Cycle 1
Health 2025-07-02 · Fire 2025-07-02
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fort Wayne, IN
Ashton Creek Health And Rehabilitation Center
4-star overall rating with 4-star inspections
4111 Park Place Drive, Fort Wayne, IN
(260) 373-2111
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
139
Certified beds
Average residents
109
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Tlc Management
Operator or chain grouping
Approved since
2012-07-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.81
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.08
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.78
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
3.54
CMS adjusted total nurse staffing hours
Case-mix index
1.58
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,989
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.2
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.81% · Performance 23.95% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.51
Baseline 6.22% · Performance 7.68% · Measure score 0.51 · Achievement 0.51 · Improvement 0
Total nurse turnover
2.51
Baseline 55.22% · Performance 53.44% · Measure score 2.51 · Achievement 2.51 · Improvement 0.09
Adjusted total nurse staffing
0.66
Baseline 3.50 hours · Performance 3.27 hours · Measure score 0.66 · Achievement 0.66 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.98% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 229 · Observed rate 9.61% · Lower 95% interval 7.18% |
| Discharge to community | 53.9% |
50.57%
3.3 pts better
|
No Different than the National Rate · Eligible stays 239 · Observed rate 48.95% · Lower 95% interval 46.84% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.26% |
95.27%
1 pts better
|
Numerator 180 · Denominator 187 |
| Falls with major injury | 1.07% |
0.77%
0.3 pts worse
|
Numerator 2 · Denominator 187 |
| Discharge self-care score | 54.55% |
53.69%
0.9 pts better
|
Numerator 54 · Denominator 99 |
| Discharge mobility score | 59.6% |
50.94%
8.7 pts better
|
Numerator 59 · Denominator 99 |
| Pressure ulcers or injuries, new or worsened | 3.21% |
2.29%
0.9 pts worse
|
Numerator 6 · Denominator 187 · Adjusted rate 2.61% |
| Healthcare-associated infections requiring hospitalization | 7.68% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 179 · Observed rate 8.94% · Lower 95% interval 4.67% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 219 |
| Staff flu vaccination coverage | 24.78% |
42%
17.2 pts worse
|
Numerator 57 · Denominator 230 |
| Discharge function score | 64.65% |
56.45%
8.2 pts better
|
Numerator 64 · Denominator 99 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 50 · Denominator 50 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 96 · Denominator 96 |
| Resident COVID-19 vaccinations up to date | 6.98% |
25.2%
18.2 pts worse
|
Numerator 6 · Denominator 86 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.6
0.2 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.2 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
93.6%
6.1 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.8% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.8%
1.4 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 6.2% · Q3 4.9% · Q4 4.9% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.5% |
24.6%
13.1 pts better
|
11.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 12.0% · Q3 7.8% · Q4 13.0% · 4Q avg 11.5% |
| Percentage of long-stay residents who lose too much weight | 10.2% |
5.6%
4.6 pts worse
|
5.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 9.2% · Q3 8.9% · Q4 9.0% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.9% |
23.5%
7.6 pts better
|
19.6%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 17.7% · Q3 15.0% · Q4 15.0% · 4Q avg 15.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.5% |
14.8%
6.3 pts better
|
16.7%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 9.4% · Q3 7.2% · Q4 7.5% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.5% |
13.3%
2.8 pts better
|
16.3%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 4.4% · Q3 13.3% · Q4 6.8% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.9% |
11.7%
0.8 pts better
|
14.9%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 9.0% · Q3 22.8% · Q4 3.9% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.4%
0.1 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.2%
1 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.8% · Q3 0.0% · Q4 2.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.9% |
24.2%
10.7 pts worse
|
19.8%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 41.8% · Q3 33.4% · Q4 33.6% · 4Q avg 34.9% |
| Percentage of long-stay residents with pressure ulcers | 10.0% |
4.1%
5.9 pts worse
|
5.1%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 10.3% · Q3 8.1% · Q4 7.4% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
81.6%
18.2 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.6% · Q3 100.0% · Q4 99.6% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
10.5%
0.4 pts better
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 10.3% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.3%
0.5 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.9% · Q3 2.5% · Q4 1.6% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.0% |
79.0%
2 pts better
|
79.7%
1.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.8% |
22.4%
6.4 pts worse
|
23.9%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.8% · Observed 28.2% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-22 · Fire 2024-07-22
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-07-11 · Fire 2023-07-11
10 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-07-11
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-08-19
F · Potential for more than minimal harm
2023-07-11
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-08-19
F · Potential for more than minimal harm
2023-07-11
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-08-19
F · Potential for more than minimal harm
2023-07-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-08-19
E · Potential for more than minimal harm
2023-07-11
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-08-19
E · Potential for more than minimal harm
2023-07-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-19
E · Potential for more than minimal harm
2023-07-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-19
E · Potential for more than minimal harm
2023-07-11
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-10-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-11
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-07-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-08-16
D · Potential for more than minimal harm
2023-11-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-07
D · Potential for more than minimal harm
2023-11-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-07
D · Potential for more than minimal harm
2023-08-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-07-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-11
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-04-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-04-12
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-04-28
Penalties and ownership
What sits behind the stars
Ownership
Riverview Hospital
5% Or Greater Direct Ownership Interest · Organization
Adams, Brian
Operational/Managerial Control · Individual
Ashton Creek Healthcare Operations Company LLC
Operational/Managerial Control · Organization
Friend, Jayna
Corporate Officer · Individual
Gibson, Derek
Operational/Managerial Control · Individual
Hyatt, David
Operational/Managerial Control · Individual
Hyatt, David
Corporate Officer · Individual
Tender Loving Care Management Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Grey Stone Health & Rehabilitation Center
Fort Wayne, IN
1-star overall rating with 1-star inspections with $165,757 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Heritage Pointe Of Fort Wayne
Fort Wayne, IN
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
#3
Lutheran Life Villages
Fort Wayne, IN
5-star overall rating with 4-star inspections with 3 recent health deficiencies
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