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Deficiency Records for Elkhorn Healthcare and Rehabilitation
A list of the most recent deficiencies for Elkhorn Healthcare and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Elkhorn Healthcare and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-03 | 2024-02-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-03 | 2024-02-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-01-03 | 2024-02-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-03 | 2024-02-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-03 | 2024-02-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-03 | 2024-02-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-03 | 2024-02-06 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-01-03 | 2024-02-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-03 | 2024-02-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-19 | 2024-01-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-19 | 2024-01-10 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-12-19 | 2024-01-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-19 | 2024-01-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-12-19 | 2024-01-10 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-01-05 | 2023-02-07 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-05 | 2023-02-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-05 | 2023-02-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-05 | 2023-02-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-05 | 2023-02-02 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-01-10 | 2023-02-02 | N |
| Establish methods for sharing information. | Fire Safety | 2023-01-10 | 2023-02-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-10 | 2023-02-02 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-01-10 | 2023-02-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-10 | 2023-02-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-01-10 | 2023-02-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-10 | 2023-02-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-10 | 2023-02-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-10 | 2023-02-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-10 | 2023-02-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-10 | 2023-02-02 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-01-10 | 2023-02-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-10 | 2023-02-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-10 | 2023-02-02 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-19 | 2022-11-25 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-01-10 | 2022-02-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-01-10 | 2022-02-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-10 | 2022-02-14 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-01-10 | 2022-02-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-10 | 2022-02-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-10 | 2022-02-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-10 | 2022-02-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-10 | 2022-02-14 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-01-10 | 2022-02-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-06 | 2022-02-09 | N |
| 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. | Health | 2022-01-06 | 2022-02-09 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-01-06 | 2022-02-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-06 | 2022-02-09 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-01-06 | 2022-02-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-01-06 | 2022-02-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-06 | 2022-02-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-06 | 2022-02-09 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-01-06 | 2022-02-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-06 | 2022-02-09 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-06 | 2022-02-09 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-01-06 | 2022-02-09 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-01-06 | 2022-02-09 | Y |
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