Inspection Report Summary
The most recent inspection on July 1, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mix of compliance and deficiencies, including issues with emergency preparedness, life safety code violations, medication management, and resident care such as abuse and improper restraint use. Inspectors cited recurring themes around emergency preparedness exercises, fire safety maintenance, medication security, and ensuring residents were free from abuse or improper restraints. Several complaint investigations were substantiated, notably one involving abuse by a staff member that led to termination, while most other complaints were unsubstantiated. The facility’s inspection history shows some improvement in recent months with the latest inspections meeting requirements, following earlier citations and corrective actions.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
98% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a July 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 0
Date: Jul 1, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00462098.
Complaint Details
Complaint IN00462098 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00462098 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 48
Total Capacity: 48
Census Payor Type Medicaid: 41
Census Payor Type Other: 7
Census Payor Type Medicare: 0
Inspection Report
Re-Inspection
Census: 45
Capacity: 60
Deficiencies: 0
Date: Mar 19, 2025
Visit Reason
This is a Post Survey Revisit (PSR) to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted on 02/26/25 by the Indiana Department of Health.
Findings
At this PSR survey, Kendallville Manor was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid and with Life Safety Code requirements. The facility is fully sprinklered except for a barn and shed used for facility services.
Report Facts
Certified beds: 60
Census: 45
Inspection Report
Life Safety
Census: 46
Capacity: 60
Deficiencies: 3
Date: Feb 26, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations on 02/26/2025.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements including failure to conduct required emergency preparedness exercises, failure to ensure kitchen cooking appliances are returned to approved positions, and failure to maintain smoke barrier door integrity.
Deficiencies (3)
Failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using emergency procedures.
Failed to provide an approved method for returning cooking appliances to the designed and installed positions for the kitchen hood extinguishing system.
Failed to ensure 1 of 3 sets of smoke barrier doors would restrict the movement of smoke for at least 20 minutes due to a one-inch gap between the smoke doors when closed.
Report Facts
Certified beds: 60
Census: 46
Residents affected by cooking hood deficiency: 30
Residents affected by smoke barrier deficiency: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony L Hill | Senior Administrator | Signed the report and plan of correction |
| Maintenance Director | Interviewed and involved in findings related to emergency preparedness, kitchen appliance positioning, and smoke barrier door deficiencies | |
| Administrator | Interviewed and involved in findings related to emergency preparedness and smoke barrier door deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 17, 2025
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey was completed on January 27, 2025.
Findings
Kendallville Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Annual Inspection
Census: 50
Capacity: 50
Deficiencies: 3
Date: Jan 21, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from January 21 to January 27, 2025.
Findings
The facility was found deficient in ensuring physician oxygen orders were obtained and implemented for residents requiring oxygen, following pharmacy recommendations for medication regimen review, and maintaining a safe, comfortable environment in resident rooms. Repairs and corrective actions were planned and initiated to address these deficiencies.
Deficiencies (3)
Failed to ensure oxygen orders were obtained and implemented for 1 of 3 residents reviewed (Resident 47).
Failed to ensure pharmacy recommendations were followed for 1 of 5 residents reviewed (Resident 1).
Failed to ensure a comfortable environment was maintained for residents in 4 of 7 resident rooms observed.
Report Facts
Census: 50
Total Capacity: 50
Inspection Dates: 5
Residents on Medicare: 1
Residents on Medicaid: 41
Residents on Other Payor: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony L Hill | Senior Administrator | Signed the report |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Interviewed regarding oxygen orders for Resident 47 |
| Director of Nursing | Director of Nursing | Interviewed regarding oxygen orders and medication regimen review |
| Licensed Practical Nurse 3 | Licensed Practical Nurse | Interviewed regarding reporting maintenance issues |
| Maintenance Director | Maintenance Director | Interviewed regarding maintenance and repair processes |
| Housekeeper 9 | Housekeeper | Interviewed regarding environmental conditions and reporting |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 11, 2024
Visit Reason
The visit was conducted as a paper compliance review related to the investigation of Complaint IN00440431 completed on August 27, 2024.
Complaint Details
Complaint IN00440431 was investigated and corrected as of August 27, 2024.
Findings
Kendallville Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 1
Date: Aug 27, 2024
Visit Reason
This visit was conducted for the investigation of complaints (IN00440431) regarding allegations of abuse by a staff member at the facility.
Complaint Details
Complaint IN00440431 was substantiated with findings supporting abuse allegations involving CNA 10. The investigation included interviews, record reviews, trauma evaluations, and statements from staff and residents.
Findings
The facility failed to ensure residents were free from abuse for 2 of 6 residents reviewed (Resident A and Resident B). Evidence included physical contact and verbal abuse by a Certified Nurse Aide (CNA 10), who was suspended and terminated following the investigation. Facility-wide interviews and skin checks found no other abuse.
Deficiencies (1)
Failed to ensure residents were free from abuse for 2 of 6 residents reviewed (Resident A and Resident B).
Report Facts
Residents reviewed for abuse: 6
Census: 46
Total capacity: 46
Staff audits: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony L Hill | Senior Administrator | Signed report and involved in quality assurance oversight |
| CNA 10 | Certified Nurse Aide | Named in abuse findings involving physical and verbal abuse of residents |
| CNA 20 | Certified Nurse Aide | Witnessed and reported verbally abusive behavior by CNA 10 |
| CNA 30 | Certified Nurse Aide | Witnessed physical abuse by CNA 10 |
| LPN 40 | Licensed Practical Nurse | Reported CNA 10 could be impatient with residents |
| Director of Nursing | Director of Nursing | Acknowledged abuse allegations were supported by evidence |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 47
Deficiencies: 0
Date: May 6, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00432435 completed on May 6, 2024.
Complaint Details
Complaint IN00432435 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. Kendallville Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00432435.
Report Facts
Census SNF/NF beds: 47
Census total residents: 47
Census Medicare residents: 3
Census Medicaid residents: 32
Census other payor residents: 12
Inspection Report
Re-Inspection
Census: 45
Capacity: 60
Deficiencies: 0
Date: Mar 15, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 02/29/24 was performed by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, Kendallville Manor was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is fully sprinklered with a fire alarm system and smoke detection in required areas.
Inspection Report
Life Safety
Census: 52
Capacity: 60
Deficiencies: 4
Date: Feb 29, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found not in compliance with Life Safety Code requirements due to deficiencies including incorrect time and date on the fire alarm control panel, use of a door kick stop on a therapy gym door preventing proper closure, failure to conduct fire drills on each shift for one quarter, and damage to the oxygen trans-filling room compromising fire-resistive construction.
Deficiencies (4)
Fire alarm control panel had incorrect time and date displayed.
Therapy gym corridor door held open with a door kick stop preventing proper closure.
Failed to conduct fire drills on each shift for one quarter.
Oxygen trans-filling room was not protected with one-hour fire-resistive construction due to holes and cutouts in the wall.
Report Facts
Certified beds: 60
Census: 52
Residents potentially affected: 5
Residents potentially affected: 20
Fire drill quarters missed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony L Hill | Senior Administrator | Named as facility representative during exit conference |
| Maintenance Director | Interviewed regarding fire alarm panel, door deficiency, fire drills, and oxygen room condition |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 23, 2024
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey was completed.
Findings
Kendallville Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Annual Inspection
Census: 50
Capacity: 50
Deficiencies: 3
Date: Feb 7, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00426221. No deficiencies related to the complaint allegations were cited.
Complaint Details
Complaint IN00426221 was investigated during the visit and no deficiencies related to the allegations were cited.
Findings
The facility was found deficient in several areas including medication security, dishwasher chemical monitoring, and maintaining a clean and sanitary environment. Specific deficiencies included medications left unsecured on a medication cart, inconsistent dishwasher chemical checks, and unclean conditions in resident rooms such as an unemptied urinal and bodily fluids on walls.
Deficiencies (3)
Medications were left unsecured on top of the medication cart accessible to residents.
Dishwasher chemical checks were not completed consistently, risking food safety.
Facility failed to maintain a clean and sanitary environment; observed unemptied urinal and bodily fluids on walls in resident rooms.
Report Facts
Residents present: 50
Total licensed capacity: 50
Medicare residents: 2
Medicaid residents: 37
Other payor residents: 11
Medication pills observed unsecured: 6
Urinal fluid volume: 150
Dishwasher temperature range: 120-140
Dishwasher sanitizer strength range: 50-100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celeste Morgan | RN DON | Signed report as Director of Nursing |
| QMA 4 | Qualified Medicine Aide | Prepared medication for Resident 17 and left medication cart unattended |
| Director of Nursing | DON | Interviewed regarding medication security and urinal cleaning policies |
| Dietary Manager | DM | Interviewed regarding dishwasher chemical testing and monitoring |
| Cook 3 | Cook | Observed washing dishes and interviewed about dishwasher chemical testing |
| Qualified Medicine Aide 2 | QMA | Interviewed regarding urinal cleaning and bodily fluid observations |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 3, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00403856 completed on March 22, 2023.
Complaint Details
Investigation of Complaint IN00403856 completed on March 22, 2023; facility found in compliance.
Findings
Kendallville Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Re-Inspection
Census: 45
Capacity: 60
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 02/21/23.
Findings
At this PSR survey, Kendallville Manor was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility was fully sprinklered except for a barn and shed providing facility services.
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 1
Date: Mar 22, 2023
Visit Reason
This visit was for the investigation of Complaint IN00403856 regarding allegations of improper use of physical restraints on a resident.
Complaint Details
Complaint IN00403856 was substantiated with federal/state deficiencies cited related to the allegations of improper physical restraint use on Resident B.
Findings
The facility failed to ensure a resident was free from physical restraints when Resident B was secured in her wheelchair with a gait belt for approximately 45-60 minutes without a physician order. Staff involved were removed from the schedule and terminated. The facility implemented corrective actions including staff in-service and monitoring to prevent recurrence.
Deficiencies (1)
Failure to ensure a resident was free from physical restraints imposed for purposes of discipline or convenience.
Report Facts
Census: 46
Medicare residents: 4
Medicaid residents: 33
Other residents: 9
Duration of restraint: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony L Hill | Senior Administrator | Signed report |
| RN 2 | Registered Nurse | Involved in placing gait belt restraint on Resident B |
| QMA 3 | Qualified Medication Aide | Assisted RN 2 in placing gait belt restraint on Resident B |
| Director of Therapy | Removed gait belt from Resident B and reported incident | |
| Director of Nursing | Interviewed regarding incident and staffing |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 45
Deficiencies: 0
Date: Feb 21, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00401312 and IN00401493.
Complaint Details
Complaint IN00401312 and Complaint IN00401493 were both unsubstantiated due to lack of evidence.
Findings
Both complaints were found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations regarding the investigation of these complaints.
Report Facts
Census: 45
Total Capacity: 45
Medicare Census: 3
Medicaid Census: 38
Other Payor Census: 4
Inspection Report
Life Safety
Census: 45
Capacity: 60
Deficiencies: 13
Date: Feb 21, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with Life Safety Code and related federal and state regulations.
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency power system testing, smoke barrier door latching, corridor egress obstructions, emergency lighting testing, battery powered smoke alarm maintenance, fire alarm system policy, sprinkler system maintenance and impairment policies, corridor door latching, fire drill completion, electrical receptacle testing, generator load testing, and oxygen storage safety.
Deficiencies (13)
Generator lacked complete required testing in accordance with LSC and NFPA 110.
Failed to maintain latching hardware on 2 of 2 corridor smoke barrier doors.
Failed to ensure 1 of 4 corridor means of egresses were continuously maintained free of obstructions.
Failed to ensure 4 of 4 battery backup lights were tested monthly.
Failed to ensure documentation for the preventative maintenance of 30 of 30 battery operated smoke alarms in resident rooms was complete.
Failed to provide a complete written policy for fire alarm system out of service procedures.
Failed to maintain 1 of 1 sprinkler system in accordance with NFPA 25 including weekly inspections.
Failed to provide correct written policies for sprinkler system impairment and fire watch procedures.
Failed to ensure 1 of 30 resident room corridor doors were provided with means suitable for keeping the door closed and latching.
Failed to conduct fire drills on each shift for 3 of 4 quarters.
Failed to ensure non-hospital grade electrical receptacles at 50 resident sleeping rooms were tested at least annually.
Failed to maintain complete written record of monthly generator load testing for 1 of 12 months and weekly inspection for 5 of 52 weeks.
Failed to ensure a minimum distance of at least five feet separated combustible materials from oxygen storage equipment in oxygen storage area.
Report Facts
Certified beds: 60
Census: 45
Deficiency count: 12
Resident rooms with non-hospital grade receptacles: 50
Resident rooms with corridor door deficiency: 1
Corridor means of egress affected: 1
Battery powered smoke alarms: 30
Battery backup lights: 4
Generator load testing missing months: 1
Generator weekly inspections missing weeks: 5
Fire drill quarters missing: 3
Combustible boxes near oxygen storage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anthony L Hill | Senior Administrator | Signed report and referenced in plan of correction |
| Maintenance Director | Interviewed and referenced in multiple findings regarding generator testing, door latching, fire drills, electrical testing, and oxygen storage |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 20, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Kendallville Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Annual Inspection
Census: 48
Capacity: 48
Deficiencies: 3
Date: Feb 3, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00397100, found unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00397100 was investigated and found unsubstantiated due to lack of evidence.
Findings
The facility was found deficient in pain management for failing to implement non-pharmaceutical interventions prior to administering PRN pain medications for 3 residents. The facility also failed to identify and manage triggers related to psychogenic nonepileptic seizures for 1 resident, and failed to arrange dental services for an abscessed tooth for 1 resident.
Deficiencies (3)
Failed to implement non-pharmaceutical interventions for pain relief prior to administering PRN pain medications for 3 residents.
Failed to identify and manage triggers related to psychogenic nonepileptic seizures for 1 resident.
Failed to arrange dental services to treat an abscessed tooth for 1 resident.
Report Facts
Residents reviewed for pain management deficiency: 3
Residents reviewed for behavioral health deficiency: 1
Residents reviewed for dental care deficiency: 1
Residents present during inspection: 48
Total licensed capacity: 48
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 28, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to bowel and bladder incontinence, catheter use, and urinary tract infections at Kendallville Manor.
Complaint Details
This Federal tag relates to Complaint IN00394874.
Findings
The facility failed to ensure interventions were initiated related to bowel incontinence and constipation for a resident with multiple diagnoses including stroke and diabetes. The resident lacked a bowel toileting program and had no care plan addressing bowel incontinence or constipation. The Director of Nursing acknowledged that interventions should have been implemented.
Deficiencies (1)
Failure to ensure interventions were initiated related to bowel incontinence and constipation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Celestine Morgan | RN | Signed as Laboratory Director's or Provider/Supplier Representative's Signature. |
| Director of Nursing | Interviewed and indicated Resident B should have had interventions implemented for bowel incontinence and constipation. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 22, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00394592.
Complaint Details
Investigation of Complaint IN00394592 completed on November 22, 2022; facility found in compliance.
Findings
Kendallville Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 49
Capacity: 49
Deficiencies: 0
Date: Oct 25, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00390889.
Complaint Details
Complaint IN00390889 was investigated and found to be unsubstantiated due to lack of evidence.
Findings
The complaint IN00390889 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type Total: 49
Census Payor Type Total: 49
SNF/NF Beds: 45
SNF Beds: 4
Medicare Residents: 4
Medicaid Residents: 34
Other Payor Residents: 11
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 10, 2022
Visit Reason
Paper compliance review to the Investigation of Complaint IN00386539 completed on August 10, 2022.
Complaint Details
Investigation of Complaint IN00386539; paper compliance review completed and found in compliance.
Findings
Kendallville Manor was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review of the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 45
Capacity: 45
Deficiencies: 1
Date: Aug 9, 2022
Visit Reason
This visit was conducted for the investigation of Complaints IN00386539 and IN00386794. Complaint IN00386539 was substantiated with related deficiencies cited, while Complaint IN00386794 was substantiated with no deficiencies cited.
Complaint Details
Complaint IN00386539 was substantiated with federal/state deficiencies cited at F690. Complaint IN00386794 was substantiated with no deficiencies cited.
Findings
The facility failed to assess and monitor chronic urinary tract symptoms for one resident (Resident C). The resident had recurrent UTIs and was on antibiotic therapy, but monitoring and documentation of urinary complaints were inadequate. The Director of Nursing confirmed that a care plan should have been developed and symptoms assessed and documented.
Deficiencies (1)
Failure to assess and monitor chronic urinary tract symptoms for Resident C.
Report Facts
Census SNF/NF beds: 45
Census total residents: 45
Census Medicare residents: 9
Census Medicaid residents: 31
Census Other payor residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding failure to develop care plan and assess urinary symptoms | |
| Resident C | Resident with chronic urinary tract symptoms involved in deficiency |
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