Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Elwood Care Center during CMS and state inspections, most recent first.
MDS Coding Errors for High-Risk Medications: The facility failed to accurately code the MDS for multiple residents by omitting or misclassifying high-risk medications. Residents had documented orders and MAR entries for medications such as clonazepam, gabapentin, and Xarelto, but the MDS did not consistently reflect anticonvulsant or anticoagulant use, and an ADON confirmed several entries were coded incorrectly.
Staff failed to perform hand hygiene between resident contacts during water pass activities. An NA was observed moving from room to room with used water mugs and a cart, entering multiple resident rooms and handling mugs without sanitizing hands between contacts. A second NA was also observed delivering water to multiple rooms on two days without hand sanitizing between resident rooms, and the ADON confirmed hand hygiene was expected on exit from each resident room.
Failure to Document Psychotropic Medication Education: The facility did not document that residents or their representatives were informed about the risks, benefits, and alternate interventions for psychotropic medications when new orders were started or existing doses were changed. Two residents were affected: one with dementia, depression, anxiety, and insomnia who received multiple antidepressant and antipsychotic medications, and another with anxiety and major depression who received routine antipsychotic and antidepressant therapy. Staff interviews confirmed the missing documentation.
A facility failed to develop and implement comprehensive, person-centered care plans with measurable goals and timeframes for 2 residents. One resident’s plan listed multiple psychotropic and other medications with broad monitoring language, but no specific measurable objectives or timelines for AIMS checks or gradual dose reductions, and staff confirmed the goals were not objective or resident-specific. Another resident’s care plan was not updated for new pain medication, Lasix, failure to thrive, CHF, edema, and worsening skin breakdown/infection, and the ADON confirmed the goals were not measurable or person-centered.
The facility failed to use proper hand sanitization and PPE during a COVID-19 outbreak, and did not perform perineal care correctly for two residents, leading to potential cross-contamination risks. Observations showed staff not following posted guidelines and outdated policies on catheter and perineal care.
The facility failed to develop comprehensive care plans for several residents, including missing interventions for a pleurX drain, chronic urinary tract infections, and an indwelling foley catheter. Additionally, a resident's care plan incorrectly listed a diagnosis of schizophrenia. These deficiencies were confirmed by the DON and ADON.
The facility failed to monitor and record hot water temperatures, leading to potential burn and scalding hazards for residents. Observations revealed that the hot water temperature in the rooms of four residents exceeded the maximum allowed temperature of 120 degrees Fahrenheit. The Maintenance Supervisor confirmed that the facility's process involved a daily visual check without documentation, and no documented temperature checks had been performed since 5/31/23.
The facility failed to timely remove an indwelling foley catheter for a resident, despite the resident meeting the criteria for removal. Conflicting instructions from therapy staff and inappropriate responses from the PCP contributed to the delay. Observations also revealed improper handling of the catheter and a lack of timely assistance when the resident needed to use the bathroom.
MDS Coding Errors for High-Risk Medications
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for 5 residents out of 12 sampled residents. For Resident 2, the MDS dated 4/24/26 showed a readmission from the hospital, a BIMS score of 3/15 indicating severe cognitive impairment, and several high-risk drug classes, but clonazepam was not included even though an order summary dated 5/4/26 showed clonazepam 0.5 mg three times daily starting 12/11/25. The ADON stated during interview that clonazepam was not identified on the MDS and therefore was not listed in the high-risk drug class section. For Resident 3, the MDS showed a hospital readmission, a BIMS score of 15/15 indicating cognitive intactness, and high-risk drug classes including hypoglycemic and opioid, but gabapentin was not coded. An order summary dated 5/4/26 showed gabapentin 300 mg every morning and 400 mg twice daily with a start date of 4/30/25. The ADON stated that gabapentin was not identified on the MDS and therefore was not listed as a high-risk drug class medication. For Resident 25, the MDS dated 3/27/26 showed a hospital admission, a BIMS score of 10/15 indicating moderate impairment, and antipsychotic use, but gabapentin was not coded even though the order summary showed gabapentin 100 mg three times daily starting 4/9/26 and the MAR showed gabapentin 300 mg three times daily from 3/1/26 through 3/27/26 with administrations completed as ordered. For Resident 16, the quarterly MDS dated 03/13/2026 did not code anticonvulsant use even though orders and MAR documentation showed gabapentin 300 mg at bedtime was administered daily throughout March 2026, and the ADON confirmed the MDS was not coded correctly. For Resident 29, the MDS did not mark anticoagulant use and instead marked antiplatelet use, even though the resident had atrial flutter, a MAR showed Xarelto 15 mg daily throughout February 2026, and the care plan referenced Xarelto as a black box medication; the ADON confirmed the resident takes an anticoagulant and does not take an antiplatelet.
Failure to Perform Hand Hygiene Between Resident Contacts During Water Pass
Penalty
Summary
Staff failed to perform hand hygiene between resident contacts during water pass activities, contrary to the facility policy titled Hand Hygiene dated 1/22/25, which required hand hygiene between resident contacts and after handling contaminated objects. On 5/4/26, Nurse Aide-D was observed moving from room to room on the 200 hallway, exiting the rooms of Residents 9, 31, 10, 3, 17, 30, 25, and 2 with used water mugs and placing them on a 3-shelf cart without performing hand sanitization between resident rooms. The same observation also showed Nurse Aide-D pushing the cart from the 200 hallway to the 100 hallway without hand sanitizing. On 5/4/26, Nurse Aide-E was observed pushing the same 3-shelf cart with mugs of water to multiple resident rooms on the 200 and 100 hallways. NA-E entered and exited the rooms of Residents 6, 9, 31, 10, 3, 17, 30, 25, 2, 22, 23, 14, and 26, carrying mugs into rooms and returning to the cart without performing hand sanitization between resident contacts. In one room, NA-E also adjusted Resident 31's blanket after placing a mug on the overbed table. On 5/5/26, NA-E was again observed entering the rooms of Residents 6, 9, 10, 3, 31, 17, 30, 25, and 2, removing used water mugs, and not performing hand sanitization between rooms. The ADON later confirmed that staff are expected to perform hand hygiene on exit from a resident room and that hand sanitization should have been performed between resident rooms during water pass.
Failure to Document Psychotropic Medication Education
Penalty
Summary
The facility failed to document that residents or resident representatives were educated in advance about the risks, benefits, and alternate interventions of psychotropic medications when new medications were prescribed or current medications were increased for 2 residents. The deficiency was identified under 175 NAC 12-006.05(E) after record review and staff interviews showed that the required education was not documented for Resident 9 and Resident 20. Resident 9 had diagnoses including Alzheimer's disease, non-Alzheimer's dementia, malnutrition, anxiety disorder, depression, and insomnia, and had a BIMS score of 14 indicating normal thinking and memory. Record review showed the resident was receiving multiple psychotropic medications, including aripiprazole, sertraline, mirtazapine, and trazodone. The record also showed medication changes over time, including a gradual dose reduction attempt that failed, an increase in sertraline, and the addition of trazodone and mirtazapine. Nursing progress notes did not document the actual risks and benefits of the psychotropic medications when the resident entered the facility, when medications were increased, or when new medications were added. Resident 20 was admitted with diagnoses of generalized anxiety disorder and major depressive disorder, and the MDS indicated routine antipsychotic and antidepressant use. The medication record showed quetiapine and citalopram were administered daily since admission, but there was no documentation in the progress notes or electronic medical record that the resident or representative was educated about the risks, benefits, and alternate interventions related to these psychotropic medications. The DON confirmed there was no documentation that the resident or representative had been educated about the risks, benefits, and alternate interventions for the psychotropic medications the resident had been receiving since admission.
Care Plans Lacked Measurable, Person-Centered Goals and Timelines
Penalty
Summary
The facility failed to ensure that comprehensive person-centered care plans were developed and implemented with measurable goals and objectives for 2 residents. The cited policy required care plans to include measurable objectives and time frames, be developed within 7 days after completion of the MDS, and address the resident’s medical, nursing, mental, and psychosocial needs. Survey review found that the care plans for the affected residents did not contain resident-specific measurable goals and timeframes tied to the identified needs and treatments. For one resident, the MDS showed diagnoses including Alzheimer’s disease, non-Alzheimer’s dementia, malnutrition, anxiety disorder, depression, and insomnia, with a BIMS score of 14. The comprehensive care plan listed multiple medications with black box warnings, including mirtazapine, trazodone, aripiprazole, furosemide, sertraline, and acetaminophen. The plan included broad approaches such as monitoring for mood changes, suicidality, unusual behavior, fluid loss, and liver failure, but no specific measurable goals and objectives were created for each medication. The plan also stated that AIMS assessments were to be completed as scheduled and that gradual dose reductions were to be done as required, but it did not identify when the assessments were to occur or provide a timeline for the dose reductions. Staff interviews confirmed that behaviors were charted in progress notes for 30 days after medication changes or behavior changes, and the DON and ADON acknowledged that the goals were broad, buried in other portions of the care plan, and not measurable or objective for each medication. For the second resident, the quarterly MDS showed severe cognitive impairment with a BIMS score of 7, use of a walker, need for assistance with ADLs, occasional urinary incontinence, and multiple diagnoses including hypertension, renal insufficiency, diabetes, difficulty speaking, anxiety disorder, asthma or COPD, anemia, and dysphagia. Additional records showed atrial fibrillation, hypothyroidism, failure to thrive, chronic kidney disease, edema, leg pain, CHF, blisters, cellulitis with skin breakdown on both buttocks, and later sores on a foot, a purple and cold right foot, bilateral leg edema, shortness of breath with activity, and poor appetite. The care plan last reviewed and revised on 01/28/2026 had not been updated to include the opioid medication for pain, Lasix for edema and CHF, concerns and goals for failure to thrive, or the skin issues involving blisters, sores, breakdown, and infection on the buttocks, legs, and feet. The ADON confirmed that the care plan goals were not measurable and objective and were not person-centered as they related to the resident.
Infection Control and Perineal Care Deficiencies
Penalty
Summary
The facility failed to use proper hand sanitization during the application and removal of personal protective equipment (PPE) and did not use the recommended PPE when providing care for residents with a communicable disease, specifically COVID-19. Observations revealed that staff members did not follow the correct procedures for donning and doffing PPE as outlined on the signage posted on residents' doors. For instance, staff members were seen not sanitizing their hands between steps, not wearing goggles, and improperly layering surgical masks with N95 masks. These actions were confirmed by interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), who acknowledged that staff should adhere to the posted guidelines and CDC recommendations for infection prevention and control. The facility also failed to perform perineal care in a manner that prevents cross-contamination for two residents. In one instance, a nursing assistant did not perform peri care before dressing a resident, did not change gloves between dirty and clean tasks, and did not clean the entire perineal area. In another instance, a nursing assistant struggled to clean a resident with a bowel movement due to visibility issues with goggles and did not call for assistance. The assistant used the same gloves to handle clean and dirty items, further increasing the risk of cross-contamination. These observations were corroborated by interviews with the DON, who confirmed the expectations for proper peri care and hand hygiene. Additionally, the facility's policies on catheter care and perineal care were outdated and had not been revised in several years. The annual competencies for staff training did not appear to be effectively implemented, as evidenced by the observed deficiencies in hand hygiene and peri care. The DON confirmed that staff education and audits are conducted annually, but the observed practices indicated a gap between policy and actual practice. This failure to adhere to proper infection control protocols had the potential to affect all residents in the facility, especially during a COVID-19 outbreak.
Deficiencies in Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan for several residents, leading to deficiencies in their care. For Resident 28, the care plan did not include any goals or interventions for the management of a pleurX drain, despite the resident having a malignant pleural effusion and requiring specific care for the drain. Staff members, including a medication aide and a nurse aide, were unaware of the necessary interventions for the pleurX drain, and the Director of Nursing (DON) confirmed that the care plan was incomplete in this regard. Resident 30's care plan also lacked goals and interventions for managing chronic urinary tract infections, despite the resident being on a prophylactic antibiotic. The Assistant Director of Nursing (ADON) confirmed that the care plan should have included these details but did not. Similarly, Resident 6's care plan incorrectly listed Risperidone for schizophrenia, a diagnosis the resident did not have. The DON acknowledged this error, noting that the resident's actual diagnoses were anxiety and depression. Additionally, Resident 33's care plan did not include specific interventions for the care of an indwelling foley catheter, which was present at admission. The catheter was later removed, but the care plan was not updated to reflect this change or to address any potential skin issues related to the catheter. The ADON admitted that the care plan had not been updated since the catheter's removal and that there was no individual care plan for the catheter. These deficiencies indicate a failure to provide comprehensive and accurate care plans for the residents, potentially impacting their overall care and well-being.
Failure to Monitor and Record Hot Water Temperatures
Penalty
Summary
The facility failed to monitor and record hot water temperatures, leading to potential burn and scalding hazards for residents. Observations revealed that the hot water temperature in the rooms of four residents exceeded the maximum allowed temperature of 120 degrees Fahrenheit. Specifically, the hot water in the bathroom of Residents 21 and 11 measured 127.2 degrees Fahrenheit, while the hot water in the bathroom of Resident 26 measured 123.9 degrees Fahrenheit, and the hot water in the bathroom of Resident 29 measured 120.3 degrees Fahrenheit. Resident 21, who has severe cognitive impairment and is able to stand independently, was observed using the bathroom unassisted. Resident 11, who has moderate cognitive impairment and uses a wheelchair, was assisted to the bathroom and able to wash their hands. Resident 26, who has moderate cognitive impairment and Parkinson's Disease, was assisted by staff to use the bathroom sink. Resident 29, who is incontinent of urine and does not allow staff assistance, was observed to be independent in the bathroom. The Maintenance Supervisor revealed that the facility's process for monitoring hot water temperatures involved a daily visual check of the thermometer in the boiler room, without documenting the temperatures. The facility had previously conducted random checks of hot water temperatures but stopped doing so about six months ago. The last documented random checks were performed on 5/31/23, and no documented temperature checks had been performed since then. The facility had also increased the hot water temperature to 180 degrees Fahrenheit months ago to treat legionella, which may have affected the mixing valve's accuracy.
Failure to Timely Remove Indwelling Foley Catheter
Penalty
Summary
The facility failed to ensure the timely removal of an indwelling foley catheter for Resident 33, who was admitted with the catheter following a left pelvis fracture. Despite orders to remove the catheter once the resident was able to ambulate and toilet with one assist, the catheter remained in place for 21 days after the resident met these criteria. The delay in removal was due to conflicting instructions from the facility's Occupational Therapist and Physical Therapist, who advised against removing the catheter despite the resident's improved mobility and the original physician's order. Additionally, the facility's nursing staff sought a diagnosis for the catheter but received inappropriate responses from the Primary Care Provider (PCP), further complicating the situation. Observations revealed improper handling of the catheter, including instances where the catheter bag was lifted above the resident and placed on the floor, increasing the risk of infection. On one occasion, the resident was left unattended in the dining room despite voicing a need to use the bathroom, indicating a lack of timely assistance. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed awareness of the order to remove the catheter but highlighted the challenges faced due to conflicting advice from therapy staff and the PCP's inadequate responses. The catheter was eventually removed and replaced due to the resident's inability to void, and a bladder training program was initiated by Occupational Therapy.
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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 Elwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bertrand Nursing Home | 12.8 mi | ★★★★★ | 0 | 0 |
| Emerald Nursing & Rehab Cozad | 20.6 mi | ★★★★★ | 1 | 0 |
| Christian Homes Health Care Center | 25.9 mi | ★★★★★ | 13 | 0 |
| Holdrege Memorial Homes, Inc | 28 mi | ★★★★★ | 0 | 0 |
| Hilltop Estates | 28.9 mi | ★★★★★ | 11 | 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 August 2026) and official state health department websites.