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 Elderwood At Grand Island during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was allegedly subjected to physical abuse by a CNA, witnessed by another CNA who delayed reporting the incident due to fear of retaliation. The incident was not reported to facility leadership or the State Survey Agency within the required two-hour timeframe, resulting in a two-day delay before the allegation was formally submitted. Staff interviews confirmed the delay and acknowledged non-compliance with reporting policies.
The facility failed to ensure the Director of Nursing (DON) only served as a charge nurse when the resident census was 60 or fewer. Despite an average census of 84, the DON was observed working as a charge nurse due to staffing shortages and training needs, violating facility policy and state regulations. Interviews and records confirmed the DON's involvement in direct care and training, leading to the deficiency finding.
The facility failed to provide necessary dental services as it neither employed a dentist nor had an arrangement with an outside service. Staff interviews revealed uncertainty about the duration of this deficiency, with residents needing dental care being sent to the county medical center or emergency room. The Administrator confirmed efforts to secure a dental contract but lacked a specific timeline.
A resident with multiple sclerosis and hemiplegia was not provided reasonable accommodations for their needs, as their call system was repeatedly found out of reach. Despite instructions to keep the call bell near the resident's chest/stomach area due to limited dexterity, staff failed to consistently follow this plan, leaving the resident unable to signal for assistance.
A facility failed to create a comprehensive care plan for a resident at high risk for elopement, despite documented wandering and exit-seeking behaviors. The resident, with Alzheimer's and PTSD, frequently attempted to leave the unit. Staff observations and assessments indicated the need for a care plan, but the interdisciplinary team did not update it to address these risks.
A resident with macular degeneration and other conditions did not receive recommended lid hygiene treatment for blepharitis due to a breakdown in communication and follow-through among staff. Despite the optometrist's recommendation being communicated, no physician's order was placed, and the resident's condition was not documented, leading to a delay in treatment.
Delayed Reporting of Alleged Physical Abuse
Penalty
Summary
The facility failed to ensure that an allegation of physical abuse was reported immediately to the Administrator and the State Survey Agency, as required by policy and regulation. A certified nursing assistant (CNA) witnessed another CNA allegedly grab a resident's hair and slam the resident's face into the mattress after the resident spat in the CNA's face during care. The witnessing CNA did not report the incident immediately due to fear of retaliation, instead leaving a note for the Director of Nursing and informing a nurse supervisor the following day. This resulted in a delay of approximately one day before the incident was brought to the attention of facility leadership. The resident involved had diagnoses including Alzheimer's disease, anxiety, and depression, and was assessed as severely cognitively impaired with a history of confrontational behavior. At the time of the survey, the resident was observed to be calm, pleasant, and showed no signs of physical abuse. Staff were seen treating the resident with respect and dignity during the observation period. Interviews with facility staff confirmed that the abuse allegation was not reported within the required two-hour timeframe. The Director of Nursing and Administrator both acknowledged that the delay in reporting was unacceptable and not in compliance with facility policy or state regulations. The incident was ultimately reported to the State Agency two days after it occurred, rather than within the mandated period.
Director of Nursing Improperly Serving as Charge Nurse
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) only served as a charge nurse when the facility had an average daily occupancy of 60 or fewer residents. The facility's average daily census was documented as 84, yet the DON was observed working as a charge nurse on multiple occasions when the census exceeded 60. This was in violation of the facility's policy and state regulations, which require the DON to focus on oversight and management duties rather than direct care when the resident census is high. The facility's staffing records revealed that the DON was counted in the facility's numbers to meet the minimum assessed staffing requirements for direct care. On several occasions, the DON worked the night shift as a charge nurse due to a lack of available staff, including Registered Nurses (RNs) and Licensed Practical Nurses (LPNs). The DON was also involved in training new employees when the educator was unavailable, further indicating that the DON was performing duties beyond their administrative role. Interviews with facility staff, including the Scheduling Supervisor and the Administrator, confirmed that the DON was scheduled to work shifts in addition to their regular 40-hour workweek as the DON. The DON was often scheduled to fill in for absent staff or to train new RNs, which was not in alignment with the facility's policy or state regulations. Despite the Administrator's statement that the DON was never acting as a charge nurse simultaneously with their DON duties, the evidence showed otherwise, leading to the deficiency finding.
Deficiency in Dental Services Provision
Penalty
Summary
The facility was found to be deficient in providing necessary dental services to its residents, as it did not employ a qualified dentist nor had an arrangement with an outside dental service. This deficiency was identified during a standard survey, where it was noted that the facility's policy required dental services to be offered either on-site or through an arrangement with a licensed dental consultant. However, the facility had not had a dentist since April 2024, and there was no current contract in place to provide these services externally. This lack of dental services had the potential to affect all 78 residents in the facility. Interviews with various staff members, including registered nurses, the unit clerk, the Director of Nursing, and the Administrator, revealed a lack of clarity and communication regarding the absence of dental services. Staff members were unsure of how long the facility had been without a dentist and indicated that residents requiring dental care were either sent to the county medical center, which had a long wait time, or to an emergency room for urgent issues. The Administrator acknowledged that a dental contract was being pursued but could not provide a specific timeline for its implementation. The facility's admission agreement inaccurately documented the availability of dental services, further highlighting the deficiency in meeting regulatory requirements for resident care.
Failure to Ensure Call System Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident received services that provided reasonable accommodations for their needs and preferences. Specifically, the call system was not within reach of the resident, who had multiple sclerosis, hemiplegia, and hemiparesis following a cerebral infarction, affecting their right dominant side. The resident was moderately cognitively impaired, totally dependent on staff for bed mobility and transfers, and had limited range of motion and poor dexterity. The comprehensive care plan and Kardex indicated that the call light should be kept within reach to provide a safe environment and encourage its use. During multiple observations, the resident's call light was found on the floor, pinned to the bed sheets out of reach, or hanging over the headboard, contrary to the instructions posted by the occupational therapist to pin it to the resident's stomach/chest area. Interviews with staff revealed that they were aware of the importance of keeping the call bell within reach but failed to consistently do so. The occupational therapist and registered nurse unit manager emphasized the need for the call bell to be accessible due to the resident's limited dexterity and range of motion.
Failure to Develop Care Plan for High-Risk Elopement Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident identified as high risk for elopement. The resident, diagnosed with Alzheimer's Disease, vascular dementia, and PTSD, exhibited wandering and exit-seeking behaviors. Despite these behaviors being documented in the Minimum Data Set (MDS) and behavior monitoring progress notes, no care plan was developed to address these risks. Observations and interviews revealed that the resident frequently wandered the unit, attempted to open exit doors, and expressed a desire to leave. Staff members, including CNAs and LPNs, noted the resident's behaviors and redirected them as needed. However, the care plan did not include interventions for wandering and elopement, despite the resident's high-risk assessment. Interviews with facility staff, including the RN Unit Manager and the Director of Nursing, indicated a lack of communication and responsibility in updating the care plan. The interdisciplinary team did not incorporate the resident's elopement risk into the care plan, and there was confusion about whether the resident's behaviors warranted care planning. This oversight resulted in the absence of a care plan to address the resident's wandering and elopement risk.
Failure to Implement Optometrist's Recommendation for Lid Hygiene
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident, resulting in a delay in treatment. The resident, who had diagnoses including macular degeneration, type 2 diabetes, and dementia, was seen by an optometrist who recommended lid hygiene twice a day for blepharitis. However, there was no physician's order for this treatment from 11/12/24 to 12/03/24, despite the recommendation being communicated to the nurse practitioner and other staff members via a secure message thread. Observations of the resident on multiple occasions revealed red and glossy eyes with dried debris, indicating that the recommended treatment was not implemented. Interviews with staff, including the Registered Nurse Unit Manager, Registered Nurse Supervisor, and Nurse Practitioner, revealed a breakdown in communication and follow-through. The secure message thread showed that the recommendation was acknowledged, but no action was taken to implement the order, and the resident's condition was not documented in the nursing report sheets. The Director of Nursing and other staff members acknowledged that the person receiving the recommendation should have followed through with obtaining the necessary order and documenting it in the resident's medical record. The failure to carry out the optometrist's recommendation and document the new order in the resident's care plan and nursing notes led to a delay in treatment, impacting the resident's quality of care.
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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 Grand Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Schoellkopf Health Center | 5.1 mi | ★★★★★ | 13 | 0 |
| Elderwood At Wheatfield | 5.2 mi | ★★★★★ | 0 | 0 |
| Niagara Rehabilitation And Nursing Center | 5.4 mi | ★★★★★ | 1 | 0 |
| Degraff Memorial Hospital-skilled Nursing Facility | 6 mi | ★★★★★ | 1 | 0 |
| North Gate Health Care Facility | 6.2 mi | ★★★★★ | 1 | 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.