Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Ashton Creek Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with fractures and inflammatory arthritis experienced unmanaged pain due to the facility's failure to provide timely and routine pain medication. Despite being prescribed opioids, the resident's pain was not adequately relieved, impacting her rehabilitation. Observations and interviews confirmed the resident's pain was not managed according to her care plan, and the facility's pain management policy was not followed.
The facility failed to ensure proper hand hygiene during meal preparation and service, affecting all residents. Observations showed staff not washing hands after potential contamination, such as touching garbage lids, uniforms, and faces, and handling food without washing hands. The Assistant Dietary Manager confirmed the need for hand hygiene, aligning with the facility's policy.
A resident with moderate cognitive loss was not provided adequate assistance with denture care and facial hair grooming. The resident's care plan lacked details on these needs, and staff were unaware of issues with the resident's partial denture fit and preferences for facial hair removal. Facility policies did not cover denture care or grooming, leading to a deficiency in care practices.
The facility failed to monitor meal intakes and weights for two residents, resulting in significant weight loss. One resident with Alzheimer's was not consistently offered meals or assistance, leading to a weight drop from 148.6 lbs to 134.6 lbs. Another resident with severe cognitive impairment experienced a 20.32% weight loss, dropping from 200 lbs to 141.2 lbs. The facility's Nutrition at Risk policy was not effectively implemented, and staff inconsistencies in weight monitoring contributed to the deficiencies.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as Resident O, who was admitted for rehabilitation following fractures of the right arm and hand, inflammatory arthritis, and muscle weakness. Upon admission, Resident O reported severe pain, rated at an 8 on a scale of 1-10, and required maximal assistance with activities of daily living. Despite being prescribed opioid medications for pain management, the resident and her family expressed concerns about the lack of routine treatment and the impact of unmanaged pain on her therapy sessions. The resident's care plan included administering medication as prescribed and monitoring side effects, but she alleged that staff did not provide pain medication timely or routinely, which hindered her ability to manage pain effectively. Observations and interviews revealed that Resident O experienced significant pain, as evidenced by her grimacing and touching her right upper arm. An admission pain evaluation indicated that her pain was relieved by medication and frequent position changes, with an acceptable pain level of 2 on the pain scale. However, the Medication Administration Records (MAR) showed that pain medication was not administered every 4 hours as needed, and her pain level never decreased to the acceptable level of 2 or below. A new physician order was issued to provide pain medication four times daily, but on one occasion, the resident did not receive her scheduled dose at 9:00 a.m. The facility's policy on pain management requires recognizing, assessing, treating, and monitoring pain consistent with professional standards and the resident's care plan. Despite this policy, the facility did not ensure that Resident O received her pain medication as scheduled, which was acknowledged by the Director of Nursing. This deficiency was identified during a complaint investigation, highlighting the facility's failure to adhere to its pain management policy and adequately address the resident's pain management needs.
Failure to Perform Hand Hygiene During Meal Preparation and Service
Penalty
Summary
The facility failed to ensure proper hand hygiene during meal preparation and service, affecting all 110 residents who consumed food prepared in the facility kitchen. Observations revealed multiple instances where staff did not perform hand hygiene after potential contamination. The Dietary Manager was seen picking up a garbage can lid from the floor and then touching kitchen equipment without washing hands. Another staff member, while preparing pureed chicken, wiped her hands on her uniform after the lid became loose and continued handling clean containers and utensils without washing her hands. Further observations showed staff in the dining room engaging in similar practices. One staff member touched her uniform multiple times and continued handling food without washing her hands. Another staff member touched his face, picked up butter pats from the floor, and continued meal tray assembly without performing hand hygiene. The Assistant Dietary Manager confirmed that staff should perform hand hygiene before starting work and whenever hands are contaminated. The facility's handwashing policy, dated 10/17, requires hand hygiene during food preparation to prevent cross-contamination.
Deficiency in Denture and Grooming Care for Resident
Penalty
Summary
The facility failed to provide adequate assistance with denture care and grooming of facial hair for a resident with moderate cognitive loss. The resident, who had Alzheimer's, anxiety, depression, and a history of stroke, was observed with coarse facial hair and missing upper front teeth. Despite requiring supervision or assistance with oral care and personal hygiene, the resident's care plan did not address these needs, nor did it include the resident's preference for facial hair removal. The resident had a partial denture to replace missing upper front teeth, but it was not included in the care plan. The resident's family reported difficulties with the denture's fit and its impact on speech, and they had informed the facility about these issues. However, the facility staff, including CNAs and the DON, were unaware of the denture's improper fit and the lack of documentation regarding the resident's refusal to wear it. The resident's Kardex and care plan were only updated after the surveyor's observation. The facility's policies on activities of daily living and oral care did not include specific guidelines for denture care or facial hair grooming. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's needs and preferences. The Regional Nurse Consultant acknowledged that facial hair removal should be offered by staff without requiring the resident to request it, highlighting a gap in the facility's care practices.
Failure to Monitor Nutritional Status and Weight Loss
Penalty
Summary
The facility failed to adequately monitor meal intakes and weights for two residents, leading to significant weight loss and potential nutritional decline. Resident B, diagnosed with Alzheimer's disease and requiring assistance with eating, was not consistently offered meal trays or assistance during meals. Meal intake records were incomplete, and there was a notable weight loss from 148.6 lbs to 134.6 lbs over a short period. Despite a care plan indicating the need for supplements, no supplements were ordered, and alternative food options were not documented. The Regional Dietician noted that weights should have been monitored weekly once weight loss was identified. Resident 305, with a history of stroke and severe cognitive impairment, also experienced significant weight loss. The resident required substantial assistance with eating and had a care plan for a mechanical soft diet and supplements. However, the resident's weight dropped from 200 lbs upon admission to 141.2 lbs, indicating a 20.32% weight loss. The facility's Nutrition at Risk (NAR) policy required aggressive monitoring and intervention for residents with significant weight changes, but this was not effectively implemented. Interviews with facility staff revealed inconsistencies in weight monitoring and documentation. The DON, Administrator, and Regional Nurse Consultant acknowledged that weights were monitored through the NAR process, but there was no consistent staff responsible for obtaining weights, leading to a lack of awareness of weight loss. The facility's failure to adhere to its NAR policy and ensure proper nutritional support contributed to the deficiencies identified in the report.
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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 Fort Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grey Stone Health And Rehabilitation Center | 0.7 mi | ★★★★★ | 17 | 0 |
| Heritage Pointe Of Fort Wayne | 2.3 mi | ★★★★★ | 4 | 0 |
| Lutheran Life Villages | 2.4 mi | ★★★★★ | 2 | 0 |
| Bethlehem Woods Nursing And Rehabilitation | 3.5 mi | ★★★★★ | 6 | 0 |
| Towne House Retirement Community | 4 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.