Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lutheran Life Villages during CMS and state inspections, most recent first.
A resident had unsecured OTC medications at her bedside, including Tums, Pepto Bismol, and Vicks Vapo Rub, even though there were no current orders for these items. The resident said family brought in some of the items and that she had kept Tums in her room for a long time. The resident was cognitively intact, but no self-administration assessment was available, and the DON and Administrator stated staff had not been aware of the bedside storage.
Hand hygiene procedures were not maintained during indwelling catheter care for a resident. A CNA sanitized hands, performed catheter care, then touched the resident’s blanket, plush toy, bed, and bedside table without removing gloves or performing hand hygiene. The CNA later acknowledged gloves should have been removed before touching items in the room, and the DON stated hand hygiene should have occurred before touching the resident’s personal belongings.
The facility failed to protect the privacy of medical records for two residents on the dementia unit. A computer screen on a medication cart displayed a resident's information, and a worksheet with personal care notes was visible. No staff attended the cart, allowing unauthorized access. Both residents were cognitively impaired, and the facility's policies on privacy were not followed.
Unsecured OTC medications found at bedside without orders or self-administration assessment
Penalty
Summary
The facility failed to ensure medications were secured for one resident observed in her room. During an observation, a partial bottle of Tums, a full bottle of Tums, a full box of Pepto Bismol tablets, and a jar of Vicks Vapo Rub with visible fingerprints in the gel and a small amount missing were found on the resident’s bedside table. The resident stated that her family had brought the unopened bottle of Tums and the box of Pepto Bismol that day, and that the partial bottle of Tums had been in her room for a long time and was normally kept on her bedside table. She also stated she always kept a supply of Tums in her room, and no one had ever said anything about it. The resident’s record showed a diagnosis of gastro-esophageal reflux disease without esophagitis and a quarterly MDS assessment indicating a BIMS score of 15, showing she was cognitively intact. Current physician orders did not include Tums, Pepto Bismol, or Vicks Vapo Rub, and there was no self-administration of medications kept at bedside assessment available for review. An LPN stated the resident did not have current orders for those items and removed them from the room, and the DON later stated staff had not been aware the resident was storing medication at her bedside. The Administrator stated a self-administration assessment had not been completed and did not believe the resident would pass the assessment criteria.
Hand Hygiene Not Maintained During Catheter Care
Penalty
Summary
Provide and implement an infection prevention and control program was cited after a continuous observation showed a CNA providing indwelling urinary catheter care for a resident while not maintaining hand hygiene procedures during direct care. The resident was in bed with the head of the bed elevated, and the CNA sanitized hands, lowered the bed, filled a basin with warm water, moved the bedside table, folded down the blanket, removed a plush toy, and positioned the bed flat before applying gloves and performing catheter care. After cleansing the resident’s genitalia and catheter tubing, rinsing the area, and patting it dry, the CNA refastened the brief, covered the resident with the blanket, and replaced the plush toy without removing gloves or performing hand hygiene before touching the resident’s personal items. The CNA again did not remove gloves or perform hand hygiene before raising the head of the bed and returning the bedside table. The CNA later placed used articles in a plastic bag, removed gloves, discarded them, and washed hands in the sink. The CNA stated they had been instructed to change gloves only if damaged or visibly soiled, and acknowledged they should have removed gloves before touching items in the resident’s room. The DON stated the CNA should have removed gloves after direct resident care and washed hands before touching the resident’s personal belongings.
Privacy Breach of Resident Medical Records
Penalty
Summary
The facility failed to ensure the privacy of medical records for two residents, Resident 50 and Resident 123, on the dementia unit. During an observation, a computer screen on top of the medication cart displayed Resident 123's picture, name, medications, and physician's orders, while a worksheet with personal care notes for residents was visible on the cart. No staff member was attending the cart, and several individuals, including two unidentified ambulatory residents, a dietary staff member, and two Certified Nurse Aides, were in the vicinity. The Licensed Practical Nurse (LPN) returned to the cart and closed the screen after a brief period. In a separate observation, a computer screen on the medication cart was open to a page listing Resident 50's medications, with a worksheet listing residents' names and care needs visible. Again, no staff member was present, and several individuals passed by the cart before the LPN returned. Both residents were cognitively impaired, with Resident 123 having a BIMS score of 10 and Resident 50 a score of 5. The facility's policy on privacy and confidentiality, as well as electronic medical records, emphasized the need to safeguard personal and medical records from unauthorized access, which was not adhered to in these instances.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kendallville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kendallville Manor | 0.4 mi | ★★★★★ | 5 | 0 |
| Orchard Pointe Health Campus | 3.2 mi | ★★★★★ | 7 | 0 |
| Ascension Living Sacred Heart Village | 5 mi | ★★★★★ | 8 | 0 |
| Miller's Merry Manor | 9.4 mi | ★★★★★ | 11 | 0 |
| Betz Nursing Home | 10.2 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.