Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elkader Care Center during CMS and state inspections, most recent first.
A resident with multiple health conditions, including diabetes and heart failure, was admitted with a stage II pressure ulcer that worsened due to inadequate care and lack of communication. The facility failed to implement a turning and repositioning program, and assessments were incomplete. The ulcer's deterioration was not promptly reported to the primary physician, contributing to the resident's sepsis and subsequent death.
The facility failed to provide timely assessments and interventions for two residents following changes in their conditions. One resident with a stage II pressure ulcer did not receive thorough assessments as required by the facility's policy. Another resident with multiple health issues experienced a decline in health, but staff did not perform comprehensive assessments or interventions, leading to her being sent to the ER and later passing away. Staff interviews revealed a lack of thorough evaluations and communication with healthcare providers.
A resident with a history of pressure ulcers developed a worsening stage II ulcer due to the facility's failure to follow its Pressure Ulcer Prevention Program. The staff did not conduct thorough assessments or communicate changes to the primary physician, and the resident was not placed on a turning program despite being at risk. The resident passed away from sepsis related to the ulcer and renal failure.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers from developing or worsening in a resident with a history of pressure ulcers. The resident, who had diagnoses including radiculopathy, cardiomyopathy, urine retention, heart failure, renal insufficiency, and diabetes mellitus, was admitted with a stage II pressure ulcer on the left buttock. Despite being at risk for pressure ulcers, the resident was not placed on a turning and repositioning program, and the initial care plan did not address skin breakdown or pressure ulcers. The resident's pressure ulcer was initially assessed on admission, but the assessment was incomplete, lacking details on exudate, odor, wound bed, and surrounding skin. By the next documented assessment, the ulcer had significantly worsened in size and condition, yet the staff failed to report these changes to the resident's primary physician in a timely manner. The physician was not informed of the ulcer's deterioration during her visit, as the facility faxed the status update after she had left, preventing her from assessing the area. Interviews with the nurse practitioner and primary physician revealed concerns about the rapid progression of the ulcer and the lack of communication from the facility. The nurse practitioner noted that the ulcer could have been prevented or minimized, and the primary physician expressed that better communication might have avoided or reduced the severity of the ulcer. The resident ultimately developed sepsis, with the ulcer being a likely source, and passed away due to complications related to the ulcer and worsening renal failure.
Failure to Provide Timely Assessments and Interventions
Penalty
Summary
The facility failed to provide timely assessments and interventions for two residents following a change in their conditions. Resident #3, who had a history of radiculopathy, cardiomyopathy, urine retention, heart failure, renal insufficiency, and diabetes mellitus, was admitted with a stage II pressure ulcer on her left buttock. The facility's Pressure Ulcer Prevention Program policy required regular assessments and documentation of the ulcer's characteristics, but staff did not complete a thorough assessment of the ulcer's exudate, odor, amount, wound bed, and surrounding skin. Additionally, the resident's care plan did not include a turning or repositioning program, which was necessary given her condition. Resident #2, diagnosed with seizure disorder, borderline personality disorder, mild intellectual disabilities, anxiety, depression, respiratory failure with hypercapnia, and morbid obesity, experienced a decline in health. Despite showing symptoms such as a runny nose, sore throat, and low oxygen saturation, the facility staff did not perform a comprehensive assessment or intervention. The resident's condition worsened, leading to lethargy, cyanotic lips, and an inability to maintain adequate oxygen saturation, resulting in her being sent to the emergency room. She later passed away from acute on chronic hypoxemic and hypercapnic respiratory failure due to viral pneumonia. Interviews with facility staff revealed a lack of thorough assessments and communication with healthcare providers. Staff members acknowledged that they should have conducted more comprehensive evaluations of the residents' conditions, including vital signs and lung sounds, and reported changes to the residents' primary physicians. The facility's failure to adhere to its policies and procedures contributed to the inadequate care provided to these residents.
Failure to Follow Pressure Ulcer Prevention Policy
Penalty
Summary
The facility staff failed to adhere to their Pressure Ulcer Prevention Program policy, resulting in the development and worsening of a pressure ulcer in a resident with a history of such ulcers. The policy required timely assessments, implementation of interventions, and communication with healthcare professionals. However, the staff did not complete thorough assessments of the resident's pressure ulcer, particularly failing to document critical details such as exudate, odor, and surrounding tissue condition. The resident, who had a stage II pressure ulcer upon admission, was not placed on a turning and repositioning program, despite being at risk for pressure ulcers and requiring substantial assistance with activities of daily living. The resident's care plan did not adequately address the pressure ulcer or include necessary interventions like a turning program. The staff also failed to communicate changes in the ulcer's condition to the primary physician, which contributed to the ulcer's rapid progression. The primary physician noted that better communication could have minimized the ulcer's deterioration. Ultimately, the resident passed away due to sepsis related to the ulcer and worsening renal failure, highlighting the severe consequences of the facility's failure to follow its own policies and procedures.
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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.
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Nursing homes near Elkader
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Strawberry Point Lutheran Home | 12.8 mi | ★★★★★ | 0 | 0 |
| Edgewood Convalescent Home | 14.2 mi | ★★★★★ | 3 | 0 |
| Guttenberg Care Center | 15.8 mi | ★★★★★ | 1 | 0 |
| Great River Care Center | 16.1 mi | ★★★★★ | 2 | 1 |
| Prairie Maison | 19.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.