Kendallville Manor

In the surveyor’s words

From the most serious findings on record at Kendallville Manor, in the surveyor’s own words.

• Actual harm, isolatedF686Mar 23, 2022

  Based on interview and record review, the facility failed to obtain a pressure relieving device to promote healing of a stage 4 pressure ulcer for 1 of 3 residents reviewed with pressure ulcers (Resident T). This resulted in the wound worsened in size. Findings include: On 3/22/22 at 11:33 A.M., the record for Resident T was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed and often includes undermining and tunneling) pressure ulcer to the sacral region, diabetes, and birth defect of the spine and spinal cord. […]

• No harm, potential for more than minimal, patternF550Aug 27, 2026

  Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity during communication and care for 6 of 6 residents reviewed for dignity (Resident B, Resident C, Resident D, Resident E, Resident F, and Resident G). Findings include:1. The record for Resident B was reviewed on 8/27/26 at 12:05 P.M. Diagnoses included stroke and impulsive behaviors. A quarterly Minimum Data Set (MDS) assessment, dated 8/8/26, indicated Resident B had severely impaired cognition. He was dependent on staff for all activities of daily living (ADL). A care plan, dated 5/4/26, indicated Resident B had difficulty communicating with words due to strokes. Staff were to talk with him when giving care and encourage him to communicate. […]

• No harm, potential for more than minimal, patternF921Jan 27, 2025

  Based on observation, interview and record review, the facility failed to ensure a comfortable environment was maintained for residents in 4 of 7 resident rooms observed. During an observation on 01/21/25 at 10:04 AM, in room [ROOM NUMBER], the wall nearest the bed headboard had missing paint and exposed drywall in vertical marks too many to count approximately 3 feet from the floor, in 3 feet wide by 12 inches to less than 1 inch in length. The opposite wall had scrape marks 12 inches from the floor and approximately 5 feet wide. The exterior bathroom wall was missing 12 inches of cove base trim. The interior bathroom wall was missing 4 inches of cove base trim. […]

• No harm, potential for more than minimal, patternF812Feb 7, 2024

  Based on observation, interview, and record review the facility failed to ensure dishwasher chemical checks were completed consistently. 47 of 50 residents residing in the facility were served food prepared in the kitchen. Findings include: During an observation and interview on 2/2/24 at 9:57 AM, Cook 3 was observed washing dishes in the dishwasher. The Dietary Manager (DM) indicated he was unable to locate the test strips to test the dishwasher sanitizer levels. In a record review beginning 2/2/24 at 9:55 AM a document titled Dishwashing temp (temperature)/PPM (parts per million) Feb (February) 2024 was reviewed. The document contained a grid with dates and columns labeled breakfast reading/initial, lunch reading/initial, and dinner reading/initial. […]

• No harm, potential for more than minimal, isolatedF695Jan 27, 2025

  Based on observation, interview, and record review the facility failed to ensure oxygen orders were obtained and implemented for 1 of 3 residents reviewed (Resident 47). Findings include: During an observation, on 1/21/25 at 11:02 AM, Resident 47 was observed lying in bed wearing a nasal cannula attached to an oxygen concentrator running at 1.75 liters per minute (lpm). A piece of tape attached to the concentrator read 3.5 lpm. Resident 47's record was reviewed on 1/21/25 at 1:16 PM. Diagnoses included adult failure to thrive and personal history of pulmonary embolism. Resident 47's current quarterly Minimum Data Set (MDS), dated [DATE], indicated their Basic Interview for Mental Status (BIMS) score was 15 (cognitively intact). The MDS indicated Resident 47 used supplemental oxygen. […]