5 CMS Surveys
Inspection Report — Mar 8, 2026
Renewal
Date: Mar 8, 2026
Visit Reason
Routine renewal inspection of the facility to assess compliance with health and safety standards.
Findings
No health deficiencies were found during this inspection. The facility met all applicable regulatory requirements.
Inspection Report — Dec 19, 2024
Complaint Investigation
Date: Dec 19, 2024
Visit Reason
The survey was conducted following a complaint investigation regarding the facility's reporting of an alleged resident-to-resident abuse incident.
Complaint Details
The complaint involved the facility's failure to timely report the findings of an investigation for an alleged resident-to-resident abuse incident involving two residents.
Findings
The facility failed to report the findings of an investigation for an alleged resident-to-resident abuse incident within five working days as required.
Deficiencies (1)
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to submit the findings of an alleged resident-to-resident abuse incident within five working days.
Inspection Report — Dec 19, 2024
Renewal
Date: Dec 19, 2024
Visit Reason
Routine renewal inspection of Elkhorn Healthcare and Rehabilitation to assess compliance with health and safety regulations.
Findings
The facility failed to maintain a clean and safe environment, provide baseline care plans to residents, properly clean an ice machine, and ensure hand hygiene during medication administration.
Deficiencies (4)
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely: the facility failed to maintain bathroom floors and caulking, exposing residents to unsanitary conditions in shared bathrooms.
F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: the facility failed to provide baseline care plans to two vulnerable residents or their representatives, with missing documentation and no copies provided.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to clean and sanitize the ice machine according to manufacturer recommendations, resulting in black buildup inside the machine.
F 0880 Provide and implement an infection prevention and control program: a staff member failed to perform hand hygiene before administering medications to a resident, increasing the risk of spreading infections.
Report Facts
Residents sampled: 24
Residents affected by environment issues: 4
Residents affected by baseline care plan issues: 2
Residents affected by ice machine sanitation: 1
Residents affected by hand hygiene issue: 1
Ice machine cleaning frequency (months): 1
Floor damage size (inches): 20
Floor damage size (inches): 15
Inspection Report — Dec 19, 2023
Renewal
Date: Dec 19, 2023
Visit Reason
Routine renewal inspection of Elkhorn Healthcare and Rehabilitation to assess compliance with care planning, life support orders, food safety, and environmental standards.
Findings
The facility failed to implement and update comprehensive care plans for residents with seizure disorders and wound care needs. Provider Orders for Life-Sustaining Treatment (POLST) forms were incomplete or unsigned for multiple residents. Food storage and sanitation practices in the kitchen and nourishment closet were inadequate, with improper labeling, temperature control, and cleanliness issues.
Deficiencies (5)
F 0656 Administrator: the facility failed to implement a comprehensive care plan addressing seizure disorder for one of 27 sampled residents.
F 0657 Administrator: the facility failed to revise care plans to reflect current wound care needs for one of 27 sampled residents, including omission of current wound dressing instructions.
F 0678 Provide basic life support, including CPR, prior to the arrival of emergency medical personnel, subject to physician orders and the resident’s advance directives: the facility failed to ensure POLST forms were completed with signatures and dates for five of 27 sampled residents.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to ensure proper food storage and labeling in the nourishment closet and kitchen, including undated opened foods and inconsistent refrigerator temperatures.
F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public: the facility failed to maintain a sanitary environment in the kitchen dish room, main entry sink area, and nourishment closet, including uncovered dishes, leaking sink, dirty floors, and unclear cleaning responsibilities.
Report Facts
Residents sampled: 27
Residents affected: 1
Residents affected: 1
Residents affected: 5
Temperature (°F): 41
Dates on food items: 0
Inspection Report — Jan 5, 2023
Complaint Investigation
Date: Jan 5, 2023
Visit Reason
Complaint survey focused on food service quality, safety, and infection control practices.
Complaint Details
The complaint survey identified deficiencies in dietary staff training, food palatability and temperature, food storage and sanitation, quality assurance processes, and infection control practices affecting multiple residents.
Findings
The facility failed to ensure dietary staff were adequately trained in food safety and hygiene, resulting in improper food handling and storage practices. Residents reported receiving cold and unpalatable food. The facility also failed to maintain proper infection control during medication administration, food service, and laundry operations.
Deficiencies (5)
F0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service: dietary personnel were inadequately trained in safe food handling and sanitary practices, including failure to wear hair coverings.
F0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature: residents received cold, dry, and unpalatable food, and the facility failed to sustain corrections from prior citations.
F0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: multiple food safety violations were observed including unsealed and undated food items, food stored on the floor, dirty kitchen equipment, and failure to wear hair coverings.
F0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action: the facility failed to implement and sustain effective quality assurance related to food palatability, temperature, and resident satisfaction despite repeated citations and corrective plans.
F0880 Provide and implement an infection prevention and control program: staff failed to follow infection control during medication administration, food service, and laundry operations, including handling medication with bare hands, contaminated name badges, and lack of PPE in laundry area.
Report Facts
Meals audited per week: 15
Residents sampled for satisfaction audits: 3
Milk cartons: 65
Breadcrumb sack weight (lbs): 25
Food expiration date: 12.11
Food sell by date: 12.23
Loading inspection reports...
