Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
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 facility failed to follow physician orders for a resident's lab draw, missing a scheduled lamotrigine level test due to an order entry error. The resident, diagnosed with Alzheimer's, bipolar disorder, and depression, had a lamotrigine level due every six months, but the test was not conducted as required. The DON acknowledged the oversight, noting the order was mistakenly entered as one-time only.
A resident experienced swelling and discoloration in their arm due to improper monitoring and maintenance of a PICC line. The facility failed to document the removal and placement of the PICC line, and the dressing lacked necessary labeling. A nurse did not measure the resident's arm circumference during a dressing change, contrary to physician orders and facility policy.
A resident with chronic obstructive pulmonary disease was prescribed Methocarbamol, which had not been used since December. A pharmacy consultation recommended discontinuing the medication due to its risks and questionable effectiveness. Although the physician and DON acknowledged the recommendation, the medication was not discontinued, leading to a deficiency in medication management.
Failure to Follow Physician Orders for Lab Draw
Penalty
Summary
The facility failed to ensure that physician orders for a laboratory blood draw were followed for a resident diagnosed with Alzheimer's disease, bipolar disorder, and depression. The physician had ordered a lamotrigine level to be drawn every six months, with the next due date being September 2024. However, a review of the lab results reports indicated that the lamotrigine level was not observed on reports dated March 3, 2024, and March 12, 2024. It was only completed on March 25, 2024, and there were no subsequent lab reports with a lamotrigine level for the resident between March 25, 2024, and March 2025. The Director of Nursing acknowledged that the lamotrigine level lab for September 2024 was missed. The order was incorrectly entered as a one-time only, leading to the oversight. The facility's policy requires nurses to electronically acknowledge orders, review them for clarity and completeness, and make necessary entries into the electronic medical record (EMR). However, this process was not adequately followed, resulting in the missed lab draw.
Failure to Monitor and Maintain PICC Line
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of a vascular access device for a resident, identified as Resident 52. On observation, the resident's right lower arm and hand were swollen and discolored due to issues with an intravenous (IV) line. The resident reported that the IV line had to be removed from their right arm, and a new line was inserted in the left arm. However, the dressing on the new IV line lacked a start or change date and time, and there was a dark brown substance observed at the insertion site. The resident's medical records indicated a history of coronary artery disease, high blood pressure, and irregular heartbeat. Physician orders required regular inspection and documentation of the PICC line site for phlebitis and infiltration, as well as dressing changes every seven days or as needed. However, the records did not document the date or time of the PICC line removal from the right arm or the placement in the left arm. Additionally, the Treatment Administration Record (TAR) did not indicate that the PICC dressing had been changed or that the resident's upper arm circumference had been measured as required. During the survey, a registered nurse was observed flushing the PICC line without a date on the dressing and later changing the dressing without measuring the resident's upper arm circumference. The Director of Nursing confirmed that the dressing should have been labeled with the date, time, and nurse initials, and the Stat Lock should have been removed and discarded before cleansing the area. The facility's policy required these steps to decrease the potential for infection, but they were not followed in this case.
Failure to Discontinue Unused Medication Despite Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were followed for a resident diagnosed with chronic obstructive pulmonary disease. The resident had been prescribed Methocarbamol, a muscle relaxant, to be taken as needed. However, the medication had not been used since December 18, 2024. A pharmacy consultation report from February 25-26, 2025, recommended discontinuing the medication due to its strong sedating anticholinergic properties, increased risk for fractures, and questionable effectiveness in older adults. The physician accepted this recommendation on February 27, 2025, and the Director of Nursing acknowledged it on March 4, 2025. Despite these actions, the medication was not discontinued, as confirmed by the Director of Nursing during an interview on March 18, 2025. The facility's policy requires a licensed pharmacist to review the resident's drug regimen at least once a month and report any irregularities to the attending physician, medical director, and director of nursing. However, the failure to act on the pharmacy's recommendation resulted in a deficiency in the facility's medication management process.
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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) |
|---|---|---|---|---|
| Ashton Creek Health And Rehabilitation Center | 2.4 mi | — | 0 | 0 |
| Grey Stone Health And Rehabilitation Center | 2.4 mi | — | 2 | 0 |
| Towne House Retirement Community | 2.7 mi | — | 0 | 0 |
| Kingston Health Center Of Fort Wayne | 2.8 mi | — | 3 | 0 |
| Canterbury Nursing And Rehabilitation Center | 3.2 mi | — | 7 | 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 August 2026) and official state health department websites.