Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greenleaf Health Campus during CMS and state inspections, most recent first.
The facility failed to maintain sanitary conditions in food storage and preparation areas, with improperly sealed and expired food items found in various fridges and storage areas. Staff members were observed not wearing hair nets as required, and a microwave in the activities kitchen was found with dried food residue. The facility's policies on food safety and hair restraint were not adhered to, affecting all residents receiving food from the dietary kitchen.
A resident experienced a fall resulting in a major injury, including a laceration and a small intraventricular hemorrhage, requiring hospitalization for more than 23 hours. The facility failed to report this incident to the Indiana Department of Health, as the Administrator misunderstood the reporting policy regarding hospitalization duration and specific injuries.
A facility failed to complete an Annual MDS assessment on time for a resident with multiple diagnoses, including dementia and type 2 diabetes. The assessment, initiated but not completed within the required timeframe, was delayed due to an incomplete section by the Life and Enrichment staff. The MDS Coordinator and Regional Support Specialist confirmed the assessment should have been completed within 14 days from the Assessment Reference Date.
A resident with severe cognitive impairment did not receive adequate ADL services, specifically nail care and facial hair removal, as outlined in her care plan. Observations showed persistent facial hair and dirt under her nails, with no documentation of refusal for care. Interviews with CNAs revealed inconsistencies in care routines, and the facility lacked a specific ADL care policy.
The facility failed to provide evening activity programs, affecting all 57 residents. A resident expressed dissatisfaction with the lack of evening activities, which was important to her as indicated in her care plan and MDS assessment. The Life Enrichment Director confirmed the cessation of evening activities due to staffing issues, despite the facility's policy requiring meaningful and diverse programs consistent with residents' needs.
A resident was found with Voltaren gel, Biofreeze, and cough drops in her room without physician orders or a self-administration assessment. The facility's policy requires medicated creams to be stored in a medication cart and mandates an assessment and order for self-administration, which were not completed. Additionally, two cognitively impaired residents on the unit were known to wander into other rooms.
The facility failed to maintain respiratory equipment for two residents, as oxygen tubing and humidifiers were not dated or stored correctly. One resident's equipment was undated despite a physician's order, and another's BIPAP tubing was left uncovered. Both residents had significant respiratory diagnoses, highlighting the need for proper equipment management.
A facility failed to discontinue or renew a PRN psychotropic medication order for a resident with bipolar disorder, depression, and anxiety after 14 days. The resident's record lacked documentation justifying the continued use of Alprazolam, as required by the facility's policy. The DON acknowledged the oversight during an interview.
A resident with a history of UTIs experienced a delay in receiving treatment due to the facility's failure to promptly notify the physician of lab results. A urinalysis with culture was ordered, collected, and results indicating Escherichia coli were received, but not reviewed until several days later, delaying the start of antibiotic treatment.
A facility failed to follow proper infection control practices during catheter care for a resident with an indwelling catheter and potential MDRO infection. A CNA did not remove gloves and wash hands before touching other items in the room, contrary to the care plan and facility policy. The CNA acknowledged the lapse in procedure during an interview.
Sanitation and Food Safety Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to maintain sanitary conditions in its food storage and preparation areas, as observed during a kitchen tour. In the walk-in fridge, a bag of salad mix was not sealed properly, and a container of salad dressing was found with an expired use-by date. In the walk-in freezer, a bag of potatoes was not sealed appropriately. The milk fridge contained a bottle of cinnamon yogurt flavoring with no use-by date and a bag of cheese with an expired use-by date. Additionally, the juice fridge had two bottles of prune juice with expired use-by dates, and the dry storage contained a box of pancake mix past its use-by date. The Assistant Director of Food Services acknowledged that foods should have been sealed properly and expired items discarded. Furthermore, the facility did not adhere to proper food preparation and serving protocols, as staff members were observed not wearing hair nets in both the main and activities kitchens. During an interview, a staff member admitted to not wearing a hair net as required. Additionally, the activities kitchen had a microwave with dried food on the glass plate and interior surfaces, which the Activities Director confirmed should have been cleaned. The facility's policies on food safety, labeling, and hair restraint were provided, indicating that prepared leftover food must be discarded within three days, and all dining service employees are required to wear hair restraints as per the 2009 Federal Food Code.
Failure to Report Major Injury from Fall
Penalty
Summary
The facility failed to report a fall resulting in a major injury to the Indiana Department of Health for a resident who required hospitalization for more than 23 hours. The incident involved a resident who was found on the floor in her room with blood coming from her head. Emergency personnel were called, and the resident was sent to the emergency room. The resident was admitted to the hospital for observation of a large hematoma and returned to the facility with a laceration on the back of her head, which required 10 staples and measured 4.5 centimeters long. A CT scan revealed a small intraventricular hemorrhage and a right posterior scalp hematoma. During an interview, the Administrator indicated that the facility reported certain injuries such as lacerations over 5 cm, fractures, and subdural hematomas. However, the Administrator was not aware of the intraventricular hemorrhage and misunderstood the policy regarding hospitalization for more than 23 hours. The facility's policy, titled 'Reportable Event Guidelines,' was provided, which included procedures for reporting large lacerations or contusions of unknown origin or those requiring hospitalization for more than 23 hours.
Failure to Complete Annual MDS Assessment Timely
Penalty
Summary
The facility failed to complete an Annual Minimum Data Set (MDS) assessment in a timely manner for one of the residents. The resident, who has diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, and type 2 diabetes, had an Annual MDS assessment initiated but not completed within the required timeframe. The assessment was started on August 26, 2024, but remained incomplete as of September 13, 2024, missing the completion deadline of September 8, 2024. The MDS Coordinator acknowledged the delay, noting that one section was still pending completion by the Life and Enrichment staff. The facility did not have a specific policy for completing MDS assessments but followed the Resident Assessment Instrument (RAI) manual. The MDS Regional Support Specialist confirmed that the assessment should have been completed within 14 days from the Assessment Reference Date.
Failure to Provide Adequate ADL Services for a Resident
Penalty
Summary
The facility failed to provide adequate ADL services, specifically nail care and facial hair removal, for a resident with severe cognitive impairment. Observations over several days revealed that the resident consistently had facial hair on her chin and a brown substance under her fingernails, indicating a lack of personal hygiene care. The resident's care plan, which required assistance with personal hygiene, included interventions such as offering facial shaving and nail care on shower days and as needed. However, the facility's records did not document any refusal by the resident to receive these services, suggesting that the care was not provided as planned. Interviews with several CNAs revealed inconsistencies in the provision of personal hygiene care, with some CNAs indicating that shaving and nail care were part of the routine, while others did not mention these tasks. The Regional Clinical Nurse confirmed that shaving and nail care should be performed during morning and nightly care routines, and any refusal should be documented. However, the facility lacked a specific policy for providing ADL care, which may have contributed to the oversight in the resident's personal hygiene maintenance.
Facility Fails to Provide Evening Activities for Residents
Penalty
Summary
The facility failed to provide evening activity programs for its residents, affecting all 57 residents in the facility. This deficiency was identified through observations, interviews, and record reviews. A resident expressed dissatisfaction with the lack of evening activities, which was important to her as indicated in her care plan and Minimum Data Set (MDS) assessment. The resident's diagnoses included hemiplegia and hemiparesis following cerebral infarction, facial weakness, unilateral primary osteoarthritis, low back pain, and other chronic pain. Despite the resident's expressed interest in group activities, the facility's activity schedules for January, August, and September 2024 showed no evening activities, except for one special themed dinner in August. The Life Enrichment Director confirmed that the last activity of the day was scheduled at 3:00 P.M., after which residents prepared for dinner. The director admitted to ceasing evening activities due to a lack of staff to work evenings, despite acknowledging that there should have been at least two evening activities scheduled per week. The facility's policy, titled "Program Components/Standards," dated June 3, 2017, was provided by the director, indicating that the Life Enrichment Department is responsible for designing programs that are meaningful, diverse, and consistent with the needs and preferences of each resident. However, the facility failed to adhere to this policy by not providing evening activities.
Unattended Medication in Resident's Room
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by leaving medication unattended in a resident's room. During observations on two consecutive days, a resident was found with a tube of Voltaren gel, Biofreeze pain relief cream, and an opened bag of Hall's cough drops on her nightstand and bedside table. A review of the resident's records revealed that there were no physician orders for these medications, nor was there an assessment for self-administration completed for the resident. An interview with RN 11 confirmed that the facility's policy required medicated creams to be stored in a medication cart and that the resident should have had an order for the use of these medications, as well as for self-administration. RN 11 also noted that the resident did not self-administer her medications and that there were two cognitively impaired residents on the unit who wandered into other residents' rooms. The facility's policy on self-administration of medications was not followed, as the medications were not kept in a locked drawer, and the resident did not have the necessary assessment and physician order.
Failure to Maintain Respiratory Equipment for Residents
Penalty
Summary
The facility failed to maintain oxygen tubing and humidifiers according to standards for two residents requiring respiratory care. For Resident 259, observations revealed that the oxygen tubing and humidifier were not dated to indicate when they were last changed. Despite a physician's order to change the oxygen tubing monthly, the humidifier remained undated until several days after the initial observation. Resident 259's diagnoses included respiratory failure and bronchitis, necessitating proper respiratory equipment maintenance. Similarly, Resident 36's respiratory care was compromised as the oxygen tubing and BIPAP equipment were not dated or stored correctly. Observations showed that the BIPAP tubing was left uncovered and undated, contrary to the facility's policy. Resident 36 had multiple respiratory diagnoses, including chronic respiratory failure and COPD, requiring consistent and accurate equipment management. An LPN confirmed the lack of proper storage and cleaning records for the BIPAP equipment, and the facility lacked a specific policy for CPAP or BIPAP equipment use and storage.
Failure to Discontinue PRN Psychotropic Medication After 14 Days
Penalty
Summary
The facility failed to discontinue or obtain a new order for a PRN psychotropic medication after 14 days for a resident with diagnoses including bipolar disorder, depression, and anxiety disorder. The resident had a physician's order for 0.5 milligrams of Alprazolam to be taken twice a day as needed, dated 8/8/2024. However, the resident's record lacked documentation justifying the continued use of the PRN psychotropic medication beyond the 14-day limit. During an interview, the Director of Nursing acknowledged that the facility should have stopped the Alprazolam after 14 days and notified the Nurse Practitioner. The facility's policy on psychotropic medication usage and gradual dose reduction, which was provided by the Director of Nursing, states that PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescriber documents a rationale for extending the order in the resident's medical record.
Delayed Notification of Lab Results for UTI
Penalty
Summary
The facility failed to promptly notify the ordering physician of laboratory results that required medical treatment for a resident who was being reviewed for antibiotics. The resident, who frequently experiences urinary tract infections (UTIs), had a urinalysis with culture ordered on April 21, 2024, after her spouse requested a test due to her head being shaky. The urine was collected on April 22, 2024, and the laboratory results, which indicated the presence of Escherichia coli, were received by the facility on April 24, 2024, and reported on April 25, 2024. However, the results were not reviewed by the Nurse Practitioner until May 1, 2024, at which point an antibiotic, Nitrofurantoin, was ordered. The delay in reviewing the laboratory results and initiating treatment was contrary to the facility's policy, which requires timely notification of diagnostic testing results to the resident's physician or practitioner. The Infection Preventionist indicated that the nurse was expected to check the electronic medical record (EMR) each shift after the culture was ordered and respond within four hours after the results were received. The delay in addressing the laboratory results could have led to a worsening of the resident's condition, as noted by the Nurse Practitioner.
Infection Control Lapse During Catheter Care
Penalty
Summary
The facility failed to ensure proper infection control practices during catheter care for Resident 259. On the observed date, CNA 3 performed catheter care by washing her hands before donning a gown and gloves. She used disposable wipes to cleanse the catheter tubing, starting at the insertion site and moving down the tube. However, after completing the catheter care, CNA 3 did not remove her gloves and wash her hands before touching other items in the room, such as the resident's bed sheets, shirt, and bedside table. This action was contrary to the facility's policy, which required the removal of gloves and handwashing immediately after the procedure. Resident 259 had a care plan indicating the need for enhanced barrier precautions due to an indwelling catheter and potential infection or colonization with a multi-drug resistant organism (MDRO). The care plan specified that hand hygiene should be performed before and after care, and gown and gloves should be used during catheter care. The facility's policy on urinary catheter care also outlined the steps for discarding gloves and washing hands before repositioning bed covers and moving the over-bed table. CNA 3 acknowledged during an interview that she should have removed her gloves and washed her hands before touching anything else in the room, indicating a lapse in following the established infection control procedures.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Elkhart
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| East Lake Nursing & Rehabilitation Center | 1.9 mi | — | 5 | 0 |
| Riverside Village | 2.1 mi | — | 8 | 0 |
| Elkhart Meadows | 2.5 mi | — | 2 | 0 |
| Woodland Manor | 2.5 mi | — | 14 | 0 |
| Brickyard Healthcare - Elkhart Care Center | 2.8 mi | — | 12 | 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 August 2026) and official state health department websites.