3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Kendallville, IN
4-star overall rating with 3-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
702 Sawyer Road, Kendallville, IN
(260) 347-3333
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
58
Certified beds
Average residents
52
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2016-10-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
1.04
Registered nurse staffing
LPN hours / resident day
0.57
Licensed practical nurse staffing
Aide hours / resident day
2.55
Nurse aide staffing
Weekend hours
3.52
Weekend nurse staffing
RN turnover
25%
Annual RN turnover
Total nurse turnover
37%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.6
0.3 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.5
0.1 pts worse
|
1.8
0.2 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 | 0.0% |
3.8%
3.8 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 9.7% |
24.6%
14.9 pts better
|
11.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 10.5% |
5.6%
4.9 pts worse
|
5.4%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.7% |
23.5%
3.8 pts better
|
19.6%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 16.7% |
14.8%
1.9 pts worse
|
16.7%
About the same
|
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 | 9.7% |
13.3%
3.6 pts better
|
16.3%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.7% |
11.7%
9 pts better
|
14.9%
12.2 pts better
|
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 | 0.6% |
1.2%
0.6 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.0% |
24.2%
5.2 pts better
|
19.8%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 0.8% |
4.1%
3.3 pts better
|
5.1%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
81.6%
18.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.7% |
10.5%
4.8 pts better
|
12.0%
6.3 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
79.0%
15.3 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.7% |
22.4%
3.7 pts better
|
23.9%
5.2 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-28
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-28
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-28
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-28
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-01
Inspection history
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-01-31
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-31
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-31
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-31
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-31
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-01-31
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-31
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-28
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-02-28
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
5% Or Greater Mortgage Interest · Organization
Corporate Officer · Individual
Corporate Director · Individual
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