Kendallville, IN

Lutheran Life Villages

5-star overall rating with 5-star inspections with 1 recent health deficiencies

351 N Allen Chapel Rd, Kendallville, IN

(260) 347-2256

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

99

Certified beds

Average residents

79

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2005-09-12

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

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

0.72

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.35

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.27

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.33

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.06

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

3.05

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.56

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.79

CMS adjusted RN staffing hours

Adjusted total hours

3.68

CMS adjusted total nurse staffing hours

Case-mix index

1.24

Higher values indicate more complex resident acuity

RN turnover

17%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

40%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,237

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

40.76

Composite VBP score used to determine payment impact.

Payment multiplier

0.9937

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

5.99

Baseline 40.79% · Performance 39.19% · Measure score 5.99 · Achievement 5.99 · Improvement 0.50

Adjusted total nurse staffing

2.16

Baseline 3.63 hours · Performance 3.69 hours · Measure score 2.16 · Achievement 2.16 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.27%	10.72% 0.5 pts better	No Different than the National Rate · Eligible stays 54 · Observed rate 7.41% · Lower 95% interval 6.75%
Discharge to community	67.64%	50.57% 17.1 pts better	Better than the National Rate · Eligible stays 44 · Observed rate 70.45% · Lower 95% interval 54.35%
Medicare spending per beneficiary	0.64	1.02 0.4 pts better
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	5.05%	8.2% 3.1 pts worse	Numerator 5 · Denominator 99
Staff flu vaccination coverage	21.1%	42% 20.9 pts worse	Numerator 23 · Denominator 109
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.2	1.6 0.4 pts better	1.9 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.7 · Expected 1.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.5	1.5 1 pts better	1.8 1.3 pts better	Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.2 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	93.6% 6.4 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
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	6.7%	3.8% 2.9 pts worse	3.3% 3.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 8.6% · Q3 6.9% · Q4 6.8% · 4Q avg 6.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.4%	24.6% 24.2 pts better	11.4% 11 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4%
Percentage of long-stay residents who lose too much weight	4.6%	5.6% 1 pts better	5.4% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 0.0% · Q3 9.1% · Q4 3.5% · 4Q avg 4.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	17.4%	23.5% 6.1 pts better	19.6% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 18.9% · Q3 14.3% · Q4 19.0% · 4Q avg 17.4%
Percentage of long-stay residents who received an antipsychotic medication	7.4%	14.8% 7.4 pts better	16.7% 9.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 5.0% · Q3 9.6% · Q4 7.5% · 4Q avg 7.4% · 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	15.9%	13.3% 2.6 pts worse	16.3% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 17.6% · Q3 15.7% · Q4 22.3% · 4Q avg 15.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	21.8%	11.7% 10.1 pts worse	14.9% 6.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 20.0% · Q3 24.5% · Q4 30.4% · 4Q avg 21.8% · 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	2.5%	1.2% 1.3 pts worse	1.7% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 2.8% · Q4 4.1% · 4Q avg 2.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.5%	24.2% 0.3 pts worse	19.8% 4.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 31.2% · Q3 21.1% · Q4 25.2% · 4Q avg 24.5%
Percentage of long-stay residents with pressure ulcers	0.7%	4.1% 3.4 pts better	5.1% 4.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	99.3%	81.6% 17.7 pts better	81.7% 17.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · 4Q avg 99.3%
Percentage of short-stay residents who newly received an antipsychotic medication	8.3%	1.3% 7 pts worse	1.6% 6.7 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 8.3% · 4Q avg 8.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	93.3%	79.0% 14.3 pts better	79.7% 13.6 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 93.3%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-18 · Fire 2025-02-18

1 health deficiencies

Top issue: Resident Rights (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-02-27 · Fire 2024-02-27

2 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 3 Health 2023-02-20 · Fire 2023-02-20

4 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-02-27

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2024-05-04

E · Potential for more than minimal harm 2024-02-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-04

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-02-18

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2025-02-26

D · Potential for more than minimal harm 2024-02-27

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2024-03-08

D · Potential for more than minimal harm 2024-02-27

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 2024-03-08

D · Potential for more than minimal harm 2023-02-20

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-03-03

D · Potential for more than minimal harm 2023-02-20

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-03-03

D · Potential for more than minimal harm 2023-02-20

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2023-03-03

D · Potential for more than minimal harm 2023-02-20

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2023-03-03

Penalties and ownership

What sits behind the stars

Ownership

Adams County Memorial Hospital

5% Or Greater Direct Ownership Interest · Organization

100% 52 facilities 2012-07-01

Adair, Heidi