A list of the most recent deficiencies for Kendallville Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-03-22 | 2023-03-31 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-02-21 | 2023-03-22 | N |
| Meet other general requirements. | Fire Safety | 2023-02-21 | 2023-03-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-21 | 2023-03-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-21 | 2023-03-22 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-02-21 | 2023-03-22 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-02-21 | 2023-03-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-21 | 2023-03-22 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-02-21 | 2023-03-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-21 | 2023-03-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-21 | 2023-03-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-21 | 2023-03-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-21 | 2023-03-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-21 | 2023-03-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-03 | 2023-02-19 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-02-03 | 2023-02-19 | N |
| Provide or obtain dental services for each resident. | Health | 2023-02-03 | 2023-02-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-11-28 | 2022-12-17 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-08-10 | 2022-08-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-23 | 2022-04-08 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-02-28 | 2022-03-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-28 | 2022-03-29 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-02-28 | 2022-03-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-02-28 | 2022-03-29 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-02-28 | 2022-03-29 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-02-28 | 2022-03-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-28 | 2022-03-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-28 | 2022-03-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-02-28 | 2022-03-29 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-02-28 | 2022-03-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-28 | 2022-03-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-28 | 2022-03-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-11 | 2022-02-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-11 | 2022-02-28 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-02-11 | 2022-02-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-11 | 2022-02-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-02-11 | 2022-02-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-12-03 | 2020-01-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-03 | 2020-01-02 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2019-12-03 | 2020-01-02 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-10-11 | 2019-10-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-11 | 2019-10-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-11 | 2019-10-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-11 | 2019-10-31 | N |
