Cycle 1
Health 2024-08-16 · Fire 2024-08-16
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fort Wayne, IN
Englewood Health & Rehabilitation Center
5-star overall rating with 4-star inspections with 1 recent health deficiencies
2237 Engle Rd, Fort Wayne, IN
(260) 747-2353
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
54
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Tlc Management
Operator or chain grouping
Approved since
1998-07-21
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
0.59
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.71
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.57
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,248
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.30
Composite VBP score used to determine payment impact.
Payment multiplier
0.9834
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.48
Baseline 75.64% · Performance 60.53% · Measure score 2.48 · Achievement 0.77 · Improvement 2.48
Adjusted total nurse staffing
2.38
Baseline 3.40 hours · Performance 3.76 hours · Measure score 2.38 · Achievement 2.38 · Improvement 1
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.56% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 3.13% · Lower 95% interval 6.12% |
| Discharge to community | 50.08% |
50.57%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 40% · Lower 95% interval 34.63% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 20 · Denominator 20 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 20 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 5% |
2.29%
2.7 pts worse
|
Numerator 1 · Denominator 20 · Adjusted rate 5.29% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.94% |
8.2%
6.3 pts worse
|
Numerator 2 · Denominator 103 |
| Staff flu vaccination coverage | 21.43% |
42%
20.6 pts worse
|
Numerator 30 · Denominator 140 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.5% |
93.6%
5.1 pts worse
|
93.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.8% · Q2 84.0% · Q3 93.3% · Q4 87.2% · 4Q avg 88.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
95.4%
2.6 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.8%
0.7 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.0% · Q3 2.2% · Q4 2.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.2% |
24.6%
19.4 pts better
|
11.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 2.3% · Q3 2.3% · Q4 7.5% · 4Q avg 5.2% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
5.6%
0.7 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 2.1% · Q3 0.0% · Q4 9.1% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.3% |
23.5%
5.2 pts better
|
19.6%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 20.4% · Q3 15.6% · Q4 13.6% · 4Q avg 18.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.8% |
14.8%
4 pts better
|
16.7%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 13.3% · Q3 10.3% · Q4 7.9% · 4Q avg 10.8% · 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 | 9.0% |
13.3%
4.3 pts better
|
16.3%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.8% |
11.7%
6.9 pts better
|
14.9%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 9.1% · Q3 4.9% · Q4 2.6% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.2%
0.7 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.3% |
24.2%
1.1 pts worse
|
19.8%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 15.4% · Q3 32.5% · Q4 25.8% · 4Q avg 25.3% |
| Percentage of long-stay residents with pressure ulcers | 10.8% |
4.1%
6.7 pts worse
|
5.1%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 8.5% · Q3 12.3% · Q4 12.6% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 62.4% |
81.6%
19.2 pts worse
|
81.7%
19.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 60.4% · Q2 66.7% · Q3 60.4% · Q4 62.7% · 4Q avg 62.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.3% |
79.0%
5.7 pts worse
|
79.7%
6.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.3% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-20 · Fire 2023-07-20
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2022-09-13 · Fire 2022-09-13
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-07-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-08-03
E · Potential for more than minimal harm
2023-07-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-03
E · Potential for more than minimal harm
2023-07-20
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-08-03
E · Potential for more than minimal harm
2023-07-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-03
D · Potential for more than minimal harm
2023-07-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-03
C · Minimal harm
2023-07-20
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-08-03
E · Potential for more than minimal harm
2022-09-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-25
E · Potential for more than minimal harm
2022-09-13
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-11-25
E · Potential for more than minimal harm
2022-09-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-25
E · Potential for more than minimal harm
2022-09-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-25
E · Potential for more than minimal harm
2022-09-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-25
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-08-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-16
E · Potential for more than minimal harm
2023-09-06
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-10-22
E · Potential for more than minimal harm
2023-07-20
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 2023-08-03
D · Potential for more than minimal harm
2023-04-18
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-12
D · Potential for more than minimal harm
2022-09-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-20
D · Potential for more than minimal harm
2022-09-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-10-20
Penalties and ownership
What sits behind the stars
Ownership
Riverview Hospital
5% Or Greater Direct Ownership Interest · Organization
Adams, Brian
Operational/Managerial Control · Individual
Englewood Healthcare Operations
Operational/Managerial Control · Organization
Friend, Jayna
Corporate Officer · Individual
Hiles, Stephanie
Operational/Managerial Control · Individual
Hyatt, David
Operational/Managerial Control · Individual
Hyatt, David
Corporate Officer · Individual
Tender Loving Care Management Inc
Operational/Managerial Control · Organization
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#3
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