Cycle 1
Health 2025-01-28 · Fire 2025-01-28
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Elkhart, IN
East Lake Nursing & Rehabilitation Center
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
1900 Jeanwood Dr, Elkhart, IN
(574) 264-1133
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
152
Certified beds
Average residents
96
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
American Senior Communities
Operator or chain grouping
Approved since
1985-10-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
91 facilities
Chain averages 4 overall / 3 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
3.39
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,498
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.64
Composite VBP score used to determine payment impact.
Payment multiplier
0.9872
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.45
Baseline 19.21% · Performance 20.76% · Measure score 1.45 · Achievement 1.45 · Improvement 0
Healthcare-associated infections
7.34
Baseline 6.75% · Performance 5.64% · Measure score 7.34 · Achievement 7.34 · Improvement 5.81
Total nurse turnover
3.48
Baseline 60.76% · Performance 49.46% · Measure score 3.48 · Achievement 3.48 · Improvement 2.65
Adjusted total nurse staffing
0.79
Baseline 3.10 hours · Performance 3.30 hours · Measure score 0.79 · Achievement 0.79 · Improvement 0.26
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.32% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 6.54% · Lower 95% interval 6.62% |
| Discharge to community | 59.68% |
50.57%
9.1 pts better
|
No Different than the National Rate · Eligible stays 99 · Observed rate 55.56% · Lower 95% interval 49.97% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.72% |
95.27%
3.5 pts better
|
Numerator 77 · Denominator 78 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 78 |
| Discharge self-care score | 34.48% |
53.69%
19.2 pts worse
|
Numerator 20 · Denominator 58 |
| Discharge mobility score | 29.31% |
50.94%
21.6 pts worse
|
Numerator 17 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 6.41% |
2.29%
4.1 pts worse
|
Numerator 5 · Denominator 78 · Adjusted rate 5.28% |
| Healthcare-associated infections requiring hospitalization | 5.64% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 1.37% · Lower 95% interval 3.15% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 134 |
| Staff flu vaccination coverage | 37.72% |
42%
4.3 pts worse
|
Numerator 63 · Denominator 167 |
| Discharge function score | 39.66% |
56.45%
16.8 pts worse
|
Numerator 23 · Denominator 58 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 34 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 14.29% |
25.2%
10.9 pts worse
|
Numerator 6 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
1.5
1.5 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
93.6%
2.3 pts better
|
93.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 92.5% · Q3 97.5% · Q4 97.4% · 4Q avg 95.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.8%
0.6 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.2% · Q3 2.5% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.6% |
24.6%
15 pts better
|
11.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 10.4% · Q3 9.2% · Q4 10.8% · 4Q avg 9.6% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
5.6%
0.2 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 1.4% · Q3 8.5% · Q4 8.6% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.1% |
23.5%
9.4 pts better
|
19.6%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 16.9% · Q3 11.3% · Q4 11.4% · 4Q avg 14.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.0% |
14.8%
11.8 pts better
|
16.7%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.3% · Q3 5.1% · Q4 1.7% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.5% |
13.3%
5.8 pts better
|
16.3%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 17.5% · Q3 6.9% · Q4 0.0% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.7% |
11.7%
5 pts better
|
14.9%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 6.0% · Q3 4.4% · Q4 4.5% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.4%
0.2 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.2%
0.9 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.3% |
24.2%
2.9 pts better
|
19.8%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.2% · Q2 15.9% · Q3 26.2% · Q4 16.0% · 4Q avg 21.3% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
4.1%
2.3 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 9.9% · Q3 9.0% · Q4 2.2% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.4% |
81.6%
5.8 pts better
|
81.7%
5.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 86.4% · Q3 84.3% · Q4 86.4% · 4Q avg 87.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.0% |
10.5%
1.5 pts better
|
12.0%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.0% · Observed 8.7% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.3%
1.1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.8% |
79.0%
12.8 pts better
|
79.7%
12.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.2% |
22.4%
3.8 pts worse
|
23.9%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.2% · Observed 26.1% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-29 · Fire 2024-01-29
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Construction (2 deficiencies)
Cycle 3
Health 2022-11-03 · Fire 2022-11-03
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-28
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-01-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-01-28
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-01-28
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-01-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-01-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-01-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-01-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-01-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-01-28
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-01-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-27
E · Potential for more than minimal harm
2024-01-29
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-01-29
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-01-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-01-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-01-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-05
F · Potential for more than minimal harm
2022-11-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-02-02
E · Potential for more than minimal harm
2022-11-03
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-02-02
E · Potential for more than minimal harm
2022-11-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-02
D · Potential for more than minimal harm
2022-11-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-24
E · Potential for more than minimal harm
2024-01-29
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-01-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-01-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-01-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-01-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-20
E · Potential for more than minimal harm
2022-11-03
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-03
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-03
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-11-28
D · Potential for more than minimal harm
2022-11-03
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-11-28
Penalties and ownership
What sits behind the stars
Ownership
The Health And Hospital Corporation Of Marion County
5% Or Greater Direct Ownership Interest · Organization
American Senior Communities LLC
Operational/Managerial Control · Organization
Babcock, Paul
Corporate Officer · Individual
Behm, Elleni
Operational/Managerial Control · Individual
Caine, Virginia
Corporate Officer · Individual
Dice, Mark
Contracted Managing Employee · Individual
Drummer, Carl
Corporate Director · Individual
Fehribach, Gregory
Corporate Director · Individual
Hanify, Thomas
Corporate Director · Individual
Harris, Lisa
Corporate Officer · Individual
Harris, Mckenzie
Operational/Managerial Control · Individual
Lazard, Robert
Corporate Director · Individual
Mantravadi, Geeta
Corporate Director · Individual
Mukes-Gaither, Beverly
Corporate Director · Individual
Payne, Monica
Corporate Director · Individual
Van Camp, Steven
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Greenleaf Health Campus
Elkhart, IN
3-star overall rating with 2-star inspections with 7 recent health deficiencies
#2
Elkhart Meadows
Elkhart, IN
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#3
Riverside Village
Elkhart, IN
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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