Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Lutheran Life Villages during CMS and state inspections, most recent first.
A resident with cognitive and anxiety disorders experienced repeated unsafe interactions with their spouse, including physical contact, medication administration, and feeding of unsafe foods. The care plan and staff assignment sheets did not address these risks or provide guidance for monitoring or intervention, and staff were only verbally instructed to monitor the situation, leaving the resident unprotected from potential abuse.
Opened meds were found without open dates, medication carts contained loose pills, debris, and sticky residue, and one resident’s treatment was stored in a med cart instead of the treatment cart. Staff also found missing temperature log entries for the Emergency Drug Kit/narcotic fridge, and an unlocked med room with an unlocked refrigerator was observed with no staff present.
A facility failed to ensure freedom from intimate touching for two residents with dementia and sexual behavior concerns. One resident with a BIMS score indicating cognitive impairment was documented with inappropriate sexual behavior, and another resident with a lower BIMS score was documented touching the first resident between her legs over clothing in the dining room. Staff intervened, but the record showed no additional nursing or SS documentation after the incident, and a scheduled Depo-Provera dose for the second resident appeared not to have been administered.
Failure to report non-consensual resident-to-resident sexual contact. A resident with dementia, behavioral disturbance, sexual dysfunction, and significant cognitive impairment touched another resident between the legs over clothing in the dining room. Staff intervened and separated the residents, but the record lacked documentation of family or NP notification. Interviews confirmed the contact should have been treated as sexual abuse, reported immediately to the Administrator, and investigated under the facility’s abuse reporting policy.
Wound care was not performed in a clean manner for a resident with a stage 3 pressure ulcer of the heel, Alzheimer’s disease, and DM2. An RN carried supplies against her body, placed items on the floor, reused uncleaned scissors after removing the old dressing, and did not perform hand hygiene after cleansing the wound and before applying the treatment. The ordered heel dressing included wound cleanser, skin prep, silver alginate, an ABD pad, and Kerlix.
Dialysis communication and assessment records were incomplete for a resident with ESRD on M/W/F dialysis. Staff reported no dialysis book was available when asked, and the Administrator later provided a dialysis communication book that contained ESRD communication forms for only two dates and missing pre- and post-dialysis assessments for two dialysis days. The Administrator stated the ESRD form was the only way the facility communicated with dialysis and that the book should have accompanied the resident to each dialysis appointment.
Failure to Complete Ordered Labs: A resident with vitamin D deficiency, fatty liver, seizures, and depression had physician orders for Depakote-related labs, ammonia, vitamin D, TSH, hepatic panel, and lipid panel, but record review showed missing results for several ordered tests. The Administrator said the MAR was not notifying staff that labs needed to be drawn, and the DON confirmed the facility did not have lab results for vitamin D, hepatic function, ammonia, or additional Depakote levels for the resident.
A resident with dementia and mobility issues experienced two falls, one resulting in a leg fracture, after staff failed to assess the root cause of falls and did not implement or update care plan interventions such as scheduled toileting or specifying required assistance for ADLs. The care plan lacked details on ambulation support and toileting needs, and interventions were only added after the resident was hospitalized for injury.
A resident with a history of CHF, syncope, and hypomagnesemia experienced multiple acute changes in condition, including unrelieved pain, low BP, dehydration, and respiratory distress, without timely notification to the physician or family. The resident's advance directives for hospital transfer were not promptly followed, and physician orders for medication administration were inconsistently documented and implemented. Staff communication with the family was inconsistent, and required notifications and assessments were not completed as per facility policy.
The facility failed to provide appropriate dementia care and services to two residents, as observed during a survey. Residents were found without engagement in activities, with some sleeping or staring blankly, and no staff present to facilitate interaction or care. One resident, diagnosed with dementia and other mental health conditions, was observed alone and disengaged, with no specific care plan for residing in a secured memory care unit or for dementia care programming. Another resident was observed fidgeting and disrobing, with no staff intervention to engage her in activities or address her behaviors. The facility's policy emphasized the importance of structured activities and interventions for dementia care, but these were not observed in practice.
Failure to Protect Resident from Abuse and Unsafe Interactions During Family Visits
Penalty
Summary
The facility failed to ensure the safety and prevention of abuse for a resident with cognitive communication deficits and generalized anxiety disorder. The resident, who had a moderate cognitive loss as indicated by a BIMS score of 7, experienced multiple incidents involving their spouse during visits. These incidents included the spouse making physical contact with the resident's face, reopening a skin tear by pulling the resident's arm, and administering unidentified medication and aspirin to the resident. Additionally, the spouse fed the resident unsafe food items and repositioned the resident without staff involvement, sometimes leading to arguments with staff and increased resident anxiety and aggression. Despite these repeated incidents, the resident's care plan did not include interventions or monitoring related to the spouse's visits, nor did it address the spouse's involvement in feeding, medication administration, or physical contact. The care plan only noted the resident's potential for verbal aggression and included general interventions for de-escalation and psychiatric support, but lacked specific guidance for staff regarding the spouse's actions. The resident profile assignment sheet also did not reflect any safety concerns or behavioral issues for this resident, leaving staff without clear written instructions for safeguarding the resident during spouse visits. Interviews with staff and the administrator confirmed that only verbal instructions had been given to monitor the resident during spouse visits, and that the care plan and assignment sheets had not been updated to reflect the ongoing issues. The administrator acknowledged awareness of the spouse's actions and the lack of documentation or formal interventions in the care plan or assignment sheets. The facility's policy required identification and intervention in situations where abuse is more likely to occur, but this was not implemented in the resident's documented care.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored in accordance with accepted professional principles. During observation of the 100 hall medication carts with the DON, several opened medications were found without open dates, including an antacid tablet bottle, morphine sulfate, guaifenesin DM, calcium-gest, and another guaifenesin-DM bottle. Two opened albuterol sulfate inhalers for one resident were also observed, one dated 1/24/25 and another dated 4/4/25. In the same carts, loose pills, debris, and a brown-reddish sticky substance were observed in the drawers, and the DON stated the carts should be cleaned. On the 400 hall medication cart, similar debris and loose tablets were observed, and two cups of medications were found for one resident, including pills in yogurt; an LPN stated the resident had gone to the beauty shop and the medications should have been discarded and re-pulled when the resident returned. On the 200 hall medication carts, debris and a brown sticky substance were observed in the drawers, and an opened bacitracin ointment treatment for one resident was found in the medication cart rather than the treatment cart. In the main medication room, the August 2025 temperature log for the Emergency Drug Kit/Narcotics fridge had multiple missing dates, and the DON stated 3rd shift was responsible for recording temperatures. On 8/28/25, the medication room on the 400 hall was observed unlocked with an unlocked small white refrigerator inside and no staff present; the Administrator stated both doors should have been closed.
Failure to Protect Residents from Intimate Touching
Penalty
Summary
The facility failed to ensure freedom from intimate touching for 2 of 19 residents reviewed, involving two residents with dementia and sexual behavior concerns. One resident had diagnoses including dementia, anxiety, and sexual dysfunction, and a current MDS assessment showed a BIMS score of 8, indicating cognitive impairment. Another resident had diagnoses including dementia with behavioral disturbance and sexual dysfunction, and a current MDS assessment showed a BIMS score of 4, also indicating cognitive impairment. A progress note documented that staff reported inappropriate sexual behavior by the first resident with a male resident, and staff intervened. No additional nursing or social services progress notes or assessments related to the sexual behavior were documented after that event. Another progress note documented that the second resident exhibited inappropriate sexual behavior in the dining room and touched the first resident between her legs over clothing, after which staff intervened and assisted the second resident away from the situation. The residents had care plans addressing impaired cognition and sexually inappropriate behavior, with interventions to intervene as necessary, update family and the NP, and supervise or reorient as needed. The Administrator stated the two residents had a history of sexual contact earlier in the year and was not aware of recent contact. The record also showed a Depo-Provera injection for the second resident was not administered as scheduled, and the vial remained unopened in the medication cart, with staff indicating this could mean the medication was not given as ordered.
Failure to Report Non-Consensual Resident-to-Resident Sexual Contact
Penalty
Summary
The facility failed to ensure an occurrence of non-consensual intimate touching was reported for Resident 99. Resident 99 had diagnoses including dementia with behavioral disturbance and sexual dysfunction, and a current annual MDS dated 7/26/25 showed a BIMS score of 4, indicating cognitive impairment. A progress note dated 8/21/25 documented that Resident 99 exhibited inappropriate sexual behavior in the dining room before the supper meal and touched Resident 53 between her legs on the outside of her clothes. Staff intervened and Resident 99 was assisted away from the situation. The record did not include notes documenting notification of the family or NP. During interviews, staff stated that when a resident touches a cognitively impaired resident in a sexual way, the residents should be separated, assessed for physical or psychosocial harm, and the Administrator, DON, family, and NP should be notified. The Administrator stated the contact between the residents should have been reported immediately so an investigation could begin, and that the occurrence and assessment findings should have been reported to the Administrator, NP, family, and the department of health according to abuse reporting protocols. The facility's Abuse Policy stated sexual abuse included intimate touching, that sexual contact was non-consensual if a resident lacked the cognitive ability to consent, and that suspected abuse should be reported to the Administrator, who would begin an investigation and report the allegation to the Department of Health within 2 hours.
Wound Care Supplies and Hand Hygiene Not Maintained During Dressing Change
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when wound care for a resident with Alzheimer’s disease, type 2 diabetes, and a stage 3 pressure ulcer of the right heel was observed. During the dressing change, the RN carried wound care supplies into the room against her body, placed supplies on the floor and on an overbed table barrier, and used scissors to remove the old kerlix dressing without cleaning the scissors afterward. The wound cleanser bottle and packages of kerlix and alginate were also placed on the floor without a barrier, and no hand hygiene occurred after cleansing the wound and before applying the wound treatment. The resident’s physician’s order directed the right heel to be cleansed with wound cleanser, patted dry, skin prep applied around the wound edges, silver alginate placed in the wound bed, covered with an ABD pad, and secured with kerlix. During interview, the RN stated she should have placed wound care supplies on a barrier instead of the floor, should have cleansed the scissors after using them to cut off the old dressing, and indicated wound care items should be carried into the room away from the staff member’s body without touching the uniform. The facility policy required hand hygiene at multiple points during the wound care procedure and stated supplies should be maintained as sterile or clean while avoiding contamination.
Dialysis Communication and Assessment Records Incomplete
Penalty
Summary
The facility failed to ensure communication with the dialysis provider for Resident 57, who had diagnoses including end stage renal disease, dependence on renal dialysis, hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease, metabolic encephalopathy, and anemia in chronic kidney disease. Physician orders indicated the resident was to leave the facility for dialysis at 4 AM on Monday, Wednesday, and Friday, and that pre- and post-dialysis assessments were to be completed. During record review and interview, RN 8 stated she had not seen a dialysis book and was told by LPN 9 that there was no dialysis book. Later, the Administrator provided a dialysis communication book for Resident 57 that contained physician orders, pre- and post-dialysis assessments for multiple dialysis dates, and ESRD communication forms for only two dates. The Administrator stated the ESRD communication form was the only way the facility had communicated with dialysis and that the dialysis book should be taken to each dialysis appointment. She also stated the facility should have completed the ESRD communication form for each dialysis appointment and that pre- and post-dialysis assessments should have been completed every Monday, Wednesday, and Friday. The Administrator further stated pre- and post-dialysis assessments were missing for 8/13/2025 and 8/20/2025.
Failure to Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure completion of physician-ordered laboratory tests for one resident who had diagnoses including vitamin D deficiency, fatty liver, seizures, and major depressive disorder. The resident had orders for Depakote-related labs, ammonia, vitamin D, TSH, hepatic panel, and lipid panel at specified intervals, but record review showed only some lab results were available. The available lab results included Valproic Acid on 12/2/2024, and lab reviews dated 5/19/2025 and 8/7/2025 did not include results for vitamin D, ammonia, hepatic function, or Depakote level. During interviews, the Administrator stated the facility had identified an issue with the MAR not notifying staff that labs needed to be drawn and indicated she could not locate additional lab results for ammonia, Depakote level, vitamin D, or hepatic function. The DON later stated the facility did not have any labs for vitamin D, hepatic function, or ammonia prior to 8/28/2025 for the resident and did not have any additional Depakote labs for the resident. The facility policy stated nurses are required to electronically acknowledge orders and notify ancillary departments required to execute the order.
Failure to Assess and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that the root cause of falls was properly assessed and that appropriate care plan interventions were developed and implemented to prevent further falls for a resident with significant fall risk. The resident, who had diagnoses including Alzheimer's dementia and a recent hip fracture, was admitted for rehabilitation and was noted to have an unsteady gait, weakness, poor balance, and required assistance for ambulation and transfers. Despite being identified as high risk for falls and in need of staff assistance for toileting and mobility, the care plan did not specify the required level of assistance for activities of daily living (ADLs), weight bearing status, or use of assistive devices. Additionally, there was no scheduled toileting plan in place prior to the resident experiencing two falls within a short period, one of which resulted in a fractured leg. The first fall occurred when the resident attempted to get up from a recliner to use the bathroom and was wearing slick shoes, leading to a loss of balance. The second fall happened when the resident again attempted to walk to and from the bathroom unassisted, resulting in her legs giving out and causing a fracture to her distal femur. Both falls were unwitnessed, and documentation indicated that the resident was not on a scheduled toileting plan, nor had an assessment been completed to determine the need for such a plan. The care plan was only updated to include increased scheduled toileting after the resident was hospitalized for the fracture. Interviews with facility leadership and therapy staff confirmed that the resident always required staff assistance for ambulation due to confusion and weakness, and that the root cause of the falls was related to the need for toileting, incontinence, and the absence of a scheduled toileting plan. The facility's fall policy required assessment, documentation, and revision of care plans following falls, but these steps were not adequately implemented prior to the incidents. The lack of timely and comprehensive assessment and intervention contributed to the resident's repeated falls and injury.
Failure to Assess, Notify, and Follow Advance Directives and Physician Orders
Penalty
Summary
The facility failed to ensure timely assessment and physician notification following acute changes in a resident's condition, did not follow the resident's advance directives for hospital transfer, and did not consistently follow physician orders for medication administration. The resident, who had a history of congestive heart failure, syncope, hypomagnesemia, and muscle weakness, was admitted for rehabilitation with the goal of returning home. Her POST form indicated she wished for full interventions, including hospital transfer and intensive care, if needed. Despite this, there were multiple instances where significant changes in her condition, such as unrelieved pain, low blood pressure, dehydration, difficulty breathing, anxiety, restlessness, and vomiting, were not promptly communicated to the physician, nurse practitioner, or family. Documentation in the resident's medical record was inconsistent regarding the administration and holding of her magnesium supplement, which was ordered to be held due to diarrhea but continued to be administered on several days. The Medication Administration Record (MAR) did not consistently reflect the reasons for holding or administering the supplement, and there was a lack of documentation supporting the clinical decisions made. Additionally, the resident's family was not promptly notified of her acute decline, and her wishes for hospital transfer were not immediately honored when her condition worsened. Staff communication with the family was inconsistent, and the family reported confusion and distress over the explanations provided and the documentation in the medical record. Interviews with facility staff, the nurse practitioner, and the resident's family revealed that the physician and family were not notified in a timely manner of the resident's significant changes in condition, including unrelieved pain, low blood pressure, dehydration, and acute respiratory distress. The facility's policies required immediate notification of significant changes, but these were not followed. The failure to assess, notify, and act according to the resident's advance directives and physician orders contributed to the deficiency identified by surveyors.
Deficiency in Dementia Care and Services
Penalty
Summary
The facility failed to provide appropriate dementia care and services to two residents, Resident J and Resident K, as observed during a survey. On the secured Memory Care Unit, residents were found without engagement in activities, with some sleeping or staring blankly, and no staff present to facilitate interaction or care. Resident J, diagnosed with dementia and other mental health conditions, was observed alone and disengaged, with no specific care plan for residing in a secured memory care unit or for dementia care programming. His care plans did not address his need for structured activities, especially during the evening when his behaviors worsened. Resident J's records indicated he had been hospitalized for medication management and was prescribed multiple psychotropic medications. Despite this, his care plan lacked updates or interventions to address his behaviors effectively. The activity report showed a lack of evening activities, which coincided with the times his behaviors typically worsened. Staff documentation of his behaviors did not include specific interventions, and there was no evidence of a structured dementia care program being implemented. Resident K, also diagnosed with dementia, was observed fidgeting and disrobing, with no staff intervention to engage her in activities or address her behaviors. Her care plan did not include specific interventions for residing in a memory care unit or for dementia care programming. The activity report indicated a lack of structured activities, particularly in the evenings. Interviews with staff revealed a lack of specific dementia programming and interventions, with reliance on general redirection and engagement attempts. The facility's policy emphasized the importance of structured activities and interventions for dementia care, but these were not observed in practice.
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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) |
|---|---|---|---|---|
| Majestic Care Of Fort Wayne | 1.8 mi | ★★★★★ | 2 | 0 |
| Englewood Health & Rehabilitation Center | 3.4 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Fort Wayne | 4.6 mi | ★★★★★ | 9 | 0 |
| Byron Health Center | 4.6 mi | ★★★★★ | 15 | 0 |
| Saint Anne Home | 4.9 mi | ★★★★★ | 4 | 0 |
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