Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Resident council grievances were not promptly resolved, and 15 anonymous residents said their concerns were not being considered or given any resolution. Minutes showed repeated complaints about shortages of drinks and food items, repetitive menus, the meal of the month not returning, and the Activity Director being pulled to the floor instead of helping with activities. The Activity Director said she was assigned as a nurse aide on multiple halls, and the Administrator said she reviewed the minutes but did not attend resident council meetings to provide resolutions.
A facility failed to maintain a safe, clean, and comfortable environment when two residents shared a room with a detached baseboard, another resident’s bathroom sink had no hot water despite repeated checks, and a fourth resident’s room had a large hole in the wall behind the door. The affected residents included individuals with dementia, severe cognitive impairment, and physical limitations, and staff interviews showed the maintenance issues were known or observed but not consistently reported or repaired.
Incomplete Person-Centered Care Plans: The facility failed to develop comprehensive care plans for multiple residents with documented cognitive impairment, dependence with transfers, ADL assistance needs, and in some cases urinary and bowel incontinence or PASRR-related needs. Care plans for several residents did not include required ADL, transfer, or incontinence interventions, and one resident’s plan did not reflect PASRR status. The DON, Administrator, and Regional Reimbursement Consultant stated care plans should be individualized and include these needs.
Inaccurate MDS Coding for Resident Assessment: A resident with traumatic brain injury had a quarterly MDS that incorrectly coded a wound, wound infection, and insulin use, even though the order summary showed no current or recent orders for those items. The Regional Reimbursement Consultant, DON, and Administrator stated the prior MDS nurse had not been completing assessments accurately and that the inaccurate coding was not recognized during oversight.
A resident with a stage 3 pressure injury to the left heel and high pressure-ulcer risk did not receive documented wound treatment for several days after the prior order was discontinued, and no wound care order was present in the EMR until a new order was entered after surveyor intervention. The DON said the order may not have been entered correctly into the MAR/TAR, and the Administrator stated staff were expected to enter orders when received or changed so residents would receive ordered care.
Damaged mechanical lift slings remained in use for three residents with severe cognitive impairment and dependence with transfers. Staff observed slings with missing, torn, or illegible tags and faded loops, while the DON, Laundry Aide, and Housekeeping/Laundry Supervisor described laundering the slings in the dryer and not knowing they should be air dried. The DON and Administrator stated weakened slings could break and cause accidents, and the manufacturer guidance said slings with removed or illegible labels must be removed from use.
A resident with DM, HTN, cerebral infarction, and cerebral aneurysm had severe cognitive impairment and was receiving enteral nutrition via G-tube. The resident’s recorded weight dropped from 163 lbs to 134 lbs, with a dietitian note documenting a 143.4 lb weight and recommending weekly weights. The DON acknowledged the initial weight was likely inaccurate, that weekly weights should have been done to establish a baseline, and that the resident was not placed on the weekly weight list after the dietitian’s recommendation. Facility policy required admission weights, weekly weights for four weeks, monthly weights thereafter, and reweighing for any 5 lb or greater change.
Opened Ozempic and Novolog Flex Pen medications were found on a nurse med cart without open or use-by dates. An LPN said she normally dates meds when opened but was unsure why these were not dated, and the DON and Administrator stated opened meds must be dated because they can go bad or lose efficacy. Facility policy and manufacturer guidance required dating and timely discard of opened injectable meds.
A facility failed to ensure working bathroom call systems were available for two residents. One resident with COPD, schizoaffective disorder, polyneuropathy, and a below-the-knee amputation had an uncovered bathroom emergency call light with exposed wire, while another resident with hepatic failure had a bathroom call light box with no cord attached. Both residents had BIMS scores of 11, and the facility policy required a means to call staff from toileting and bathing areas.
Smoking Area Not Kept Free of Trash: A facility failed to follow its smoking policy when paper and plastic trash were found in ashtrays and a red fire can in a designated smoking area. An observation showed empty cigarette boxes in an ashtray and plastic cups and a plastic bottle in the fire can. Staff interviews indicated the trash was often placed there by staff, the area was cleaned daily by housekeeping or maintenance, and the ashtrays and fire can were intended for cigarette butts only.
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.
Resident Council Grievances Not Promptly Resolved
Penalty
Summary
The facility failed to consider and respond promptly to grievances and recommendations raised by the resident council and family group regarding resident care and life in the facility. Record review showed resident council minutes from 4/16/2026 and 5/21/2026 documenting concerns about running out of tea, milk, juice, salt, grease, and other items; having water for all meals; wanting the meal of the month to return; needing more money for activities; and wanting the Activity Director back on the floor because she made residents happy. The minutes showed the Activity Director was the staff member in attendance at those meetings. During a confidential interview, 15 anonymous residents stated their grievances were not being considered and that they were not given any resolutions. They reported concerns about activities, including the Activity Director being pulled to work on the floor for the past 2 months, bingo being called about four times a week by residents, and no prizes being provided, which made activities less enjoyable. They also reported the meal of the month had not been offered since October 2025, that the menu was repetitive, and that meals had been served on paper plates for over a month because of hot water concerns in the kitchen. The Activity Director stated she had been assigned to work as a nurse aide on 2 of 5 halls and had been pulled to the floor when the facility was short staffed, which limited her ability to help with activities. She said she took notes at resident council meetings and gave the minutes to the Administrator, but the Administrator had not attended a resident council meeting since she started at the facility. The Administrator stated she reviewed the minutes after each meeting and tried to resolve the concerns, but she had not formally gone to the meetings afterward to provide the group with any resolutions. Facility policies stated grievances, complaints, and recommendations from residents or family groups would be considered and responded to in writing, and that the administrator and staff would make prompt efforts to resolve grievances to the satisfaction of the resident or representative.
Unsafe Room Conditions and Lack of Hot Water
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents in 4 of 8 residents observed for room conditions. Resident #2 and Resident #44 shared a room that had a baseboard detached from the wall for several days. Resident #2 had COPD, PVD, and vascular dementia, with severe cognitive impairment and wheelchair use. Resident #44 had Parkinson’s disease and Alzheimer’s disease, was rarely/never understood, had a BIMS score of 0, and was dependent on staff for all ADLs. The detached baseboard was observed on multiple days and remained unrepaired during the survey observations. The facility also failed to ensure hot water was available in the bathroom sink for Resident #33. Resident #33 was a male admitted with hepatic failure and had moderately impaired cognition with a BIMS score of 11. He told surveyors he did not have hot water in his bathroom sink. When the water was run and allowed to flow for 5 minutes on two separate observations, it remained cold to the touch. Resident #33 stated, “It’s always like that; I don’t want to wash my hands in cold water.” His care plan did not address his ADL status. The facility further failed to maintain Resident #40’s room in good repair. Resident #40 had hemiplegia affecting the left non-dominant side, dementia, and major depressive disorder, with moderate cognitive impairment and a BIMS score of 12. During observation, surveyors noted a large hole in the wall behind his door, and the hole remained present on later observations. Staff interviews showed housekeeping had noticed the hole but did not report it, while maintenance staff were aware of the issue and had sheetrock available to repair it. The Administrator stated she was not aware of the detached baseboard or the hole in the wall, and the Maintenance Director stated the water heater pilot light sometimes blew out, affecting hot water to resident rooms.
Incomplete Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for 6 of 12 residents reviewed. The missing care plan elements involved activities of daily living, transfer status, urinary and bowel incontinence, and PASRR status. The cited residents were Resident #23, Resident #24, Resident #26, Resident #31, Resident #33, and Resident #53. Resident #23 had diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, was rarely/never understood, had severely impaired cognition, and was dependent with transfers, but the care plan did not address ADLs or transfers. Resident #24 had Alzheimer’s disease, was rarely/never understood, had severe cognitive impairment, and was dependent for transfers, but the care plan did not address ADL status or transfers. Resident #26 had autistic disorder, hypertension, and legal blindness, was rarely/never understood with a BIMS score of 0, was dependent for personal hygiene and bathing, and was frequently incontinent of urine and bowel, but the care plan did not reflect ADLs, incontinence interventions, or PASRR status despite documentation of intellectual and developmental disability screening and evaluation. Resident #31 had epilepsy, a BIMS score of 6, severe cognitive impairment, and was dependent with transfers, but did not have an ADL care plan. Resident #33 had hepatic failure, a BIMS score of 11, moderate cognitive impairment, and was independent with personal and oral hygiene, but the care plan did not address ADL status. Resident #53 had lung cancer, hypertension, and COPD, had moderate impairment in thinking with a BIMS score of 12, was dependent for toileting hygiene, needed substantial/maximal assistance with bathing, and was always incontinent of urine and bowel, but the care plan did not indicate the assistance needed for ADLs or address urinary and bowel incontinence. The DON, Administrator, and Regional Reimbursement Consultant stated that care plans should be individualized, reviewed quarterly and as needed, and include items such as ADLs, transfers, and other resident needs; the Regional Reimbursement Consultant also stated incomplete care plans could cause a delay in resident care.
Inaccurate MDS Coding for Resident Assessment
Penalty
Summary
The facility failed to ensure Resident #15’s quarterly MDS assessment was coded accurately. Resident #15 was a male resident admitted with a diagnosis of traumatic brain injury. The quarterly MDS assessment indicated that he had a wound, a wound infection, and was receiving insulin, but the order summary report showed no current or discontinued orders in the prior 6 months for a wound, infection, or insulin. During interviews, the Regional Reimbursement Consultant stated the previous MDS nurse had not been completing MDS assessments accurately and was no longer in that position. She said the facility had changed electronic charting systems and the MDS assessments began to be incorrect, and that she was responsible for oversight of the assessments but had not recognized Resident #15’s assessment was inaccurate. The DON stated she was not sure how the MDS was coded incorrectly and said the resident had never had a wound, wound infection, or used insulin. The Administrator stated the previous MDS nurse was not completing assessments accurately and that the Regional Reimbursement Consultant had been monitoring the MDS assessments monthly without realizing this assessment was inaccurate.
Missed Wound Care Order for Left Heel Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident with a stage 3 pressure injury to the left heel received necessary wound treatment and services consistent with professional standards of practice. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction and hypertension, and an MDS assessment showed a BIMS score of 10 with moderate cognitive impairment, dependence with most ADLs, and two stage 3 pressure ulcers. A Braden Scale score of 12 identified the resident as high risk for pressure ulcers. Wound care physician evaluations documented a stage 3 pressure injury to the left heel on 5/22/26 and 5/29/26, with the wound showing improvement and no signs of infection. Record review showed the treatment order for the left heel wound was discontinued on 5/25/26, and there was no documentation of wound treatment being administered from 5/25/26 through 5/31/26. On 6/3/26, there was no wound care order in the electronic medical record for the left heel pressure ulcer. A new order for cleansing the left heel, applying calcium alginate and Medi honey, and securing with an island dressing was entered on 6/3/26 after surveyor intervention. During interview, the DON stated that if wound care orders were not entered correctly, they would not appear on the MAR/TAR for nurses to perform the care, and she acknowledged she had been performing the wound care because she knew to do it, but was unsure how the order was missed. The Administrator stated staff were expected to enter orders when received or changed so residents would receive ordered care.
Damaged mechanical lift slings remained in use
Penalty
Summary
The facility failed to ensure the residents’ environment remained as free of accident hazards as possible for 3 of 10 residents reviewed. Resident #23 was a male admitted with hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and his MDS indicated he was rarely/never understood, had severely impaired cognition, and was dependent with transfers. Resident #24 was a male admitted with Alzheimer’s disease, and his MDS indicated he was rarely/never understood, had severe cognitive impairment, and was dependent with transfers. Resident #31 was a female admitted with epilepsy, and her MDS indicated a BIMS score of 6, severely impaired cognition, and dependence with transfers. None of the three residents had an ADL care plan addressing transfer status. During observations, Resident #24 was seen in a geri-chair with a blue mesh mechanical lift sling underneath him with no tag present, the sling appearing to have been ripped off, and the loops faded in color. Resident #31 was observed in the dining room with a solid blue mechanical lift sling underneath her; the tag on the back was torn and illegible. Resident #23 was later observed in the dining room with a blue mesh mechanical lift sling underneath him and no tag observed, appearing to have been ripped off. The DON stated she did not know why the sling tags were getting messed up unless it was because of the dryer. The Laundry Aide said she might use bleach on the slings, was unsure of the wash setting, and said she dried them in the dryer, not knowing they were supposed to be air dried. The Housekeeping/Laundry Supervisor said slings were dried in the dryer and that they did not have an appropriate place to hang them to dry. The DON and Administrator stated that weakened slings could break and cause accidents. A facility policy required routine checks and maintenance of lifting equipment, and the manufacturer guideline stated that if sling labels are removed or no longer legible, the sling must be immediately removed from use.
Failure to Monitor Weight Loss and Tube Feeding Nutrition
Penalty
Summary
The facility failed to ensure Resident #7 maintained acceptable nutritional status and electrolyte balance, as the resident experienced significant weight loss while receiving tube feeding. Resident #7 was a male with diagnoses including Type 2 diabetes mellitus, hypertension, cerebral infarction, and cerebral aneurysm, and the admission MDS indicated severe cognitive impairment. The resident’s nutrition section showed that he received 51% or more of calories from tube feeding, and his physician orders included nothing by mouth with Osmolite 1.2 at 65 cc/hr via G-tube. Record review showed Resident #7’s weights changed from 163.0 lbs on 3/26/2026 and 4/7/2026 to 130.8 lbs on 4/8/2026, then 134.0 lbs on 5/5/2026, reflecting a 29 lb loss and a 20.7% decrease from the earlier recorded weight. The dietitian note on 5/5/2026 documented a weight of 143.4 lbs with a mechanical lift and recommended weekly weights, continuation of the current enteral feeding order, and monthly dietitian review. The resident’s care plan identified impaired nutrition related to G-tube feeding and included a dietician consult. During interviews, the DON stated she was responsible for reviewing weights and acknowledged awareness of the weight discrepancy. She said the initial 163.0 lb weight was not accurate, that weekly weights should have been obtained upon admission to establish a baseline, and that Resident #7 should have been reweighed when the significant difference was noted. She also stated weekly weights were not placed after the dietitian’s recommendation and that this was overlooked. The Administrator stated the DON was responsible for the weight program and that not weighing residents per recommendations or policy could delay identification of weight loss or gain. The facility policy required residents to be weighed upon admission or readmission, weekly for four weeks as determined by the IDT, monthly thereafter, and reweighed for any weight change of 5 lbs or more.
Undated Opened Injectable Medications on Nurse Cart
Penalty
Summary
The facility failed to ensure medications were labeled in accordance with accepted professional principles for 1 of 2 medication carts reviewed. During an observation on 6/3/26 at 7:40 am, an opened multi-dose Ozempic injector pen for Resident #22 was found on the nurse medication cart without an opened date or use-by date, and an opened multi-dose Novolog Flex Pen for Resident #4 was also observed without an opened date or use-by date. The Ozempic label showed it had been filled on 2/20/26, and the Novolog had been filled on 5/5/26. During interviews, LVN B said she normally dates medications when opened but was unsure why these medications were not dated and stated another nurse must have opened them. She said residents should not receive medications that may be old or outdated. The DON stated that medications without an open date could go bad and should not be given if they are old because they may not work as well. The Administrator stated she expected nursing staff to date medications once opened and that efficacy could be compromised if medications were used past the date. Record review showed the facility policy required opened multi-dose vials to be dated and discarded within 28 days unless the manufacturer specifies otherwise, and manufacturer information indicated Ozempic should be discarded after 56 days once opened and Novolog Flex Pen after 28 days.
Bathroom Call Systems Not Functional for Two Residents
Penalty
Summary
The facility failed to ensure a working call system was available in resident bathrooms and bathing areas for 2 of 12 residents reviewed. Resident #3, a male admitted with COPD, schizoaffective disorder, polyneuropathy, and an acquired absence of the right leg below the knee, had a BIMS score of 11 and was documented as always continent of bowel and bladder and independent with toileting transfers. His care plan identified him as at risk for falls and included ensuring the call light was available, but observations on 6/1/2026 and 6/2/2026 showed the emergency call light in his bathroom had no cover and exposed black and red plastic-coated wire protruded from the uncovered area. Resident #33, a male admitted with hepatic failure, also had a BIMS score of 11 and was documented as independent with personal and oral hygiene. His care plan did not address his ADL status. During observation on 6/1/2026, his bathroom call light was seen with no call light cord connected to the call light box. The Maintenance Director stated he was putting a new string on the call light, and the DON and Administrator stated they expected all bathrooms to have functioning call lights for residents to use in an emergency. The facility policy stated each resident is provided with a means to call staff directly for assistance from toileting and bathing facilities and from the floor.
Smoking Area Not Kept Free of Trash
Penalty
Summary
The facility failed to follow its smoking policy for 1 of 2 smoking areas when paper and plastic trash were found in the designated ashtrays and red fire can. During an observation on 6/02/2026 at 11:48 am, the smoking area off the secured unit had 2 ashtrays and 1 red fire can; 1 ashtray contained 3 empty cigarette boxes, and the red fire can contained 4 plastic cups and 1 plastic bottle. During interviews, CNA A said staff assist residents to smoke and only take the lighter and cigarette outside, and she believed the trash was probably placed there by staff. She stated maintenance or housekeeping were responsible for cleaning the ashtrays and fire can, though staff had been told not to place trash in them because it could cause a fire. The Housekeeping/Laundry Supervisor said she and the Maintenance Director had to clean the smoking areas daily because staff often put trash in the ashtrays and fire can. The Administrator stated the smoking area was to be monitored with each smoke break and cleaned daily by housekeeping or maintenance, and that the ashtrays and fire can were for cigarette butts only. The facility policy titled Smoking Policy dated October 2022 stated the facility shall establish and maintain safe resident smoking practices and that ashtrays are emptied only into designated receptacles.
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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What surveyors actually found near you
We read the 36 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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 | ★★★★★ | 1 | 0 |
| Avir At Town Creek | 9.7 mi | ★★★★★ | 1 | 0 |
| Greenbrier Nursing & Rehabilitation Center Of Pale | 11.9 mi | ★★★★★ | 6 | 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 October 2026) and official state health department websites.