Elkhorn Healthcare and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Elkhorn Healthcare and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF761Feb 10, 2026

  Based on observations, interviews, and record review, the facility failed to remove expired items for disposal for one medication room, one central supply room, storage closet, and three medication carts; keeping items off the floor in one medication room, one supply room and a storage closet; store supplies in a clean environment, free from debris falling on supplies for one central supply room; and failed to ensure a schedule II controlled substance, morphine, was locked up from other residents and staff preventing the risk of tampering for 1 (#59) of 27 sampled residents. These failures increased the risk of expired items being used, when stored unsafely, for resident care, if taken from the identified medication rooms and carts. […]

• No harm, potential for more than minimal, widespreadF804Feb 10, 2026

  Based on observation and interview, the facility failed to ensure the food temperature was served at a palatable temperature for 5 (#s 20, 24, 36, 58 and 59) of 27 sampled residents. This deficient practice resulted in residents reporting disliking the food and resulted in residents eating less. Findings include:During an interview on 2/7/26 at 3:08 p.m., resident #59 stated the food was cold when it arrived to her room.During an observation and interview on 2/8/26 at 7:57 a.m., staff member S measured the temperatures from the steam table. The bread puree was at 133 degrees Fahrenheit. […]

• No harm, potential for more than minimal, widespreadF865Feb 10, 2026

  Based on interview and record review, the facility leadership failed to maintain a QAPI system to identify quality of care and quality of life deficient practices, and show how deficiencies were identified, tracked, corrected, and monitored. The facility was cited with 17 deficiencies during the survey. These failures had the potential to affect all the residents of the facility due to needed corrections not being identified and addressed by the facility. Findings include: During an interview on 2/10/26 at 10:40 a.m., staff member A stated the facility talks about QAPI every morning. Staff member A stated, We go through the processes, and QAPI is involved in identifying deficiencies at morning meetings. […]

• No harm, potential for more than minimal, widespreadF880Feb 10, 2026

  Based on observation, interview, and record review, the facility failed to ensure staff followed hand hygiene practices for glove changes during a dressing change and failed to ensure a clean barrier was put down to keep the supplies clean for 1 (#49) of 27 sampled residents. Findings include:During an observation on 2/9/26 at 10:04 a.m., staff member M was performing wound care and a dressing change on resident #49's coccyx. Staff member M placed the dressing change supplies on the resident's wheelchair but didn't place a clean barrier between the wheelchair and the supplies. Staff member M donned a gown, mask, and gloves due to enhanced barrier precautions. Staff member M removed the dressing from the resident's coccyx and discarded the dressing in the garbage. […]

• No harm, potential for more than minimal, widespreadF802Jan 5, 2023

  Based on observation, interview, and record review, the facility failed to ensure dietary personnel were adequately trained to have the competencies and skill sets to identify safe food handling practices and maintain a sanitary environment. These failures had the potential to affect all residents who consumed food prepared in the kitchen. Findings include: During an observation on 1/3/23 at 1:23 p.m., staff member J was not wearing a covering over his hair. During an observation on 1/4/23 at 2:52 p.m., staff member J was not wearing a covering over his hair. During an interview on 1/4/23 at 3:05 p.m., staff member D stated training for the kitchen staff consists of on the job training. There needs to be competency training for dietary staff. […]