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 Avir At Elkhart during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, Type 2 DM, and muscle wasting, who required supervision and set-up for all ADLs, reported that a shared shower was consistently dirty, not cleaned between users, and had broken shower head holders and a torn curtain for an extended period. Surveyors observed the shared shower with a ripped curtain, missing or broken shower head holders, and disposable gloves on the floor. Staff interviews showed conflicting understandings of whether CNAs or housekeeping were responsible for cleaning and sanitizing showers between residents and revealed gaps in maintenance reporting, with some CNAs unaware of how to use the electronic system and others relying on verbal reports. Leadership (DON, ADM, Maintenance Supervisor) described expectations that CNAs clean and disinfect showers between residents and that housekeeping perform daily cleaning, but the observed conditions and staff statements demonstrated that these expectations were not consistently carried out, resulting in a failure to provide a clean, sanitary, and homelike shower environment.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as identified through staffing records and surveyor observation.
Surveyors found that food items in the kitchen were not properly labeled or stored, with bulk ingredients lacking expiration dates and opened juice concentrates missing open dates. There was also a significant gap under a window AC unit near the handwashing station and dirty buildup on the AC vents above the clean dish station. The dietary manager acknowledged responsibility for staff training but confirmed these sanitation and labeling practices were not being followed.
Four residents with orders for pureed diets due to dysphagia and other conditions received meals that were not blended to the required pudding consistency. Staff prepared pureed foods without a recipe, did not check for proper texture, and used inadequate equipment, resulting in meals with chunks. The issue was confirmed by dietary and administrative staff, who acknowledged that the pureed foods did not meet the facility's standards.
A resident with multiple chronic conditions was ordered naproxen 250 mg twice daily, but staff consistently administered 220 mg tablets instead, due to only having the lower dose available. The discrepancy between the physician's order and the medication provided was not identified by the medication aide or charge nurse until observed by a surveyor, despite facility policy requiring verification of medication dosage prior to administration.
A resident with multiple medical conditions had sliced cheese and sandwich meat stored in a personal refrigerator without required labeling or dating, in violation of facility policy. Staff interviews revealed confusion over responsibility for monitoring and labeling food items, and the Administrator admitted to purchasing and storing food without proper labeling. The deficiency was observed on multiple occasions, despite staff being previously in-serviced on the policy.
Two burners on the kitchen gas stove were found to be nonfunctional and covered in hard carbon buildup from spilled food. The issue had been ongoing, with the previous maintenance director and Administrator aware, but no maintenance request was submitted and the current Maintenance Director was not informed. Facility policy required regular cleaning and maintenance, but records showed no recent requests for repair.
Two residents with cognitive impairments were found to have nonfunctional bathroom call light pull cords, with the call light boxes detached from the wall. Staff had not promptly reported the issue in the maintenance log, and the Maintenance Director was unaware of one of the problems. Bells were provided as a temporary measure, and facility policy required prompt reporting of defective call lights.
The facility did not follow its policy for safe smoking practices in a secured unit smoking area, as cigarette butts and paper trash were found mixed in ashtrays and a fire can, with evidence of burned ash. Staff interviews revealed confusion about responsibility for cleaning and maintaining the area, and the facility's monitoring schedule and policy required separate disposal of cigarette butts and trash to prevent fire hazards.
A resident with dementia and schizophrenia was verbally abused by a staff member, HSK A, who yelled and cursed at the resident after an altercation. The incident was witnessed by other staff members, leading to HSK A's termination. The resident was known for behavioral issues and was placed under observation following the incident.
Failure to Maintain Clean, Safe Shared Shower Environment and Consistent Cleaning Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike shared shower environment, specifically Shower A, and to ensure showers were cleaned and sanitized between residents. A female resident with Parkinson’s disease, Type 2 diabetes mellitus, and muscle wasting, with moderately impaired cognition (BIMS 11) and requiring supervision and set-up assistance for all ADLs, reported that the shared showers were always dirty and not cleaned regularly between residents. She stated she had complained about the condition of the showers for four months without correction, describing broken shower head holders that required her to hang the shower head on grab bars, from which it often slipped to the floor, and characterizing the showers as unsanitary. On observation of Shower A, which served two halls, surveyors noted a ripped/torn shower curtain, missing or broken shower head holders, and disposable gloves on the floor. The resident reported that the shower curtain had been ripped and the shower head holders broken for over a month and that, although a CNA stayed with her to assist with showers, she never saw staff clean or sanitize the shower between residents. The facility’s own policy on a homelike environment required a clean, sanitary, and orderly environment, which was not reflected in the observed condition of Shower A. Interviews with staff revealed inconsistent understanding and implementation of responsibilities for cleaning and sanitizing the showers and for reporting maintenance issues. The Maintenance Supervisor stated he had recently replaced the shower head holders in Shower A based on a verbal report and had no work order or invoice, and he was unaware of the torn shower curtain. LVNs A and B stated CNAs were expected to clean and sanitize showers between residents, with housekeeping performing daily cleaning, and that they monitored CNAs through visual checks and follow-up. However, CNAs gave conflicting accounts: one CNA said CNAs cleaned but did not sanitize showers and reported the shower head holders had been broken for several months and the curtain torn for weeks, adding she did not know how to use the electronic maintenance reporting system; another CNA stated CNAs were responsible for cleaning and sanitizing and that she had verbally reported the broken shower heads and torn curtain two weeks earlier; a third CNA believed housekeeping was responsible for cleaning and sanitizing between residents. The Floor Tech stated housekeeping cleaned showers once per shift and that CNAs were responsible for cleaning/sanitizing after every resident. The DON and Administrator both stated CNAs were responsible for cleaning and disinfecting showers between residents, with housekeeping cleaning once in the morning and once in the evening, underscoring the discrepancy between expectations and actual practice.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing records, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Deficient Food Storage, Labeling, and Kitchen Sanitation Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food storage, labeling, and sanitation. In the dry storage area, bulk food items such as granulated sugar, powdered sugar, flour, and corn meal were stored in clear plastic bins without best by or expiration dates. An open box of dry pinto beans was left unsealed and exposed to air. Additionally, containers of opened juice concentrate connected to the juice dispenser were found without open dates, despite the dietary manager stating that these juices have a shelf life of seven days after opening. The dietary manager confirmed responsibility for training staff on kitchen sanitation, including labeling and dating food items, but acknowledged these practices were not being followed at the time of the survey. Further observations revealed a gap approximately 1 inch by 18 inches under a window air conditioning unit beside the employee handwashing station, with the outside visible through the gap. The air conditioning unit above the clean dish station had dirty lint and black buildup on the vents. The dietary manager stated that the previous maintenance person was aware of the gap, but she had not reported it to the new maintenance staff. Both the registered dietician and the administrator confirmed that proper labeling, storage, and sanitation measures were not being followed, which could result in contamination and illness if not addressed.
Failure to Prepare Pureed Diets to Required Consistency
Penalty
Summary
The facility failed to ensure that pureed diets were prepared to the required consistency for four residents with orders for pureed diets due to conditions such as dysphagia, muscle weakness, and dementia. Observations revealed that the staff member responsible for preparing pureed foods did not use a recipe, added milk and thickener to all items, and did not taste test or routinely check if foods were fully blended. The pureed meatloaf and roasted potatoes served contained chunks and did not meet the pudding consistency required by the facility's diet manual. The dietary manager confirmed that the equipment used for pureeing, a blender, was inadequate after the Robot Coupe had stopped working over a year prior, making it difficult to achieve the correct texture for certain foods. Interviews with the registered dietitian and the administrator confirmed that the pureed foods were not being sampled for texture and that the current preparation process did not ensure a smooth, palatable, and nutritional product as required. The facility's own diet manual specified that pureed foods should be blended to a mashed potato or pudding consistency for residents unable to tolerate solid food. The failure to properly prepare pureed foods was directly observed and acknowledged by staff, with the risk of choking and decreased nutritional intake noted by those interviewed.
Failure to Administer Correct Dosage of Ordered Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administration of medications for a resident with multiple medical conditions, including heart failure, ankylosing spondylitis, and spinal stenosis. The resident had a physician's order for naproxen 250 mg to be administered twice daily, but instead, staff consistently administered an over-the-counter naproxen 220 mg tablet. This discrepancy was not identified by the medication aide or the charge nurse until it was observed by a surveyor during a medication pass. The medication administration record (MAR) and active physician orders both reflected the 250 mg dosage, but only 220 mg tablets were available and given. The medication aide admitted to administering the 220 mg tablets since the order was written, without noticing the dosage mismatch. The charge nurse was also unaware of the discrepancy until notified during the survey. Both staff members acknowledged that medication administration should involve verifying the correct dosage against the physician's order and the medication label. The facility's policy required staff to check the medication label three times to ensure the right resident, medication, dosage, time, and route before administration. Despite this policy and documented competency in medication administration, the error persisted for several months. The Director of Nursing and the Administrator were not aware of the mismatch until the survey, and both confirmed that staff are expected to verify medication orders and dosages prior to administration.
Failure to Label and Date Food in Resident Refrigerator
Penalty
Summary
The facility failed to maintain safe and sanitary storage of food items in a resident's personal refrigerator, as required by facility policy. Specifically, a plastic bag containing sliced cheese and sandwich meat in the refrigerator of a resident with multiple medical conditions, including PVD, disorganized schizophrenia, and acute ischemic heart disease, was found to be unlabeled and undated during multiple observations. The facility's policy requires that all food stored in residents' room refrigerators be labeled with a date, and that staff inspect these refrigerators weekly to ensure no expired foods are present and cleanliness is maintained. Interviews with staff revealed confusion regarding responsibility for checking personal refrigerators, with housekeeping staff indicating they were responsible for temperature checks and nursing staff for monitoring expired foods. However, nurse aides stated they were not responsible for these checks. The Administrator acknowledged purchasing food for the resident and failing to label or date the items. The DON confirmed that staff had been in-serviced to ensure foods brought in by family or visitors were labeled and dated, but the deficiency persisted, as evidenced by the continued presence of unlabeled and undated food items in the resident's refrigerator.
Failure to Maintain Gas Stove in Safe Operating Condition
Penalty
Summary
The facility failed to maintain all essential equipment in safe operating condition, specifically regarding the gas stove in the kitchen. Two of the six burners (rear middle and front middle) did not light automatically when the knob was turned, and the pilot lights on these burners would not ignite. Both burners had a significant buildup of hard, black carbon from spilled foods. The Dietary Manager demonstrated that the burners did not work and stated that the kitchen staff were responsible for cleaning the stove burners, but the burners had not worked for a long time. The Dietary Manager also indicated that the previous maintenance director and the Administrator were aware of the issue, but the current Maintenance Director had not been notified to address the problem. The Maintenance Director, who had been employed for two weeks, was unaware of the malfunctioning burners and stated there was no maintenance request in the logbook. The Administrator confirmed that dietary staff were responsible for daily cleaning, while the Maintenance Director was responsible for maintaining equipment and ensuring it was fully operational. A review of the maintenance request binder showed no entries from dietary staff regarding the stove burners in the past three months. Facility policy required the range to be kept clean to minimize food hazards, including scraping off burned particles and grease.
Nonfunctional Bathroom Call Light Systems for Two Residents
Penalty
Summary
The facility failed to ensure that a working call system was available in the bathrooms of two residents. For one resident with a traumatic brain injury and moderately impaired cognition, the bathroom call light box was not attached to the wall, and the pull cord did not function, although the button would activate the light. The resident's friend reported that the box had been fixed previously but broke again, and the resident stated he would yell for help if needed. For another resident with severe cognitive impairment, the bathroom call light box was also not attached to the wall, and the pull cord was nonfunctional, though the button still worked. This resident was unable to be interviewed. Staff interviews revealed that the call lights were noticed to be broken on the morning of the survey, and although there was a maintenance log for reporting such issues, the staff had not yet logged the problem. The Maintenance Director was unaware of one of the broken call lights and stated that repairs could not be completed until parts arrived. In the interim, bells were placed in the bathrooms for emergencies. Facility policy required prompt reporting of defective call lights to the nurse supervisor.
Failure to Maintain Safe Smoking Area and Proper Disposal of Smoking Materials
Penalty
Summary
The facility failed to follow its established policy regarding the safe disposal of cigarette butts and paper trash in the secured unit smoking area. During an observation, it was noted that the ashtray contained both cigarette butts and empty cigarette boxes, while the red fire can also contained paper trash and cigarette butts, with evidence of burned ash. Facility policy required that paper trash and cigarette butts be disposed of separately to prevent fire hazards, and that the smoking areas be checked and maintained daily by housekeeping and maintenance staff. Interviews with staff revealed a lack of clarity and adherence to responsibilities for maintaining the smoking area. A CNA stated that staff supervising residents during smoke breaks should ensure no paper is disposed of in ashtrays or fire cans. However, a housekeeper reported she was unaware that the smoking area was her responsibility, as she had only been cleaning inside the facility since starting a month prior. The housekeeping supervisor confirmed that her department was responsible for the area and acknowledged recent staff turnover, indicating a need for retraining. The administrator also confirmed that both housekeeping and maintenance were responsible for daily checks and proper disposal practices, as outlined in facility policy and the Smoking Area Monitoring Schedule.
Verbal Abuse Incident Involving Staff and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, identified as HSK A. On June 25, 2024, HSK A was involved in an altercation with a resident, during which HSK A yelled and cursed at the resident. The incident began when HSK A was cleaning the resident's room, and the resident allegedly struck HSK A. In response, HSK A engaged in a verbal confrontation with the resident, which was overheard by other staff members. The resident involved in the incident was an elderly male with a history of dementia, schizophrenia, and hypertension. He was known to have behavioral issues, including verbal outbursts directed at others. On the day of the incident, the resident reportedly struck HSK A, who then retaliated by yelling and making threats towards the resident. The altercation was witnessed by several staff members, who reported hearing HSK A's loud and aggressive behavior. The facility's response to the incident included immediate intervention by the administrator, who escorted HSK A out of the building and subsequently terminated his employment. The resident was placed under observation, and a skin assessment revealed a scratch on his shoulder. Despite the facility's actions to address the situation, the initial failure to prevent the verbal abuse constituted a deficiency in ensuring the resident's safety and well-being.
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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) |
|---|---|---|---|---|
| Trucare Living Centers | 8.1 mi | ★★★★★ | 3 | 0 |
| Legacy At Town Creek | 9.6 mi | ★★★★★ | 2 | 0 |
| Avir At Town Creek | 9.7 mi | ★★★★★ | 15 | 0 |
| Greenbrier Nursing & Rehabilitation Center Of Pale | 11.9 mi | ★★★★★ | 8 | 0 |
| Winfield Rehab & Nursing | 22.2 mi | ★★★★★ | 14 | 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.