Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elkhorn Healthcare And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found expired meds and supplies in multiple storage areas, including med carts, med room, central supply, respiratory cart, wound cart, and a closet, along with items stored on the floor and a dirty med room with damaged flooring. A resident’s morphine infusion via CADD pump was left unsecured in the room instead of being locked, and staff acknowledged the narcotic was not properly secured.
A facility failed to serve food and drinks at an appetizing temperature for several residents. One resident said her meal arrived cold in her room, and staff measured multiple items below proper hot or cold holding temperatures, including puree, waffles, sausage, juice, hashbrowns, biscuits, and pasta salad. Residents reported cold meals and staff noted the oven had broken repeatedly, the right side would not stay lit, and food was difficult to keep warm during service.
Failure to Maintain an Effective QAPI System: Facility leadership failed to maintain a QAPI system that identified, tracked, corrected, and monitored deficient practices. Staff reported QAPI was discussed in morning meetings, but the facility was not tracking improvement measures, and a long-running PIP involved moving a coffee cart due to contamination concerns. After the survey, the facility identified concerns with falls, med storage, med error rate, central supply, and food temperatures.
Hand Hygiene and Clean Barrier Not Followed During Wound Care An LPN performing wound care for a resident’s coccyx placed dressing supplies on the resident’s wheelchair without a clean barrier and changed gloves multiple times without washing hands or using hand sanitizer between glove changes. The LPN stated she had not performed hand hygiene between glove changes, and facility guidance stated hand hygiene was required before donning and after removing gloves.
A resident reported the dining room and hallways were often very cold, and staff observations confirmed low temperatures in the dining area. Another resident who was paralyzed from the waist down said her bed was not turned to face outside and her pictures were left unhung for weeks, leaving her frustrated with the clutter and room layout; staff noted the bed could be repositioned and that the pictures required maintenance because some were heavy.
Staff lacked hands-on BLS certification. Review of certifications showed most staff were certified through the National CPR Foundation, which did not provide hands-on training. An LPN and another staff member stated their CPR classes were entirely online and did not include compressions on a dummy or instructor feedback. The State Operations Manual requires CPR certification for healthcare providers to include a hands-on session.
Medication pass errors resulted in a 10.71% error rate, with staff pre-pouring meds at the start of the shift and leaving cups labeled only with resident names. An LPN opened a gabapentin capsule and placed it in pudding without an order directing that method, dropped a pantoprazole DR tablet onto the floor during prep, and administered an Advair inhaler without having a resident rinse and spit afterward as required by the manufacturer and facility policy.
The facility failed to ensure that two residents receiving psychotropic meds had GDRs and behavioral interventions attempted, and it did not maintain documentation of prior GDR failures. Consultant pharmacist reviews identified multiple psychotropic meds being used without GDRs, but the physician responses cited prior GDR failure or guardian refusal, while staff later stated there was no documentation of a failed GDR for either resident.
The facility failed to keep PASRR Level I screens current for 3 residents after new mental health diagnoses were documented in the EHR. One resident had PTSD, another had major depressive disorder, and a third had residual schizophrenia, but the PASRRs on file did not reflect those diagnoses. Staff stated a new PASRR should have been completed because of the new diagnoses, but they were unaware of them due to miscommunication from the MDS dept.
Failure to Provide ADL Care and Maintain Resident Dignity: A resident who needed help with bathing, dressing, grooming, and oral care was observed disheveled, in the same clothes, with uncombed hair, facial whiskers, and body odor on multiple occasions, despite care plans and hospice support for hygiene. Another resident who was paralyzed from the waist down said staff often missed basic ADL care, did not offer a warm washcloth or toothbrush consistently, and did not provide the preferred shower frequency; the EHR showed hospice showers and four bed baths in 30 days.
Failure to Support Communication for a Resident With Hearing Loss: A resident with significant hearing loss and communication deficits was observed struggling to hear and became frustrated during an interview because he had not been offered an amplifier or communication board. His care plan identified impaired communication related to hearing loss, but it did not include staff interventions to help with daily communication, and staff acknowledged they had not considered a pocket talker for him.
A resident with severe cognitive impairment had repeated falls, including unsafe transfers and use of a bedside table as a walker, while the care plan lacked daily direct-care interventions and was not updated after recent falls. Staff also left the call light out of reach and the resident’s walker was removed. Another high fall risk resident reported delayed response to the call light and was observed self-transferring and wheeling herself to the bathroom while staff nearby continued other tasks.
Inconsistent Repositioning for Pain Relief: A resident reported moderate pain when she was not repositioned promptly, stating she sometimes waited 15 to 25 minutes for staff response and that this occurred a couple of times a week. Records noted ongoing muscle pain and cramps, use of Voltaren gel, and assistance with repositioning, while the care plan called for frequent repositioning for comfort and the facility pain management policy included turning and repositioning as a non-pharmacological intervention.
A resident with no teeth reported that he could not chew or swallow many foods, feared choking, and wanted dentures, but said dental services were never offered. During observation, he coughed multiple times while eating oatmeal and stated he was having a hard time swallowing. Staff said fear of leaving the building may have contributed to no dental appointment being made, and no dental referral documentation was provided.
Failure to address swallowing concerns and meal positioning for a resident with no teeth and a BIMS of 13. The resident reported coughing on food, difficulty swallowing, and fear of choking, while staff were unaware of the issue or did not treat it as significant. Observations showed the resident eating while reclined, coughing during meals, and unable to fully swallow food until positioned upright. The care plan listed tray setup assistance but no swallowing interventions, and the diet order included soft bite-sized texture with regular bread per resident request.
Food items were not properly date-marked or stored. During a kitchen observation, opened dry goods, deli turkey, lemonade, and cranberry juice lacked required open, receive, prepared, or discard dates, and 14 servings of peach parfait on a tray cart were uncovered, not chilled, and warm to the touch. An LPN stated opened items should have a receive date sticker and written open date, and the parfait should have been covered.
The facility failed to properly clean and sanitize an ice machine used for providing ice to the dietary department and residents. A black substance was observed inside the machine, which fell into the ice bin. Staff reported monthly cleaning procedures, but the buildup was not previously noticed. Manufacturer instructions required sanitizing all surfaces with a sanitizer/water solution.
A staff member failed to perform hand hygiene between administering medications to two residents, contrary to the facility's infection control policy. This lapse was observed during a medication pass, where the staff member did not sanitize hands after disposing of a medication cup and before administering medications to another resident.
The facility did not report the findings of an investigation into an alleged resident-to-resident abuse incident involving two residents within the required timeframe. The incident occurred, but the findings were submitted late. A staff member confirmed the delay during an interview.
The facility failed to maintain a clean and well-maintained environment for four residents. In one shared bathroom, a large area of missing linoleum exposed the concrete foundation, which was found to be dirty. A resident noted that the flooring was supposed to be redone but had not been completed. In another shared bathroom, the caulking around the toilet was cracked and discolored, failing to seal the toilet base properly. A staff member confirmed that daily cleaning was expected, but this was not observed.
The facility did not provide baseline care plans to two residents or their representatives within 48 hours of admission. Both residents reported not receiving any information or copies of their care plans. A review showed that sections for acknowledging receipt of the care plan were left blank, and no documentation was provided to confirm the provision of these plans.
Expired Medications and Unsecured Morphine Found in Storage Areas
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted principles when a schedule II controlled substance, morphine, was left accessible in a resident’s room rather than being locked up. Resident #59 had an IV bag of morphine 10 mg/mL hanging on a command strip at the top of the bed and running through a CADD pump into a PICC line. The pump was not locked to prevent access, and staff stated the medication was not locked up. The resident reported the pump had been in the room for a few weeks and hospice managed it. During interviews, staff members stated narcotics were supposed to be double locked in the medication cart, and several staff acknowledged the morphine was not secured. One staff member stated there was potential for another resident or staff member to steal or divert the medication because it was not locked up. Another staff member stated the CADD pump had a code and tubing cassette lock, but the medication itself was not locked. A facility leader stated this was the first CADD pump the facility had used and did not know why it had never been locked up. The hospice document reviewed stated the pump keypad and cassette should be locked to prevent tampering when there is risk of misuse. The facility also failed to remove expired items and maintain proper storage conditions in multiple areas. Surveyors found expired medications and supplies in a medication cart, medication supply room, central supply room, respiratory cart, wound cart, and storage closet. Items were stored on the floor in the medication room, central supply room, and storage closet, and the medication room floor was dirty with missing tile. In the central supply room, a sharps container had a used needle with no lid, and the wall behind catheter supplies had moisture damage with exposed rotten wood causing debris to fall onto sterile supplies. The facility policy stated medications were to be stored to ensure sanitation, temperature, light, ventilation, moisture control, segregation, and security.
Cold Food Served to Residents
Penalty
Summary
The facility failed to ensure food and drink were served at a palatable and safe temperature for 5 of 27 sampled residents, including residents 20, 24, 36, 58, and 59. Resident 59 stated the food was cold when it arrived in her room. During observation, staff measured the bread puree on the steam table at 133 degrees Fahrenheit, below the temperature staff stated it should be held at, 145 to 170 degrees Fahrenheit. Resident 36’s meal delivered to her room included yogurt at 61 degrees Fahrenheit, a waffle at 107 degrees, sausage at 109 degrees, and sugar-free Crystal Lite at 55 degrees; staff stated the cold items should have been 40 degrees Fahrenheit or below. Resident 36 stated the waffle was cold, the strawberry sauce made it soggy, the sausage felt lukewarm, and the juice was semi cold. Residents 20 and 58 stated their hashbrowns were cold, and staff measured hashbrowns at 110 degrees and a biscuit at 66 degrees in the food window. Staff also stated the oven had been broken three times in the last month, the right side would not stay lit, and it was difficult to keep food warm. Resident 58 and 24 stated their food was often cold, including lunch, and staff measured a cold pasta salad at 45 degrees Fahrenheit while it sat on top of ice in a large bin.
Failure to Maintain an Effective QAPI System
Penalty
Summary
The facility leadership failed to maintain a QAPI system to identify quality of care and quality of life deficient practices, and to show how deficiencies were identified, tracked, corrected, and monitored. During an interview, staff member A stated the facility talks about QAPI every morning and that QAPI is involved in identifying deficiencies at morning meetings, but also stated the facility found they were not tracking improvement measures. Staff member A said the facility had a performance improvement project involving moving the coffee cart from the dining room to behind the nurses' station because of the potential for contamination, and that the project had been open for a while. Staff member A also stated that, because of the survey, the facility identified falls, med storage, med error rate, central supply, and food temperatures as concerns. Staff member A said the facility's Governing Body monitors QAPI from outside the facility and provides feedback. Review of the facility policy titled Quality Assurance and Performance (QAPI) Plan showed the administrator is responsible and accountable to the corporation for ensuring QAPI is implemented throughout the organization, and that corrective action plans or performance improvement projects are implemented when the need is identified.
Hand Hygiene and Clean Barrier Not Followed During Wound Care
Penalty
Summary
The facility failed to ensure staff followed hand hygiene practices during wound care for resident #49 and failed to ensure a clean barrier was placed to keep dressing change supplies clean. During an observation, staff member M performed wound care and a dressing change to the resident’s coccyx. Staff member M placed the dressing change supplies on the resident’s wheelchair without placing a clean barrier between the wheelchair and the supplies, then donned a gown, mask, and gloves for enhanced barrier precautions. During the dressing change, staff member M removed the old dressing, discarded it, and removed gloves, but did not sanitize or wash hands before donning clean gloves. Staff member M repeated this action after cleansing the wound with wound cleanser and again before applying the clean dressing. In interview, staff member M stated she had not washed her hands or used hand sanitizer between glove changes. Facility documentation stated staff were to wash hands or use hand sanitizer before applying and after removing PPE, including gloves, and that glove use does not replace hand hygiene.
Cold Dining Areas and Unfinished Room Setup
Penalty
Summary
The facility failed to provide a comfortable environment or temperature in the dining room and hallways for resident #49. During interview, resident #49 stated the dining room and hallways were often very cold, so she ate in her room. Staff also described the building as often cold, and observations showed the dining room thermometer at 66 degrees Fahrenheit on one occasion and 64 degrees Fahrenheit on another. Staff members stated the temperature fluctuated with the outside temperature and that the dining room was often cold, possibly because of the large number of windows in that area. The facility also failed to provide a homelike environment for resident #59. Resident #59, who was paralyzed from the waist down and unable to ambulate or move out of bed, stated she wanted her bed turned to face outside because she enjoyed looking out the window. She also said she had asked for her picture frames to be hung up since admission, but the task was delayed for weeks, leaving her frustrated with the room layout and clutter. She pointed to her cluttered bedside table and said the mess in her room irritated her, and she relied on staff to help organize and clean the area. Staff stated there was no reason her bed could not be turned to look outside and that hanging the pictures required maintenance because some were heavy and needed drilling.
Staff Lacked Hands-On BLS Certification
Penalty
Summary
The facility failed to ensure staff received hands-on BLS certification. Review of all staff BLS certifications showed that all staff members except one were certified through the National CPR Foundation, which did not provide hands-on training. During interviews, staff member P stated their CPR class at the current position was entirely online and did not include any hands-on training, compressions on a dummy, or feedback on CPR performance. Staff member P stated they had prior BLS experience from another job and felt relief because they might need that experience in their current position. During another interview, staff member N stated their CPR certification was done completely online and there was no hands-on experience. Review of staff members P and N's certifications showed Healthcare - CPR/AED. The State Operations Manual stated that CPR certification for healthcare providers must include a hands-on session either in a physical or virtual instructor-led setting in accordance with accepted national standards.
Medication pass errors and improper administration practices
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less for 2 of 4 residents observed. Surveyors observed 28 medications and identified 3 errors, resulting in a medication error rate of 10.71 percent. During the medication pass, staff member G had all morning medications pre-poured into eight cups in the top drawer of the medication cart, and staff member G stated that pre-pouring medications at the beginning of the shift was common practice. Staff member G also stated she could not describe the medications in the cups because they had been prepared early in the shift, and the cups were labeled only with resident names, not medication names. Staff member J later stated that her medications were also pre-poured at the beginning of the shift and that she would need to review the MAR to identify what was in the cups. During administration to resident #43, staff member G opened a gabapentin 300 mg capsule and placed it in pudding, stating the resident had previously had difficulty taking the medication. After administration, staff member G stated she was not aware gabapentin was contraindicated for opening capsules for administration. The resident's gabapentin order did not direct that it be given in pudding or opened, although the resident's crush order stated that meds may be crushed or capsules opened as needed unless contraindicated. During administration to resident #19, staff member G popped a pantoprazole 20 mg delayed-release tablet from the card and the tablet fell onto the floor, which the surveyor stopped to avoid a safety hazard. Staff member G then administered medications and an Advair inhaler to resident #19 but did not have the resident rinse and spit afterward, and stated she was not aware this was required. The manufacturer's patient information and the facility's inhaler policy both reflected that residents should rinse and spit after use of Advair Diskus.
Failure to Document GDRs for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents who were receiving psychotropic medications had gradual dose reductions and behavioral interventions attempted in an effort to discontinue the drugs, and it also failed to maintain documentation of gradual dose reduction failures for 2 residents. For one resident, consultant pharmacist recommendations noted Buspirone, Abilify, and Citalopram were being used without a gradual dose reduction, and the pharmacist recommended a GDR. The physician responded that the guardian refused GDRs due to past GDR failure, and in another recommendation the physician stated there had been a previous in-facility GDR failure for behavioral symptoms related to dementia or that use was in accordance with current standards of practice for psychiatric disorder. However, staff later stated there was no documentation of a failed GDR for this resident in the facility or outside the facility. For a second resident, consultant pharmacist recommendations identified Aripiprazole, Fluoxetine, Trazadone, and Hydroxyzine being used without a gradual dose reduction, and a GDR was recommended. The physician responded that there had been a previous in-facility GDR failure for behavioral symptoms related to dementia. During interview, staff stated the facility had no documentation of a failed GDR for this resident in the facility or outside the facility, and that the resident never failed a GDR. The facility policy stated residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions unless clinically contraindicated, in an effort to be managed at a lower dose or discontinued from these drugs.
PASRR Screens Not Updated for New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure current PASRR screenings were completed for 3 residents with newly documented mental health diagnoses. Resident #64’s EHR showed post-traumatic stress disorder, while the PASRR Level 1 on file listed bipolar disorder and major depressive disorder but did not include PTSD. Resident #14’s EHR showed major depressive disorder, but the PASRR Level 1 on file listed only mood disorder and did not include major depressive disorder. Resident #13’s EHR showed residual schizophrenia, while the PASRR Level 1 listed schizoaffective disorder and did not include residual schizophrenia. During interview, staff member C stated a new PASRR should have been completed for these residents because of the new diagnoses and said they were unaware of the new diagnoses due to miscommunication from the MDS department. The facility policy stated that a negative Level I screen permits admission to proceed and ends the PASRR process unless a possible serious mental disorder or intellectual disability arises later.
Failure to Provide ADL Care and Maintain Resident Dignity
Penalty
Summary
The facility failed to provide dignity and assistance with ADLs for a resident who was unable to care for himself. Resident #18 was observed on multiple occasions looking disheveled, wearing the same clothes as the prior day, with uncombed hair, increased whiskers on his face, and a foul body odor in a dark room that smelled of body odor. Staff stated that residents should be offered showers, have their faces washed, hair combed, and be encouraged to assist with cleaning and changing clothes. The resident’s care plan identified him as needing assistance with showering, bathing, personal hygiene, and dressing, and the hospice coordinated plan showed a hospice aide was scheduled to assist with bathing and personal hygiene on Wednesdays. A facility document also showed showers were to occur on Tuesdays and Fridays. The facility also failed to provide basic ADL care for another resident who was paralyzed from the waist down and depended on staff for assistance. Resident #59 stated that staff frequently missed basic cares, that the last warm washcloth and toothbrush offer was from a staff member the prior Friday, and that the last bed bath was the prior Sunday and was provided by hospice. She said staff did not prioritize her care or check on her enough and that she received one bed bath a week even though she wanted two. The EHR showed a task for showers every Wednesday morning by hospice and Sunday evening, and documented four bed baths in the last 30 days. The facility policy stated that bathing, dressing, grooming, and oral care are to be provided as part of ADL care, and the dignity policy stated that all staff are involved in providing care to promote and maintain resident dignity and respect resident rights.
Failure to Support Communication for a Resident With Hearing Loss
Penalty
Summary
The facility failed to ensure resident #70 received the level of assistance needed for hearing loss and communication deficits. During an observation and interview, resident #70 was lying in bed with the lights on and was very hard of hearing, requiring the surveyor to get very close and speak loudly to be heard. The resident stated he had not been offered any amplifier or communication boards to help him communicate, became frustrated while trying to speak with the surveyor because he could not hear the questions, and said he would be willing to use a pocket talker if offered. Record review showed resident #70’s care plan, updated 2/4/26, identified impaired communication related to hearing loss, but the only interventions listed were identifying specific communication barriers and ordering Debrox solution per physician order. The care plan did not include interventions for staff to use to assist with daily communication or the hearing deficit. Staff member E stated she had not considered a pocket talker for the resident, acknowledged he was very hard of hearing, and later stated occupational therapy had taken the resident a pocket talker and he was successfully using it to communicate. The facility policy on assistive devices stated the facility would provide assistive devices for residents who need them and that nursing, dietary, social services, and therapy would work together with the resident and responsible parties to ensure availability of devices.
Failure to Provide Fall Prevention Interventions and Timely Toileting Assistance
Penalty
Summary
The facility failed to ensure interventions were implemented based on the care plan and person-centered to prevent ongoing falls for one resident, and failed to offer assistance with ambulation to the toilet for another resident. Resident #15 had severe cognitive impairment with a BIMS of 3 and had fallen eight times in six months. During observation, the resident was in bed with a tray table beside the bed and the call light pinned near the head of the bed. The resident’s visitor stated the resident had many falls, had previously had one-to-one supervision in the hallway, and was concerned about more falls after that supervision ended. Staff stated the resident was too weak to use a walker, required total assistance to the toilet, and had become more disoriented after a room move. Review of the resident’s fall reports showed repeated falls related to unsafe attempts to transfer or ambulate, including using the bedside table as a walker, tripping over oxygen tubing, and attempting to self-transfer to the toilet without using the call light. The interventions documented after these falls included removing the bedside table, educating the resident to use the call light, pinning the call light near the resident’s hand, and adding glow-in-the-dark tape. The care plan identified the resident as at risk for falls due to debility, generalized weakness, and lack of confidence, but it did not include daily interventions for direct care staff to use, and it was not updated with interventions from the most recent falls. Staff also stated the bedside table should not have remained at the bedside except during meals and that the call light should have been within reach rather than near the resident’s head. For the second resident, the resident stated staff sometimes took a long time to respond to the call light and that she would wait a few minutes and then ambulate herself to the restroom because she was afraid of having an accident. During observation, the resident waited for help, looked for staff outside her room, and then transferred herself from bed to wheelchair and wheeled into the bathroom while a medication nurse continued preparing medications nearby. The nurse called for a CNA to assist but did not stop medication preparation while the resident got up on her own. Another staff member arrived after the resident had already reached the restroom and commented that she was impatient. Nursing notes identified the resident as a high fall risk.
Inconsistent Repositioning for Pain Relief
Penalty
Summary
The facility failed to consistently provide pain relief through repositioning for resident #59, who reported moderate pain when repositioning was not provided. During interviews, the resident stated she experienced pain rated 6 out of 10 when she needed to be repositioned and said she would wait 15 minutes in agony because she needed repositioning. She reported that her legs often hurt because they remained in the same position for long periods and that the wait was worst during dining times when staff were moving residents to the dining room. She also stated that on another morning around breakfast she waited 20 to 25 minutes for staff to respond to her call light and that this happened a couple of times a week. A nurses note documented continued complaints of muscle pain and cramps in her legs and elbows, with Voltaren gel applied twice overnight and the nurse helping reposition her. Her care plan included repositioning frequently for comfort, and the facility pain management policy listed turning and repositioning as a non-pharmacological intervention.
Failure to Offer Dental Services
Penalty
Summary
The facility failed to offer dental services for 1 of 27 sampled residents, resident #11. During interviews, resident #11 stated he had no teeth, could not eat or swallow many foods because he was afraid of choking, and had not been to a dentist but wanted dentures. He also stated dental services were not offered to him. On observation, resident #11 was eating oatmeal while positioned with his legs off the bed and his upper body leaning back against the wall, and he coughed multiple times while stating he was having a hard time swallowing. Staff member W stated that many residents, including resident #11, feared going out of the building, which may be why a dental appointment was never made. A survey documentation request for dental referral notes for resident #11 produced no documentation, and the facility policy stated that the dental needs of each resident are identified through the physical assessment and MDS assessment processes and addressed in the plan of care.
Failure to Address Swallowing Concerns and Meal Positioning
Penalty
Summary
Therapeutic diet and swallowing concerns were not properly identified or addressed for one resident who was edentulous and had a BIMS score of 13. The resident stated he could not eat many foods because he had no teeth and was afraid he would swallow food and choke. He also reported that he often coughed on food, had difficulty swallowing, and was not always helped to sit upright for meals. Staff members stated they were unaware of a swallowing issue or had not heard concerns reported to them, and one staff member said the resident did not need help with tray setup or positioning, despite the care plan listing tray setup assistance. During observations, the resident was seen eating while leaning back against the wall, coughed multiple times while eating oatmeal, and later was fed a cookie while lying in bed at about a 30-degree angle. He stated he could not fully swallow the cookie until he was told to sit up at the edge of the bed. The physician order listed a regular diet with soft bite-sized texture and regular bread products per patient request, but the care plan did not include interventions for swallowing concerns or deficits.
Food items were not date-marked or properly stored
Penalty
Summary
Food was not properly monitored, marked, or discarded in a reasonable amount of time to prevent bacterial growth. During a kitchen observation, the chicken gravy mix and country style gravy had no open date, both the full and opened bags of [NAME] classic egg noodles and Roseli egg noodles had no open or receive date, five slices of deli turkey in the refrigerator were labeled only with the date 12/5, and the lemonade pitcher and cranberry juice in the refrigerator had no prepared, discard, or open date. In addition, 14 prepared servings of peach parfait on the room tray cart were scheduled for lunch but were not covered or chilled, and the container was warm to the touch. Staff member X stated opened items should have a green receive date sticker and a written open date, and stated the peach parfait should have at least been covered. The facility policy titled Date Marking for Food Safety stated refrigerated ready-to-eat time/temperature control for safety food shall be held at 41 degrees Fahrenheit for a maximum of 7 days.
Ice Machine Cleaning Deficiency
Penalty
Summary
The facility failed to clean and sanitize an ice machine in accordance with manufacturer recommendations, which was used to provide ice to the dietary department and all residents. During an observation, a noticeable amount of black substance was found inside the ice machine above the door, which fell into the ice bin when wiped with a paper towel. Staff member I stated that the ice machine was cleaned monthly by emptying the ice, soaking and scrubbing the trays, running them through the dishwasher, and wiping down the machine. However, the black buildup was not previously noticed. The cleaning instructions on the inside panel of the machine indicated that a sanitizer/water solution should be used to sanitize all surfaces of the ice machine.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Staff member G failed to perform hand hygiene before administering medications to a resident, which was observed during a medication pass. After administering medications to one resident, staff member G disposed of the medication cup and proceeded to retrieve and administer medications to another resident without performing hand hygiene. This action was contrary to the facility's policy on hand hygiene, which requires hand sanitizing between each resident during medication administration. The facility's policy on administering medications also emphasizes following established infection control procedures, including handwashing, to prevent the spread of healthcare-associated infections.
Delayed Reporting of Abuse Investigation Findings
Penalty
Summary
The facility failed to report the findings of an investigation into an alleged resident-to-resident abuse incident involving two residents within the required five working days. The incident occurred on August 13, 2024, at 11:30 a.m., but the findings were not submitted until August 26, 2024. During an interview on December 17, 2024, a staff member confirmed that the findings were not submitted within the mandated timeframe.
Facility Fails to Maintain Clean and Safe Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and well-maintained environment for four residents, as observed during a survey. In the shared bathroom of two residents, a significant area of linoleum was missing, exposing the concrete foundation. This area was found to be dirty, as evidenced by a paper towel becoming soiled with orange, brown, and black particles and hair when wiped across the exposed concrete. One of the residents mentioned that the flooring was supposed to be redone the previous spring, but it had not been completed. Additionally, in another shared bathroom used by two other residents, the caulking around the toilet was cracked, discolored, and not properly sealing the base of the toilet to the linoleum. A staff member confirmed that the expectation was for resident bathrooms to be cleaned daily, but the observations indicated otherwise. The facility's maintenance policy, which was last revised in 2009, stated that maintenance should ensure the building is in good repair and free from hazards, but this was not adhered to in the observed cases.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to provide a baseline care plan to two residents, identified as #22 and #64, or their representatives, within 48 hours of admission. During interviews, both residents stated they had not received any information or a copy of their baseline care plans. A review of their admission and baseline care plan summaries revealed that sections indicating whether the resident or their representative received a copy of the plan, declined to receive printed copies, or provided a signature were left blank. Despite a request for documentation regarding the provision of these care plans, no information was provided before the survey concluded. Staff member C indicated that residents typically sign off on the baseline care plan summary and are asked if they want a printed copy, but this process was not completed for the two residents in question.
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Illustrative
What surveyors actually found near you
We read the 89 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Clancy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mount Ascension Transitional Care Of Cascadia | 8.9 mi | ★★★★★ | 28 | 0 |
| Cooney Healthcare And Rehabilitation | 9.1 mi | ★★★★★ | 61 | 0 |
| Ivy At Deer Lodge | 35.5 mi | ★★★★★ | 10 | 0 |
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