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

Staffing

Hours and turnover

RN hours / resident day

0.72

Registered nurse staffing

LPN hours / resident day

0.35

Licensed practical nurse staffing

Aide hours / resident day

2.27

Nurse aide staffing

Weekend hours

3.05

Weekend nurse staffing

RN turnover

17%

Annual RN turnover

Total nurse turnover

40%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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