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 Orchard Pointe Health Campus during CMS and state inspections, most recent first.
A resident with hypertensive heart disease, chronic kidney disease, and heart failure was discharged from the hospital with orders for a 3 g sodium-restricted diet and identified in the care plan as needing a low salt diet due to malnutrition risk and metabolic demands. Despite dietary assessments by a Diet Tech and RD recommending a no added salt (NAS) diet because of diuretic use, abnormal labs, daily weights, and 4+ pitting edema, the resident continued to receive a regular diet. The active diet order allowed regular bacon and extra gravy/sauce and did not include NAS, contrary to facility policy that NAS replaces low sodium and cardiac diets, resulting in failure to provide the ordered therapeutic diet.
A resident with a hip fracture who was cognitively intact and required set-up assistance with meals was seated in the restorative dining room while another resident at the same table was already eating. Staff informed the resident they were looking for her lunch tray, but the tray was significantly delayed, leading the resident to repeatedly state she did not want to be a bother and could return to her room without eating. CNAs offered watermelon while she waited and helped her complete a lunch order form, yet the meal tray was not delivered for an extended period. Staff later acknowledged the resident waited an excessive amount of time, could not explain the delay, and the DON confirmed there was no policy addressing timely meal service, despite a resident rights policy requiring treatment with dignity and respect.
A cognitively intact resident reported not having a shower since before admission and stated she needed a shower badly, while records showed she repeatedly received only partial bed baths instead of scheduled showers. The shower schedule binder and the resident’s care plan indicated she was to receive showers twice weekly, but a QMA and an RN were unaware of when her showers were due, and the RN noted that shower days were not assigned in the electronic record. The DON stated showers are ordered twice weekly for all residents unless contraindicated, and the Executive Director acknowledged there was no facility policy on shower frequency, resulting in the resident’s bathing needs and preferences not being reasonably accommodated.
A resident with an intertrochanteric femur fracture and intact cognition was prevented from eating in the dining room and remained in bed for a meal because staff reported she lacked appropriate clothing. The resident expressed being very upset, stated she preferred to eat in the dining room, and questioned why she was confined to bed. Staff noted there were no pants in her closet; an LPN said the family had not brought enough clothes and only a hospital gown was available, while a CNA checked lost and found but did not seek further assistance. The Social Services Director later reported that donated clothing was available and that staff should have contacted her, but no one had done so. The resident was positioned upright in bed for lunch yet required frequent repositioning due to leaning to one side, and facility policy affirmed residents’ rights to choose daily activities and use dining rooms.
A resident with diabetes, Alzheimer’s, and epilepsy had a physician order for close monitoring of weight, oral intake, dental status, medication side effects, and for physician notification every shift due to malnutrition risk. Over a period of several weeks, the resident lost more than 3% of body weight and had multiple meals with 50% or less intake, including some with minimal or no intake, yet there was no documentation that the physician was notified or that alternatives or supplements were offered. The DON and an LPN confirmed that physician notifications are expected to be documented in progress notes and a communication book, but no such entries existed for this resident, demonstrating a failure to follow the physician’s orders for monitoring and notification.
The facility failed to maintain proper food temperatures, with observations showing food served below required temperatures. A cooler was found at 62°F with items needing disposal, and pureed food was served at 89°F, below the policy of 135°F. A resident's family member reported cold food complaints, and Resident Council minutes highlighted ongoing issues with cold food and improper handling by dietary aides.
The facility failed to maintain safe and sanitary food storage and serving practices. Observations revealed moisture between lids on the drying rack, expired and improperly stored food items in the pantry, and uncovered and undated food in the refrigerator. Additionally, a broken eggshell was found on the floor. Interviews confirmed that all residents consumed food prepared in the kitchen, and facility policies on food labeling and storage were not followed.
The facility failed to maintain proper infection control and hand hygiene practices. Two residents had improperly stored disposable gowns, posing contamination risks. During meal service, staff did not follow hand hygiene protocols, with inadequate handwashing observed. These actions were contrary to the facility's infection prevention policies.
The facility failed to protect two residents from verbal and physical abuse by a QMA, who was reported to have acted inappropriately during a breakfast service. Despite a vendor witnessing and reporting the incident, the facility did not conduct a thorough investigation or report the abuse to authorities. Resident A, with a history of brain injury and dementia, and Resident B, with dementia and intellectual disabilities, were not assessed for the effects of the abuse. Staff interviews revealed inconsistent reporting and investigation procedures, leading to a deficiency in resident protection.
A facility failed to report an allegation of abuse involving two residents to the Department of Health. A QMA was verbally abusive to a resident, witnessed by a vendor who reported it to the Administrator. The Administrator did not investigate or report the incident, citing no evidence of abuse, despite facility policy requiring such actions. The residents involved had conditions like dementia and traumatic brain injury, affecting their ability to recall the incident.
Failure to Implement Physician-Ordered Low Sodium Diet for Heart Failure Resident
Penalty
Summary
The facility failed to provide a physician-ordered therapeutic low sodium diet for a resident with hypertensive heart and chronic kidney disease with heart failure. The resident’s admission MDS indicated no therapeutic diet had been prescribed prior to or since admission, despite hospital discharge orders specifying a regular diet with a 3-gram sodium restriction and mechanically soft foods with thin liquids. The resident’s care plan, initiated shortly after admission, identified her as at risk for malnutrition due to her diagnoses, inadequate nutrient and energy intake, and metabolic demands, and set a goal for her to tolerate a physician-ordered low salt diet, with interventions to provide the diet as ordered. However, the record showed that she was receiving a regular diet without the specified sodium restriction. Subsequent dietary assessments documented the need for sodium restriction due to the resident’s heart failure and related clinical status. A Dietary Tech review noted that the resident was receiving a regular diet and recommended discontinuing that diet and changing to a regular diet with no added salt (NAS) to reduce sodium at meals. A nurse’s note indicated that orders were received to change the diet to regular with NAS, and a Registered Dietician note confirmed the need to maintain an NAS diet given the resident’s use of diuretics, abnormal labs, daily weights, 4+ pitting edema, and anticipated fluid shifts. Despite these recommendations and the facility policy requiring each diet order to include a therapeutic component and specifying that NAS replaces low sodium/low salt and similar cardiac diets, the actual diet order in the chart was for a regular diet with ground meat, allowance for regular bacon, and extra gravy/sauce, with no indication of NAS, showing that the therapeutic sodium restriction was not implemented as ordered.
Failure to Provide Timely and Dignified Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to provide dignified and timely meal service to one cognitively intact resident. During continuous observation, the resident was assisted to a table in the restorative dining room at 1:04 PM while another resident at the same table was already eating lunch. By 1:17 PM, a CNA informed the resident that staff were looking for her lunch tray. The resident, who had a diagnosis including a displaced intertrochanteric fracture of the left femur and required set-up assistance with meals per her care plan, stated she did not want to be a bother and offered to return to her room without eating. The CNA encouraged her to stay, but the meal tray still did not arrive. At 1:24 PM, another CNA offered the resident a cup of watermelon to eat while waiting for her meal tray, and the resident again expressed that she did not want to be a bother and could go back to her room. A third CNA then assisted the resident in filling out a lunch order on a menu form. The resident’s lunch tray was not delivered until 1:33 PM. Staff interviews confirmed that residents should be served promptly at mealtime and that the resident waited an excessive amount of time for her tray, with staff unable to explain what went wrong or provide updates while the tray was being sought on the hall tray cart or in the kitchen. The DON reported that the facility did not have a policy addressing timely meal service, and the existing Resident Rights Guidelines policy stated that residents have a right to be treated with dignity and respect.
Failure to Provide Scheduled Showers and Accommodate Resident Bathing Preferences
Penalty
Summary
Surveyors found that the facility failed to reasonably accommodate a cognitively intact resident’s bathing needs and preferences by not providing scheduled showers. The resident, who had a BIMS score of 15 on admission, reported on two separate interviews that she had not had a shower since before admission and stated she needed a shower badly. Record review of bathing notes from 3/5/26 to 3/10/26 showed the resident did not receive a shower on the scheduled shower day of 3/7/26 and instead only received partial bed baths on multiple consecutive days. The facility’s shower schedule binder listed the resident for showers twice weekly on specific days and shifts, and the resident’s care plan indicated she was to have showers twice a week per schedule, while the admission agreement stated residents had a right to receive services with reasonable accommodation of their needs and preferences. During interviews, both a QMA and an RN who assisted the resident indicated they did not know when the resident was due for a shower, and the RN noted that scheduled shower days had not been assigned in the electronic record. The DON stated that showers are ordered two days a week for every resident unless contraindicated, and the Executive Director reported the facility did not have a policy about shower frequency. This combination of staff unawareness of the resident’s shower schedule, lack of assignment in the electronic record, and absence of a facility policy resulted in the resident not receiving showers as planned and requested.
Failure to Honor Resident Choice in Dining Location and Dressing Due to Clothing Shortage
Penalty
Summary
The facility failed to honor a cognitively intact resident’s right to choice in dining location and daily routine, including dressing. A resident with a diagnosis of displaced intertrochanteric fracture of the left femur, and a BIMS score of 13 indicating intact cognition, was observed one day fully dressed and seated in the restorative dining room awaiting lunch, and the next day positioned in bed with a lunch tray on an overbed table. During the second observation, the resident reported being very upset and stated that staff told her she could not get out of bed. She questioned whether she had a serious disease confining her to bed that she had not been informed about and stated she preferred to eat in the dining room but was not allowed to get out of bed. She also reported she was not in a comfortable position to eat and kept falling to her right side. Record review showed no clothing or personal items documented on the resident’s Inventory of Personal Items. An LPN stated the resident could not get out of bed because her family had not brought in enough clothes and that the facility had no clothing to offer other than a hospital gown. The Social Services Director reported that staff should contact family when clothing is lacking and that the facility maintained donated clothing of all sizes for such situations, but no staff had notified her of a shortage for this resident. A CNA reported that no pants were available in the resident’s closet on the morning in question, that she checked lost and found without success, and that she did not contact the Social Services Director for additional assistance. The CNA stated the resident was positioned upright in bed for lunch but required frequent repositioning due to leaning to the right. The facility’s Resident Rights Guidelines policy stated that residents have the right to enjoy full use of all campus areas, including dining rooms, and to exercise choice in daily activities.
Failure to Follow Physician Orders for Nutritional Monitoring and Notification
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for monitoring and responding to a resident’s nutritional risk. Resident 8, who had diagnoses including diabetes, Alzheimer’s disease, and epilepsy, had a physician order dated 1/13/26 stating the resident was at risk for malnutrition related to comorbidities. The order directed nursing to monitor weight and intakes as ordered, monitor dental status for adequate chewing ability, follow up with the dietitian as recommended, monitor medications for adverse effects such as nausea, vomiting, diarrhea, and decreased appetite, monitor for negative outcomes such as decreased oral intake or weight loss, and notify the physician every shift. Record review showed that Resident 8’s weight decreased from 175 lbs on 2/9/26 to 168.8 lbs on 3/4/26, a 3.54% loss in 23 days, with no documentation that the physician was notified of this weight loss. Progress notes for March 2026 contained no evidence of physician notification regarding the weight loss, and the physician communication book for 3/4/26 through 3/10/26 also lacked any entry about this issue. The DON stated that staff are expected to fax or call the provider about resident changes and document physician notification in a progress note, but confirmed there was no such documentation for this resident. A QMA reported that the resident ate in the restorative dining room so staff could assist and monitor intakes, and that changes in eating would be reported to a nurse. Review of intake records between 2/9/26 and 3/4/26 showed multiple meals at 50% or less intake, including several meals at 1–25% or zero, with no documentation that alternatives or supplements were offered. An LPN explained that staff receive alerts when weight changes require dietitian notification and that staff become concerned at specified weight-loss thresholds, but there was no documentation that the physician was notified as ordered. The facility’s Provider Notification Guidelines policy required documentation of attempts to notify the provider and their response in the electronic health record but did not address following specific physician orders.
Deficiency in Food Temperature Management
Penalty
Summary
The facility failed to ensure that food was served at a proper temperature, as observed in two separate instances. During an observation, the temperature of an alcohol cooler was found to be 62 degrees Fahrenheit, containing several bottles of alcohol, bottled water, and a cheese tray, which an employee indicated would be discarded. Additionally, two out of three plates of pureed food were measured at 89 degrees Fahrenheit, below the facility's policy requirement of at least 135 degrees Fahrenheit for hot food. A resident's family member reported that the resident had complained about receiving cold food, and Resident Council minutes from the past three months consistently noted issues with cold food being served and improper handling by dietary aides. The facility's current policy, dated January 2024, requires hot food to be held at 135 degrees Fahrenheit or higher and served at a minimum of 120 degrees Fahrenheit.
Deficiency in Food Storage and Serving Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and serving practices, as observed during a survey. During a continuous observation, it was noted that the drying rack had clear, round lids stacked with moisture between them, and the floor in the dishwashing area and dry pantry contained dry, brown particles. In the dry pantry, an opened bottle of molasses had an expired use-by date, and there were onions that were sprouting and one that was brown, black, and soft. Additionally, a yellow cake mix was found with an expired date. In the walk-in refrigerator, six bowls of cottage cheese were uncovered and undated, and there were strawberries with white, fuzzy substances on them. A broken eggshell with its contents was spread on the floor. In the walk-in freezer, a frozen leftover turkey with an expired use-by date was not sealed, and a bag with pork patties was neither labeled nor sealed. Interviews with the Director of Food Service and the facility administrator confirmed that 57 residents consumed food prepared in the kitchen. The facility's policies on food labeling, dating, and storage procedures were not adhered to, contributing to the deficiency.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper sanitary handling of personal protective equipment (PPE) and hand hygiene practices, leading to deficiencies in infection prevention and control. In the case of Resident 45, a yellow disposable gown was observed hanging in the doorway, touching the doorframe and handle, which posed a contamination risk. The gown was improperly stored on the roommate's side of the room, near personal belongings. The resident, who was cognitively intact and had an indwelling catheter, was in the shower at the time of observation. The facility's policy required that gowns be stored in a hallway closet and disposed of after use, which was not followed. Similarly, for Resident 34, a disposable gown was found wadded up and stuffed into the inside door handle, contrary to the facility's guidelines for handling potentially contaminated items. Additionally, during meal service in the assisted dining room, staff failed to perform adequate hand hygiene. A Qualified Medicine Aide (QMA) was observed passing trays and touching residents' utensils and belongings without sanitizing hands between interactions. The QMA washed hands with insufficient scrubbing time, contrary to the facility's policy requiring 20 seconds of friction. A Certified Nurse Aide (CNA) also washed hands inadequately after assisting a resident. Both staff members acknowledged the lapse in proper hand hygiene, attributing it to being in a hurry. The facility's guidelines clearly stated the need for hand hygiene before and after serving meals and direct resident contact, which was not adhered to during the observation.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure freedom from verbal and physical abuse for two residents, identified as Resident A and Resident B. The incident involved a Qualified Medicine Aide (QMA) who was reported to have been verbally abusive to Resident A and physically rough with Resident B. A facility vendor witnessed the QMA's agitated demeanor and inappropriate actions during a breakfast service, where the QMA raised her voice at Resident A and forcibly removed a clothing protector from Resident B's mouth. Despite the vendor reporting the incident to the Administrator, the facility did not conduct a thorough investigation or report the incident to the relevant authorities. Resident A, who had a history of traumatic brain injury and dementia, was unable to recall the abusive event, and no assessments or interviews were conducted to evaluate the psychosocial effects of the verbal abuse. Similarly, Resident B, who also had dementia and intellectual disabilities, was not assessed for any effects of the physical abuse. The facility's progress notes did not document any follow-up on the incident, indicating a lack of appropriate response to the abuse allegations. Interviews with various staff members revealed a lack of consistent reporting and investigation procedures. While some staff members were aware of the protocols for reporting abuse, the Administrator did not suspect abuse and failed to initiate an investigation. The facility's policy on abuse and neglect required immediate reporting and thorough documentation of any suspected abuse, which was not adhered to in this case. The failure to follow these guidelines resulted in a deficiency related to the protection of residents from abuse.
Failure to Report Alleged Abuse to Health Authorities
Penalty
Summary
The facility failed to report an allegation of abuse to the Department of Health involving two residents. During a complaint review, it was found that a Qualified Medicine Aide (QMA) was verbally abusive to Resident A, as witnessed by a facility vendor. The vendor reported the incident to the Administrator, who, along with the Assistant Director of Nursing, did not inform Resident A's family or the State Department of Health. Resident A, who has a history of traumatic brain injury and dementia, was unable to recall the incident. The QMA's behavior was also directed towards Resident B, who has dementia and intellectual disabilities, by forcibly removing a clothing protector from her mouth. The Administrator was informed of the incident but did not conduct an abuse investigation or report it, citing a lack of evidence of abuse. The facility's policy requires the Administrator to investigate and report all allegations of abuse to the Department of Health within 24 hours. However, the Administrator did not follow this policy, as there was no documentation or investigation conducted regarding the QMA's behavior. The Administrator only disciplined the QMA for slamming a tray in front of a student, without addressing the reported abuse towards the residents. This lack of action and failure to report the incident resulted in a deficiency citation related to the complaint.
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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 | 2.9 mi | ★★★★★ | 5 | 0 |
| Lutheran Life Villages | 3.2 mi | ★★★★★ | 2 | 0 |
| Ascension Living Sacred Heart Village | 6 mi | ★★★★★ | 8 | 0 |
| Miller's Merry Manor | 11.7 mi | ★★★★★ | 11 | 0 |
| Betz Nursing Home | 13.3 mi | ★★★★★ | 1 | 0 |
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