Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 East Lake Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that staff repeatedly administered antihypertensive medications to two residents despite physician orders to hold the drugs when BP readings were below specified parameters, as documented on multiple MARs. A resident on antiplatelet therapy, care planned as at risk for bruising, was observed with multiple purple and red bruises on both arms, yet there were no corresponding physician orders to monitor bruising, no nursing documentation of the bruises over a documented period, and a missed weekly skin assessment. Another resident with vascular disease and cellulitis, care planned and ordered to have heel boots on at all times with heel checks every shift, was repeatedly observed without heel boots in place while MAR entries indicated they had been applied, and the resident reported he was also supposed to have compression socks that were not provided.
Surveyors found that three residents receiving oxygen therapy did not have care consistent with physician orders. One resident with chronic respiratory failure and heart disease was repeatedly observed on 7 L/min via nasal cannula despite an order for 2 L/min. Another resident with COPD and pleural effusion was observed on 2.5–3 L/min even though the order specified 2 L every shift, and an agency LPN confirmed and corrected the incorrect setting. A third resident with dementia, CHF, pleural effusion, and emphysema was observed on 3.5 L/min oxygen after the prior order for 2.5 L/min had been discontinued, with no current physician order in place while oxygen continued to be administered.
Staff failed to follow infection control practices by not using required PPE for residents on Enhanced Barrier Precautions and Droplet Precautions and by not disinfecting shared equipment between residents. During pressure ulcer care and toileting assistance for residents with sacral wounds, a wound nurse, ADON, an LPN, and a CNA provided high-contact care while wearing only gloves and no gowns, despite posted Enhanced Barrier Precautions requiring both gown and gloves. An LPN disconnecting an IV antibiotic for a resident on Enhanced Barrier Precautions also wore only gloves, and another LPN administering medications to a resident on Droplet Precautions for pneumonia did not use required eye protection, even though face shields were available. Additionally, an LPN and an RN used a multi-use blood pressure and pulse oximetry machine on several residents without cleaning and disinfecting it between uses, and the DON confirmed there was no specific policy for cleaning this equipment, contrary to the facility’s standard precautions policy requiring disinfection of shared equipment between residents.
A resident with multiple chronic conditions and a Stage 2 sacral pressure ulcer did not receive daily wound care as ordered by the physician. The care plan required daily cleansing, triad paste, and foam dressing, but staff observations on separate shifts found the sacral dressing unchanged and still dated from a prior day, even though the MAR reflected that treatments had been signed out as completed. An LPN acknowledged not changing the dressing despite believing it was a daily treatment, and the wound nurse later confirmed that weekday wound care was her responsibility while nursing staff were responsible on weekends, stating the treatment should have been done as ordered.
Surveyors found that the facility failed to document food and fluid intake for three residents with dementia, renal disease, heart failure, dysphagia, and significant weight loss, despite care plans and MD orders requiring monitoring and recording of meal percentages and additional fluids. Review of food consumption logs and point‑of‑care charting over several months showed numerous missing entries for breakfast, lunch, and dinner, including multiple days with no intake documented at all, while the DON confirmed staff were expected to chart meal consumptions after each meal and acknowledged that meals and fluids were not documented.
A facility failed to provide timely assistance with ADLs for a resident, specifically regarding nail care and shaving. The resident, with a history of chronic conditions and an amputation, expressed a preference for weekly shaving and indicated willingness to trim his own nails if provided with clippers. Despite receiving bed baths, staff only offered shaving assistance infrequently, and the facility lacked a specific policy for nail care or shaving.
A facility failed to follow a care plan requiring two staff members to assist a resident with multiple health conditions, including hypertension and diabetes, during personal care. Observations showed a CNA providing care alone, contrary to the care plan's instructions. Interviews revealed staff were unaware of the paired care requirement, and the DON confirmed the absence of a policy to ensure compliance.
The facility failed to follow infection control measures during medication administration and linen handling. A QMA dropped a calcium tablet onto a medication cart, picked it up with bare hands, and placed it with other medications for a resident. The QMA and Assistant DON were unsure of the policy for contaminated medications. Additionally, a linen cart was left uncovered, exposing clean linens and an open bleach wipes container. CNAs acknowledged the linens should have been covered, and the wipes container should not have been left open.
Failure to Follow BP Medication Parameters, Monitor Bruising, and Apply Ordered Heel Boots
Penalty
Summary
The deficiency involves the facility’s failure to follow physician-ordered blood pressure parameters and medication holds for two residents receiving antihypertensive medications. One resident with hypertension and atherosclerotic heart disease had an order for Clonidine 0.3 mg three times daily with instructions to hold the dose if the systolic blood pressure was less than 140. Despite this, the MARs for March and April 2026 show numerous administrations of Clonidine at ordered times when the recorded systolic blood pressure was below 140. Another resident with dementia, diabetes, atrial fibrillation, heart disease, heart failure, and mood disorders had orders for Carvedilol 12.5 mg twice daily and Hydralazine 50 mg three times daily, both to be held if blood pressure was under 110/60. Across multiple months (January through April 2026), the MARs document repeated administrations of both medications at ordered times when the resident’s blood pressure was below the ordered parameters. The deficiency also includes failure to assess and monitor bruising for a resident at risk for bruising related to antiplatelet therapy. This resident, cognitively intact and diagnosed with heart disease, heart failure, and hypertension, had a care plan identifying risk for bruising with an approach to observe for bruises and a physician’s order for daily Aspirin 81 mg. During observations, surveyors noted purple and red bruises on both arms, but there were no physician’s orders to monitor bruising, no nursing progress note documentation of bruising between early April and mid-April, and a weekly skin assessment documented no bruising. Additionally, a weekly skin assessment due mid-April was not completed. When later assessed, multiple dark purple bruised areas of varying sizes were documented on both lower arms. A further deficiency concerns failure to implement ordered heel protection for a resident at risk for skin breakdown. This resident, cognitively intact and diagnosed with cellulitis of the left lower limb, heart disease, peripheral vascular disease, and heart failure, was care planned as at risk for skin breakdown due to limited mobility and rare skin moisture, with approaches including heel boots to both lower extremities to be on at all times. A physician’s order also directed heel checks every shift and heel boots on at all times each shift. During multiple observations, the resident was seen in a wheelchair with both legs dependent, darkened, and edematous, without heel boots in place. The resident reported he was supposed to have compression socks but was told the facility had run out, and he had no heel boots on. Despite this, the MAR indicated heel boots were signed out as applied over several days when observations showed they were not on the resident.
Failure to Follow Oxygen Orders and Maintain Current Oxygen Therapy Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care by not ensuring oxygen was set at the correct flow rate and not obtaining current physician orders for oxygen therapy for three residents. For one resident with chronic respiratory failure with hypoxia, heart disease, peripheral vascular disease, and heart failure, surveyors repeatedly observed oxygen being administered via nasal cannula at 7 L/min from a concentrator, while the physician’s order dated 4/2/26 specified oxygen at 2 L/min via nasal cannula. The resident’s care plans, dated 4/2/26, directed staff to administer oxygen as ordered for risks related to heart failure and impaired gas exchange, but the observed oxygen flow rate did not match the physician’s order. Another resident with COPD, pleural effusion, heart disease, chronic kidney disease, hypertension, and depression was observed multiple times receiving oxygen via nasal cannula at 2.5 L/min and later at 3 L/min on the concentrator, despite a physician’s order dated 4/3/26 for oxygen at 2 L every shift. An agency LPN confirmed the concentrator was set at 3 L/min and then adjusted it back to 2 L/min, acknowledging it should have been set at 2 L/min. A third resident with dementia, heart failure, hypotension, depression, dysphagia, pleural effusion, and emphysema was observed on two occasions receiving oxygen via nasal cannula at 3.5 L/min. The record showed a prior physician’s order for continuous oxygen at 2.5 L/min via nasal cannula dated 4/6/26 that had been discontinued on 4/8/26, and there was no current physician’s order for oxygen therapy at the time of observation, despite the resident’s care plan directing staff to administer oxygen as ordered.
Inadequate PPE Use and Failure to Disinfect Shared Equipment
Penalty
Summary
The deficiency involves multiple failures to follow the facility’s infection prevention and control practices, particularly related to the use of personal protective equipment (PPE) for residents on Enhanced Barrier Precautions and Droplet Precautions. In one instance, during a sacral pressure ulcer treatment for a resident, the Wound Nurse and Assistant Director of Nursing (ADON) repositioned the resident and removed the sacral dressing without donning gowns, despite the resident being on Enhanced Barrier Precautions requiring gown and gloves for direct resident contact. Later, an LPN assisting the same resident back into bed after administering nasal spray also only wore gloves and did not don a gown, even though the door signage specified Enhanced Barrier Precautions. The Infection Preventionist confirmed that gowns should have been worn before repositioning and assisting the resident. Additional failures to use appropriate PPE occurred with other residents on Enhanced Barrier Precautions and Droplet Precautions. An LPN disconnected an IV antibiotic and flushed the line for a resident on Enhanced Barrier Precautions while wearing only gloves and no gown, contrary to the posted requirement for gown and gloves during direct resident contact. Another LPN entered the room of a resident on Droplet Precautions for pneumonia wearing a gown, N95 mask, and gloves to administer medications but did not wear eye protection, despite the droplet precaution signage specifying the need for eye protection and face shields being available on the isolation cart. For another resident with a sacral pressure ulcer and a bandage to the sacral area, a CNA assisted with toileting and an LPN performed a skin assessment; both staff members wore only gloves and did not don gowns, even though a sign later observed on the resident’s door indicated Enhanced Barrier Precautions requiring gown and gloves for high-contact care activities such as toileting and wound care. The facility also failed to ensure that multi-use vital sign equipment was disinfected between residents. An LPN checked a resident’s blood pressure and pulse oximetry using a multi-function blood pressure machine and then placed the machine in the hallway near the medication cart without sanitizing it, and it remained unsanitized several minutes later while the LPN continued medication administration. In another series of observations, an RN used the same type of multi-use blood pressure machine to obtain vital signs for one resident in the dining room, returned it to the wall and plugged it in without cleaning, and later used it again in another resident’s room without disinfecting it between uses. The RN acknowledged not sanitizing the machine after each resident, and the DON reported there was no facility policy for cleaning the multi-use blood pressure machine, despite the facility’s Standard and Transmission-Based Precautions policy stating that shared equipment should be cleaned and disinfected between each resident use.
Failure to Perform Ordered Daily Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer treatment as ordered by the physician for a resident with a sacral Stage 2 pressure ulcer. The resident, who had multiple diagnoses including compression fracture, COPD, pleural effusion, heart disease, chronic kidney disease, hypertension, and depression, and was moderately impaired for daily decision making, reported that her pressure ulcer bandage was not changed every day. During an observation, a CNA assisted the resident to the bathroom and noted that the sacral dressing was dated 4/11/26, which was confirmed again later the same day when an LPN performed a skin assessment and observed the same 4/11/26 date on the dressing. The LPN acknowledged she had not changed the bandage and believed the treatment was supposed to be done daily. The resident’s care plan documented impaired skin integrity with a sacral pressure ulcer and directed staff to provide treatment as ordered by the physician. A physician’s order dated 4/6/26 specified cleansing the wound, patting it dry, applying triad paste, and covering with a foam dressing once a day. The MAR for April 2026 showed the treatment signed out as completed on 4/11 and 4/12/26, despite the dressing still being dated 4/11/26 on 4/13/26. A wound NP note on 4/6/26 documented the ulcer at 1 cm by 0.5 cm with 100% epithelial tissue, and a subsequent note on 4/14/26 documented the ulcer at 0.5 cm by 0.5 cm with 100% epithelial tissue. During a wound treatment on 4/16/26, the wound nurse removed the sacral dressing and observed minimal drainage and a red wound base. The wound nurse stated she worked Monday through Friday and that nursing staff were responsible for treatments on weekends, and indicated the treatment should have been done as ordered by the physician.
Failure to Document Food and Fluid Intake for Residents With Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to document food and fluid intake for residents with known weight loss and identified nutritional risk. One resident with Alzheimer’s disease and end stage renal disease on dialysis had a care plan directing staff to monitor food and fluid intake at meals. However, review of the Food Consumption Log over a one‑month period showed numerous missing entries for breakfast, lunch, and dinner, including multiple days with no intake documented for any meal. The DON stated the resident’s food intake should have been documented and suggested the resident may have been at dialysis for some breakfasts, while the Unit Manager reported the resident received breakfast before going to dialysis. Another resident with dementia, type 2 diabetes, heart disease, heart failure, and depression had documented significant weight loss and was care planned for altered nutrition with approaches requiring documentation of breakfast, lunch, and dinner intake percentages. Weight records showed a decline from 144 pounds to 126 pounds over several months, with a later increase to 133 pounds. Despite this, point‑of‑care charting revealed extensive gaps in documentation of breakfast, lunch, and dinner intake across multiple months, with many dates lacking any recorded meal consumption. The DON confirmed that staff were expected to complete meal consumption documentation after every meal and reported there was no facility policy available for review. A third resident with dementia, heart failure, low blood pressure, depression, dysphagia, and a mechanically altered diet had experienced a 19.8% weight loss over six months. Physician’s orders and care plans directed staff to offer an additional 120 ml of fluid every shift, record fluid intake, monitor food and fluid intake at meals, monitor weight, and document meal percentages and fluid consumption. Review of the Food Consumption Log over approximately six weeks showed numerous missing entries for breakfast, lunch, and dinner, including several days with no food consumption documented at all. The DON acknowledged that there were meals and fluids not documented and did not provide additional information.
Failure to Provide Timely ADL Assistance for Resident
Penalty
Summary
The facility failed to provide timely assistance with Activities of Daily Living (ADLs) for a dependent resident, specifically related to nail care and shaving. Observations and interviews revealed that the resident, who had a full beard and jagged nails with a brown substance under them, was not regularly offered assistance with shaving and nail care. The resident expressed a preference for weekly shaving and indicated that he would attempt to trim his own nails if provided with clippers, but these were not offered. Despite receiving bed baths twice a week, the resident reported that staff only offered shaving assistance once or twice a month. The resident's medical history includes hypertension, heart and chronic kidney disease, peripheral vascular disease, type 2 diabetes mellitus, and a right above-the-knee amputation. A Quarterly Minimum Data Set (MDS) assessment indicated that the resident's cognition was intact, and he required substantial assistance with personal hygiene and was dependent on staff for bathing. Interviews with CNAs revealed that while they provided various aspects of personal care, they did not consistently notice or address the resident's need for nail care and shaving. The facility lacked a specific policy for nail care or shaving, relying instead on regulations related to resident rights.
Failure to Follow Care Plan for Paired Assistance
Penalty
Summary
The facility failed to adhere to the care plan for a resident who required assistance from two staff members for care. During observations, it was noted that a CNA exited the resident's room alone after providing toileting assistance, despite the care plan specifying that care should be provided in pairs. The resident confirmed that typically only one caregiver assisted him, citing staffing limitations as the reason. The care plan, initiated in 2017 and updated in 2020, clearly indicated the need for paired care, which was emphasized in capital letters. Interviews with CNAs revealed a lack of awareness regarding the requirement for paired care for any residents in the hall. The Director of Nursing (DON) confirmed that the facility did not have a policy in place to ensure adherence to the care plan. The resident involved had multiple diagnoses, including hypertension, heart and chronic kidney disease, peripheral vascular disease, type 2 diabetes, and a right above-knee amputation, necessitating substantial assistance with personal hygiene and bathing.
Infection Control Lapses in Medication Administration and Linen Handling
Penalty
Summary
The facility failed to adhere to infection control measures during a medication administration observation for one resident and in the handling of clean linens. During a medication pass, a Qualified Medication Aide (QMA) dropped a calcium tablet onto the medication cart and then picked it up with her bare hand, placing it into a medication cup with other medications for the resident. The QMA acknowledged that she should not have administered the contaminated medications and was unsure of the facility's policy for the destruction of such medications. The Assistant Director of Nursing, present at the time, also indicated uncertainty regarding the policy. Additionally, a linen cart in one of the facility's halls was observed with its cover on top, exposing clean linens and an open container of micro kill bleach wipes with a wipe hanging out. Certified Nursing Assistants (CNAs) acknowledged that the linens should have been covered and the bleach wipes container should not have been left open. The facility's policy requires clean linen to be protected from contamination, and carts must be covered during transportation. The Director of Nursing provided a policy indicating that medications not in protective containers should be discarded if dropped, but the staff involved were not aware of these 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 Elkhart
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenleaf Health Campus | 1.9 mi | ★★★★★ | 7 | 0 |
| Elkhart Meadows | 3.9 mi | ★★★★★ | 4 | 0 |
| Riverside Village | 4 mi | ★★★★★ | 8 | 0 |
| Woodland Manor | 4.4 mi | ★★★★★ | 14 | 0 |
| Brickyard Healthcare - Elkhart Care Center | 4.5 mi | ★★★★★ | 30 | 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.