel movement charting.

The inspection was conducted to evaluate compliance with life safety code standards and other regulatory requirements related to fire safety, emergency systems, and electrical wiring in the facility.

The facility failed to maintain all means of egress readily accessible due to storage of equipment in corridors, failed to maintain components of the fire alarm system, automatic sprinkler system, emergency generator lighting, and electrical wiring in accordance with NFPA standards.

This document is a plan of correction related to a paper revisit survey of Elkins Rehabilitation & Care Center.

The document references a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand. No other findings are detailed.

The inspection was conducted as part of an annual survey to assess compliance with federal regulations regarding resident care, medication management, physician visits, and clinical record keeping.

The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents with chronic pain and dialysis needs, failure to implement appropriate pain management and medication interventions, failure to ensure timely physician visits and proper documentation, failure to prevent unnecessary drug use, and incomplete clinical records.

The inspection was conducted to review facility documentation, staff interviews, and observations to determine compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

The facility was found to be in compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition based on the review.

The inspection was conducted in response to complaints referenced #2-6065 and #2-6073.

The complaint records were found to be unsubstantiated with no deficiencies cited during the investigation.

Complaint references #2-6065 and #2-6073 were investigated and found to be unsubstantiated with no deficiencies cited.

The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.

The inspection was conducted as an annual survey of the Elkins Rehabilitation & Care Center to assess compliance with federal regulations governing nursing facilities.

The facility was found deficient in multiple areas including resident rights and services, staff treatment of residents, accommodation of needs, activities program, infection control, drug regimen review, nutritional adequacy, sanitary conditions in food preparation, and clinical record maintenance. Specific issues included failure to ensure proper exercise of resident rights, failure to inform residents of risks related to medications, inadequate reporting and investigation of abuse allegations, failure to maintain dignity in care, inadequate activity offerings, noisy environment at night, improper medication administration, and failure to follow dietary orders.

Complaint investigation triggered by complaint reference #2-5311 regarding failure to consult physician immediately after a resident fall and other care deficiencies.

The facility failed to consult the physician immediately after a resident sustained a fall, failed to use an ordered electric lift for transfers resulting in injury, failed to report neglect and abuse allegations to appropriate authorities, failed to ensure staff wore identification badges, and failed to ensure timely physician visits for multiple residents.

Complaint reference #2-5311 substantiated with state licensure and federal certification deficiencies cited. The complaint involved failure to consult physician after resident fall, failure to use ordered transfer equipment, failure to report neglect and abuse, and failure to provide timely physician visits.

The inspection was conducted as a complaint investigation based on complaint record 2-5165.

The complaint was substantiated; however, no deficiencies were cited during the investigation.

Complaint record: 2-5165. Substantiated complaint record with no deficiencies cited.

The inspection was conducted as a complaint investigation related to a substantiated complaint concerning staff treatment of residents and medication administration errors.

The facility failed to report a medication administration error involving Resident #41, who received a tenfold overdose of Phenobarbital, resulting in gastric lavage and hospitalization. The facility did not follow the plan of care for this resident and failed to report the incident to the state survey and certification agency as required.

Complaint reference #2-5035 was substantiated with deficiencies cited related to medication administration errors and failure to report the incident.

This document is a plan of correction related to deficiencies identified in a prior survey of the facility.

The document includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges in writing and orally in a language they understand, as required by regulation.

The inspection was conducted as an annual survey to assess compliance with federal regulations regarding quality of life, quality of care, medication management, infection control, and residents' rights at Elkins Rehabilitation & Care Center.

The facility was found deficient in providing a quiet environment conducive to sleep for residents, proper use of safety alarms, appropriate use and monitoring of psychotropic medications, failure to attempt gradual dose reductions of antipsychotic drugs, and improper infection control technique during dressing changes.

The survey was conducted to assess the facility's compliance with the Life Safety Code NFPA 101 - 2000 Existing.

Based on observation, performance testing, and review of facility documentation during the survey from 10/18/04 to 10/20/04, the facility was determined to be in compliance with the Life Safety Code NFPA 101 - 2000 Existing.

The inspection was conducted as a complaint investigation referenced as #2-3304.

The complaint was substantiated but no deficiencies were cited during the investigation.

Complaint reference #2-3304 was substantiated with no deficiencies cited.

The inspection was conducted in response to complaints referenced #2-3287 and #2-3289.

The complaint investigation was unsubstantiated with no deficiencies cited.

Complaint references #2-3287 and #2-3289 were investigated and found to be unsubstantiated with no deficiencies cited.

The inspection was conducted to assess compliance with fire safety codes and other regulatory requirements related to resident rights and facility safety.

The facility was found deficient in staff familiarity with fire plan procedures, failure to maintain self-closing devices on hazardous area doors, and improper storage of oxygen cylinders not secured against unauthorized entry.

The inspection was conducted based on complaints from residents regarding dietary requests, quality of life issues, and other concerns related to resident care and facility policies.

The facility failed to promptly address dietary complaints from diabetic residents, did not perform required criminal background checks on new employees, restricted residents from opening windows, provided inadequate weekend activities, inaccurately completed resident assessments, and failed to administer medications via gastrostomy tube according to policy.

The complaint investigation was substantiated by findings that the facility failed to address diabetic residents' dietary requests, failed to conduct required criminal background checks, restricted residents' ability to open windows, provided insufficient weekend activities, inaccurately completed resident assessments, and failed to properly administer medications via gastrostomy tube.

The inspection was conducted as a comprehensive annual survey of the nursing facility to assess compliance with federal regulations related to resident rights, quality of care, infection control, dietary services, physician visits, and other regulatory requirements.

The facility was found deficient in multiple areas including failure to ensure residents' rights were exercised by appointed representatives, inadequate staff screening for abuse history, poor dining environment and assistance, incomplete resident assessments and care plans, improper administration of tube feedings, inadequate supervision of residents with restraints, failure to meet special dietary needs, delayed physician visits, and poor infection control practices.

The inspection was conducted to review the facility's compliance with the provisions of NFPA 101, Life Safety Code, 1985, based on documentation review, staff interview, observations, and performance testing.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 1985.

The inspection was conducted to assess compliance with federal regulations regarding resident rights, transfer and discharge requirements, quality of care, and medication management at Elkins Rehabilitation & Care Center.

The facility was found deficient in providing residents or their legal representatives with written notice containing the name, address, and telephone number of the State long term care ombudsman at discharge. Additionally, the facility failed to adequately assess the effectiveness of an antipsychotic medication before administering an anxiolytic drug to a resident, indicating issues with medication management.

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically focusing on the design, installation, and maintenance of the facility's commercial cooking equipment fire-extinguishing system.

The facility's rangehood wet chemical extinguishing system was found not to be inspected monthly as required by NFPA 17A. The service tag lacked dates and initials verifying monthly inspections from August 2001 to October 2001, and the maintenance director confirmed no inspections were conducted during that period.

Based on observation and review of facility documentation from September 26-28, 2000, the inspection was conducted to determine compliance with Section 483.70 Physical Environment of 42 CFR Part 483.

The facility was found to be in compliance with the physical environment requirements of 42 CFR Part 483.

Based on observation and review of facility documentation from September 26-28, 2000, the facility was surveyed to assess compliance with the Life Safety Code.

The facility was determined to be in compliance with the Life Safety Code (short form) based on the observation and documentation review.

Routine inspection of Elkins Rehabilitation & Care Center to assess compliance with federal regulations regarding resident rights, quality of care, physical restraints, resident assessments, care planning, dietary services, and medication management.

The facility was found deficient in multiple areas including improper use of physical restraints, failure to maintain resident dignity and privacy, inadequate accommodation of resident preferences, incomplete resident assessments and care plans, failure to provide necessary care and services to maintain residents' well-being, failure to provide restorative services as ordered, inadequate assistance with eating, and serving food at improper temperatures.

The inspection was conducted as a routine survey to assess compliance with quality of care, dietary services, and resident rights regulations at the nursing facility.

The facility was found deficient in providing necessary personal and oral hygiene services to five residents unable to carry out activities of daily living, failed to ensure adequate supervision and assistive devices to prevent accidents for one resident who sustained a hip fracture, and failed to store and serve food under sanitary conditions, including expired cottage cheese stored with usable food items.