Inspection Reports for
Kendallville Manor

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.

The facility was found deficient in ensuring proper oxygen orders and administration for a resident, following pharmacy recommendations for medication discontinuation, and maintaining a safe, clean, and comfortable environment in resident rooms due to wall damage and maintenance issues.

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.

This citation relates to Complaint IN00440431. The abuse allegations were supported by evidence including interviews, written statements, and trauma evaluations.

The facility failed to ensure residents were free from abuse for 2 of 6 residents reviewed. Evidence supported that a Certified Nurse Aide (CNA 10) pushed residents' arms and used excessive force on a resident's door, with multiple staff and resident interviews confirming the incidents.

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.

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.

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.

Complaint IN00426221 was investigated during the visit and no deficiencies related to the allegations were cited.

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.

The visit was complaint-related, triggered by concerns about medication security, dishwasher sanitation, and facility cleanliness. The findings substantiated issues with medication security for Resident 17, inconsistent dishwasher chemical testing affecting 47 residents, and unsanitary conditions affecting Residents 30 and 31.

The facility failed to secure medications properly for one resident, inconsistently completed dishwasher chemical checks affecting food safety for 47 residents, and did not maintain a clean and sanitary environment for two residents.

The visit was complaint-related, triggered by concerns about medication security, dishwasher sanitation, and cleanliness of resident rooms. The complaints were substantiated based on observations and interviews.

The facility failed to secure medications properly for one resident, inconsistently completed dishwasher chemical checks affecting food safety, and did not maintain cleanliness in resident rooms, including failure to clean bodily fluids and properly manage urinals.

This Federal tag relates to Complaint IN00403856. The complaint involved the improper use of physical restraints on Resident B without a physician order.

The facility failed to ensure a resident was free from physical restraints when a gait belt was improperly used to secure Resident B in her wheelchair. Staff involved were terminated and the facility's abuse policy prohibits such restraints unless medically necessary.

Complaint IN00403856 was substantiated with federal/state deficiencies cited related to the allegations of improper physical restraint use on Resident B.

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.

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.

The facility failed to implement non-pharmacological interventions for pain relief for multiple residents, failed to identify and manage triggers related to psychogenic nonepileptic seizures for one resident, and failed to arrange dental services for a resident with an abscessed tooth.

Complaint IN00397100 was investigated and found unsubstantiated due to lack of evidence.

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.

This Federal tag relates to Complaint IN00394874.

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.

Complaint IN00386539 was substantiated with federal/state deficiencies cited at F690. Complaint IN00386794 was substantiated with no deficiencies cited.

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.