Created on: 12/2/2022
Posted to the Web on: 12/14/2022
Basic Information
FACILITY CONTACT INFORMATION:
Address: 1433 S MAIN STREET
City: KENDALLVILLE
Telephone: (260) 347-3612
Web Site:
NAME CHANGES:
Most recent name change: N/A
Date of most recent name change: N/A
LICENSE INFORMATION:
License number: 21-000402-1
License effective date: 8/1/2021
License expiration date: 7/31/2022
Administration and Staff
Administrator:
Start date: N/A
Medical director: David Ilo
Start date: / /
Wound care specialist:
Start date: / /
Infection preventionist:
Start date: / /
Ownership
CURENT OWNERSHIP:
Owning corporation: HENRY COUNTY MEMORIAL HOSPITAL
N/A
N/A N/A N/A
Ownership type: OTHER
Officer(s): STUART REED
MICHAEL REED
PREVIOUS OWNERSHIP CHANGES:
Name of previous owner: HICKORY CREEK HEALTHCARE FOUNDATION INC
Date of last change of ownership:
Bed Counts and Census
COMPREHENSIVE CARE BEDS:
Number of Medicaid beds (NF): 0
Number of Medicare beds (SNF): 0
Number of Medicare/Medicaid beds (SNF/NF): 36
Number of non-certified comprehensive care beds (State Licensed only): 0
Total number of comprehensive care beds: 36
RESIDENTIAL CARE BEDS:
Total number of residential beds: 0
Total number of beds in facility: 36
CENSUS:
Facility census: 21
As reported by the facility on: 1/13/2022
Number of comprehensive care beds occupied in this facility. 0
As reported by the facility on: 1/13/2022
Residential care beds occupied: 0
As reported by the facility on: 1/13/2022
Alzheimer Beds: 0
Alzheimer Beds Occupied: 0
As reported by the facility on: / /
Ventilator Beds: 0
Ventilator Beds Occupied: 0
As reported by the facility on: / /
Sprinklers and Smoke Detectors
This facility is: FULLY SPRINKLERED
Number of comprehensive care resident rooms: 18
Number of comprehensive care resident rooms with battery
operated smoke detectors: 18
Number of comprehensive care resident rooms
with hard wired and/or wireless smoke detectors: 0
Person completing form - KIM STANLEY
Title of the person who completed the sprinkler, smoke detector form submitted to the ISDH. EXECUTIVE DIRECTOR
Date form completed - 3/29/2022
Nurse Aide Training
NURSE AIDE TRAINING PROGRAM APPROVALS:
Nurse aide training and competency evaluation program (NATCEP) approved: 3/22/2000
Nurse aide training and competency evaluation program (NATCEP) expires: 4/1/2002
Nurse aide training and competency evaluation program (NATCEP) banned: No
Nurse aide training and competency evaluation program (NATCEP) ban expires: N/A
CLINICAL TRAINING SITES:
This facility is a Clinical training site for the following nurse aide training (NAT) classroom sites:
HICKORY CREEK AT COLUMBIA CITY
Approved: N/A
Terminated: 3/20/2002
HICKORY CREEK AT BLUFFTON
Approved: 11/13/1998
Terminated: 3/20/2002
HICKORY CREEK AT GOSHEN
Approved: 8/20/1996
Terminated: 3/20/2002
HICKORY CREEK AT HUNTINGTON
Approved: 4/20/1999
Terminated: 1/15/2004
HICKORY CREEK AT WARSAW
Approved: 11/30/1998
Terminated: 3/20/2002
HICKORY CREEK AT KENDALLVILLE
Approved: 1/13/1998
Terminated: 3/20/2002
FWCS CAREER ACADEMY AT ANTHIS
Approved: 2/17/1998
Terminated: 3/20/2002
IMPACT INSTITUTE
Approved: 10/29/2021
Terminated: N/A
ASC TRAINING CENTER
Approved: 10/1/2021
Terminated: N/A
Complaints
NUMBER OF SUBSTANTIATED COMPLAINTS:
Current year: 0
Previous year: 1
2 years previous: 0
Enforcement Actions
Federal Certification Actions Imposed
Civil Money Penalty
Date Imposed: 1/4/2021 Date Ended: 1/4/2021
Amount proposed per day: 1000
Date terminated from Medicare/Medicaid: 6/4/2022
Survey History
The survey report is not posted until the report has been provided to the facility and their plan of correction submitted and approved.
The survey report therefore will likely not be posted until four to six weeks after the exit date.
In the grid below click on an event ID that is underlined to see the survey report for that event.
