Deficiencies (last 2 years)
Deficiencies (over 2 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% worse than Montana average
Montana average: 5.8 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 19, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely report the findings of an investigation for an alleged resident-to-resident abuse incident involving residents #8 and #18.
Complaint Details
The complaint investigation found that the facility did not submit the findings of an alleged resident-to-resident abuse incident involving residents #8 and #18 within five working days as required. The incident occurred on 2024-08-13, but findings were submitted on 2024-08-26. Staff member A acknowledged the delay during an interview.
Findings
The facility failed to report the findings of the investigation within five working days as required. The incident occurred on 2024-08-13, but the findings were submitted on 2024-08-26. Staff member A confirmed during an interview that the findings were not submitted within the required timeframe.
Deficiencies (1)
Failed to timely report suspected abuse and the results of the investigation to proper authorities within five working days.
Report Facts
Incident date: Aug 13, 2024
Findings submission date: Aug 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A interviewed regarding failure to submit findings timely |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Dec 19, 2024
Visit Reason
The inspection was conducted as a regulatory annual survey to assess compliance with health and safety standards in the facility.
Findings
The facility was found deficient in maintaining a clean and safe environment, providing baseline care plans to residents, cleaning and sanitizing equipment such as the ice machine, and ensuring proper infection control practices during medication administration.
Deficiencies (4)
Failed to provide a clean and well-maintained environment, including damaged flooring and unsealed caulking in resident bathrooms.
Failed to provide a baseline care plan to vulnerable residents or their representatives upon admission.
Failed to clean and sanitize the ice machine according to manufacturer recommendations, resulting in black substance contamination.
Staff member failed to perform hand hygiene before administering medications, increasing risk of infection transmission.
Report Facts
Residents sampled: 24
Residents affected by environment deficiency: 4
Residents affected by baseline care plan deficiency: 2
Residents affected by ice machine sanitation deficiency: Some
Residents affected by infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Mentioned regarding cleaning expectations for toilets, floors, and sinks | |
| Staff member C | Provided information about baseline care plan distribution and hand hygiene practices | |
| Staff member G | Failed to perform hand hygiene before medication administration | |
| Staff member I | Described ice machine cleaning procedures and manufacturer recommendations |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Dec 19, 2023
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Elkhorn Healthcare and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans addressing specific resident needs such as seizure disorder and wound care, incomplete Provider Orders for Life-Sustaining Treatment (POLST) forms lacking signatures and dates, improper food storage and temperature monitoring, and failure to maintain a clean and sanitary environment in the nourishment closet and kitchen areas.
Deficiencies (5)
Failed to implement a comprehensive care plan addressing seizure disorder for resident #26.
Failed to revise care plans to reflect current care needs for resident #39, including wound care management.
Failed to ensure POLST forms were completed with provider signature, date, and time for 5 residents (#36, 48, 59, 119, 121).
Failed to ensure proper food storage and temperature control in kitchen and nourishment closet.
Failed to maintain a clean and sanitary environment in the nourishment closet and kitchen dish room.
Report Facts
Residents sampled: 27
Residents affected by seizure care plan deficiency: 1
Residents affected by wound care plan deficiency: 1
Residents affected by incomplete POLST forms: 5
Temperature threshold: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member B | Interviewed regarding care planning collaboration and acknowledged care plan should include seizure precautions | |
| Staff member A | Part of interdisciplinary team; agreed care plan should have seizure precautions | |
| Staff member D | Part of interdisciplinary team; agreed care plan should have seizure precautions; also interviewed regarding POLST completion process | |
| Staff member H | Interviewed about wound care management and care plan updates responsibility | |
| Staff member C | Responsible for updating care plans in EHR; was out of facility during survey | |
| Staff member E | Interviewed about nourishment fridge temperature checks and cleaning responsibilities | |
| Staff member F | Interviewed about cleaning responsibilities for nourishment room | |
| Staff member G | Interviewed about POLST binder and nourishment room cleaning | |
| Staff member I | Interviewed about POLST binder review | |
| Staff member J | Interviewed about determining CPR status from POLST or EHR |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 8, 2023
Visit Reason
The inspection was conducted as a standard annual survey of Elkhorn Healthcare and Rehabilitation to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jan 5, 2023
Visit Reason
The inspection was conducted based on complaints and concerns regarding food service quality, food safety, infection control practices, and overall facility compliance with regulatory standards.
Complaint Details
The visit was complaint-related, triggered by concerns about food palatability, temperature, infection control, and staff training. The facility had prior citations for similar issues and failed to sustain corrections. Resident interviews confirmed dissatisfaction with food quality and temperature. Staff interviews revealed inadequate training and inconsistent infection control practices.
Findings
The facility was found deficient in multiple areas including inadequate training and competency of dietary staff, failure to ensure palatable and properly heated food, improper food storage and sanitation practices, failure to sustain corrections from previous citations, and lapses in infection prevention and control practices during medication administration, food service, and laundry operations.
Deficiencies (5)
Dietary personnel were inadequately trained to identify safe food handling practices and maintain a sanitary environment.
Residents received food that was not palatable, often cold, and not properly monitored for temperature or taste.
Food was stored, prepared, and served in unsanitary conditions, including unsealed food items without dates, food on floors, and dirty equipment.
The facility failed to sustain corrections related to food palatability, temperature, and resident satisfaction despite multiple citations.
Staff failed to adhere to proper infection control practices during medication administration, food service, and laundry operations.
Report Facts
Certificates of completion: 2
Residents sampled: 2
Surveys cited: 3
Plan of correction completion date: Nov 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member J | Observed not wearing hair covering during food preparation and later wearing a hat | |
| Staff member D | Interviewed about dietary training and cleaning schedules; acknowledged lack of competency training | |
| Staff member M | Interviewed about dietary training and time spent in kitchen | |
| Staff member A | Provided dietary staff training certificates and commented on certification needs | |
| Staff member K | New kitchen staff with limited training | |
| Staff member L | Assistant Dietary Manager | Stepped down but continued to assist with training |
| Staff member E | Observed improper infection control during medication administration | |
| Staff member F | Observed with contaminated name badge during food service | |
| Staff member G | Observed not wearing apron or gown in laundry area | |
| Staff member H | Lacked training on PPE use in laundry area | |
| Staff member I | Mentioned need for masks in laundry area; no infection control training provided | |
| Staff member B | Interviewed about medication administration expectations | |
| Staff member C | Interviewed about infection control training in laundry area |
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