Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Elwood Care Center during CMS and state inspections, most recent first.
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 Observations showed staff not following posted guidelines and outdated policies on catheter and perineal care.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.
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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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 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.