Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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.
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.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 254 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lutheran Life Villages.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.