Cycle 1
Health 2025-09-26 · Fire 2025-09-26
7 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Elkhart, IN
Greenleaf Health Campus
3-star overall rating with 2-star inspections with 7 recent health deficiencies
1201 E Beardsley Ave, Elkhart, IN
(574) 206-0086
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2010-07-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
125 facilities
Chain averages 4 overall / 3 health / 3 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
0.70
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
2.21
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.71
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.71
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.22
CMS adjusted total nurse staffing hours
Case-mix index
1.58
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,889
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9886
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.76
Baseline 21.76% · Performance 21.16% · Measure score 0.76 · Achievement 0.58 · Improvement 0.76
Healthcare-associated infections
4.47
Baseline 7.59% · Performance 6.50% · Measure score 4.47 · Achievement 4.47 · Improvement 3.70
Total nurse turnover
7.16
Baseline 59.57% · Performance 34.43% · Measure score 7.16 · Achievement 7.16 · Improvement 6.74
Adjusted total nurse staffing
1.5
Baseline 2.69 hours · Performance 3.31 hours · Measure score 1.5 · Achievement 0.80 · Improvement 1.5
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.79% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 252 · Observed rate 13.49% · Lower 95% interval 9.91% |
| Discharge to community | 61.33% |
50.57%
10.8 pts better
|
Better than the National Rate · Eligible stays 255 · Observed rate 58.04% · Lower 95% interval 56.13% |
| Medicare spending per beneficiary | 1.24 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 180 · Denominator 180 |
| Falls with major injury | 2.22% |
0.77%
1.5 pts worse
|
Numerator 4 · Denominator 180 |
| Discharge self-care score | 63.36% |
53.69%
9.7 pts better
|
Numerator 83 · Denominator 131 |
| Discharge mobility score | 61.83% |
50.94%
10.9 pts better
|
Numerator 81 · Denominator 131 |
| Pressure ulcers or injuries, new or worsened | 2.78% |
2.29%
0.5 pts worse
|
Numerator 5 · Denominator 180 · Adjusted rate 2.78% |
| Healthcare-associated infections requiring hospitalization | 6.5% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 179 · Observed rate 5.03% · Lower 95% interval 3.76% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 111 |
| Staff flu vaccination coverage | 27.86% |
42%
14.1 pts worse
|
Numerator 39 · Denominator 140 |
| Discharge function score | 71.76% |
56.45%
15.3 pts better
|
Numerator 94 · Denominator 131 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 49 · Denominator 49 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 114 · Denominator 114 |
| Resident COVID-19 vaccinations up to date | 14.14% |
25.2%
11.1 pts worse
|
Numerator 14 · Denominator 99 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.6
0.1 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
93.6%
5 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 94.1% · 4Q avg 98.6% |
| 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 | 6.8% |
3.8%
3 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 7.7% · Q3 11.1% · Q4 5.9% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
24.6%
21.7 pts better
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.7% · Q4 6.5% · 4Q avg 2.9% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
5.6%
About the same
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 6.2% · Q3 6.5% · Q4 7.1% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.4% |
23.5%
1.9 pts worse
|
19.6%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 31.2% · Q3 19.4% · Q4 20.7% · 4Q avg 25.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.6% |
14.8%
9.2 pts better
|
16.7%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 0.0% · Q3 10.7% · Q4 4.0% · 4Q avg 5.6% · 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 | 7.4% |
13.3%
5.9 pts better
|
16.3%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.0% |
11.7%
7.7 pts better
|
14.9%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 0.0% · Q4 13.8% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.8% |
24.2%
4.6 pts worse
|
19.8%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.1% · Q2 33.5% · Q3 37.2% · Q4 22.6% · 4Q avg 28.8% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
4.1%
2.1 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 6.4% · Q3 1.7% · Q4 3.7% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.1% |
81.6%
7.5 pts better
|
81.7%
7.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 84.6% · Q3 84.4% · Q4 92.1% · 4Q avg 89.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
10.5%
0.7 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 9.2% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.3%
0.3 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.3% · Q3 1.3% · Q4 1.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.3% |
79.0%
3.3 pts better
|
79.7%
2.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.5% |
22.4%
5.1 pts worse
|
23.9%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.5% · Observed 24.3% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-17 · Fire 2024-09-17
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-10-11 · Fire 2023-10-11
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-17
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-10-26
F · Potential for more than minimal harm
2024-09-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-26
F · Potential for more than minimal harm
2024-09-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-26
F · Potential for more than minimal harm
2024-09-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-26
E · Potential for more than minimal harm
2024-09-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-26
F · Potential for more than minimal harm
2023-10-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-26
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-12-19
E · Potential for more than minimal harm
2025-09-26
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-12-19
E · Potential for more than minimal harm
2025-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-09-26
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-09-26
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 2025-12-19
D · Potential for more than minimal harm
2025-09-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-09-26
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-12-19
F · Potential for more than minimal harm
2024-09-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-17
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-17
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 2024-10-17
D · Potential for more than minimal harm
2024-09-17
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-17
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 2024-10-17
D · Potential for more than minimal harm
2024-09-17
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-10-17
D · Potential for more than minimal harm
2024-09-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-17
D · Potential for more than minimal harm
2023-10-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-10-11
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 2023-11-15
D · Potential for more than minimal harm
2023-10-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-10-11
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 2023-11-15
D · Potential for more than minimal harm
2023-10-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-08-09
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 2023-09-08
D · Potential for more than minimal harm
2023-08-09
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-08
Penalties and ownership
What sits behind the stars
Ownership
Witham Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Bardoczi, Stephen
Corporate Officer · Individual
Bardoczi, Stephen
W-2 Managing Employee · Individual
Bayston, Brett
Corporate Director · Individual
Brand, John
Corporate Director · Individual
Braverman, Kelly
Corporate Officer · Individual
Castetter, Andrea
Corporate Director · Individual
Hawkins, Claude
Corporate Director · Individual
Jones, Jack
Corporate Director · Individual
Plantinga, Judy
W-2 Managing Employee · Individual
Pogas, George
Corporate Officer · Individual
Trilogy Healthcare Of Elkhart, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
East Lake Nursing & Rehabilitation Center
Elkhart, IN
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
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
#3
Elkhart Meadows
Elkhart, IN
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
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