Cycle 1
Health 2025-08-29 · Fire 2025-08-29
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fort Wayne, IN
Lutheran Life Villages
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
6701 S Anthony Blvd, Fort Wayne, IN
(260) 447-1591
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
92
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.53
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.58
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.99
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,845
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.40
Composite VBP score used to determine payment impact.
Payment multiplier
1.0010
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.02
Baseline 18.02% · Performance 18.64% · Measure score 6.02 · Achievement 6.02 · Improvement 0
Healthcare-associated infections
4.39
Baseline 7.06% · Performance 6.52% · Measure score 4.39 · Achievement 4.39 · Improvement 2.11
Total nurse turnover
6.13
Baseline 50.82% · Performance 38.61% · Measure score 6.13 · Achievement 6.13 · Improvement 4.2
Adjusted total nurse staffing
2.41
Baseline 3.64 hours · Performance 3.76 hours · Measure score 2.41 · Achievement 2.41 · Improvement 0.07
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.56% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 8.7% · Lower 95% interval 6.82% |
| Discharge to community | 60.55% |
50.57%
10 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 58.33% · Lower 95% interval 47.94% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 36 · Denominator 36 |
| Falls with major injury | 5.56% |
0.77%
4.8 pts worse
|
Numerator 2 · Denominator 36 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 18 · Denominator 27 |
| Discharge mobility score | 55.56% |
50.94%
4.6 pts better
|
Numerator 15 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 2.78% |
2.29%
0.5 pts worse
|
Numerator 1 · Denominator 36 · Adjusted rate 3.45% |
| Healthcare-associated infections requiring hospitalization | 6.52% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 2.7% · Lower 95% interval 3.18% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 139 |
| Staff flu vaccination coverage | 11.11% |
42%
30.9 pts worse
|
Numerator 19 · Denominator 171 |
| Discharge function score | 74.07% |
56.45%
17.6 pts better
|
Numerator 20 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.5
1.1 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.3% |
93.6%
4.3 pts worse
|
93.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.9% · Q2 90.7% · Q3 86.1% · Q4 89.3% · 4Q avg 89.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.4% |
95.4%
5 pts worse
|
95.5%
5.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.8% |
3.8%
3 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 9.3% · Q3 7.6% · Q4 4.8% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
24.6%
23.7 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 1.2% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 8.2% |
5.6%
2.6 pts worse
|
5.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 6.8% · Q3 13.0% · Q4 4.2% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.5% |
23.5%
12 pts better
|
19.6%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 9.6% · Q3 12.9% · Q4 16.7% · 4Q avg 11.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.7% |
14.8%
0.9 pts worse
|
16.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 15.7% · Q3 16.1% · Q4 14.0% · 4Q avg 15.7% · 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 | 18.3% |
13.3%
5 pts worse
|
16.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 29.0% · Q3 15.3% · Q4 8.1% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.0% |
11.7%
18.3 pts worse
|
14.9%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.5% · Q2 36.9% · Q3 33.8% · Q4 17.2% · 4Q avg 30.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.4%
0.9 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.1% · Q3 0.0% · Q4 1.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 32.1% |
24.2%
7.9 pts worse
|
19.8%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 33.6% · Q3 26.3% · Q4 39.4% · 4Q avg 32.1% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
4.1%
0.5 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.6% · Q3 3.1% · Q4 4.8% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.2% |
81.6%
10.4 pts worse
|
81.7%
10.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 67.9% · Q2 63.9% · Q3 70.1% · Q4 85.9% · 4Q avg 71.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.1% |
10.5%
6.4 pts better
|
12.0%
7.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.1% · Observed 3.7% · Expected 10.2% · Used in QM five-star |
| 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 | 42.9% |
79.0%
36.1 pts worse
|
79.7%
36.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 42.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
22.4%
1.7 pts worse
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 18.5% · Expected 18.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-10 · Fire 2024-10-10
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-10-02 · Fire 2023-10-02
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-11-05
F · Potential for more than minimal harm
2025-08-29
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-11-05
F · Potential for more than minimal harm
2025-08-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-11-05
F · Potential for more than minimal harm
2025-08-29
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-11-05
E · Potential for more than minimal harm
2025-08-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-11-05
E · Potential for more than minimal harm
2025-08-29
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-11-05
E · Potential for more than minimal harm
2025-08-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-11-05
E · Potential for more than minimal harm
2025-08-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-11-05
E · Potential for more than minimal harm
2024-10-10
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-10
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2024-11-07
C · Minimal harm
2024-10-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-07
E · Potential for more than minimal harm
2023-10-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-24
E · Potential for more than minimal harm
2023-10-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-24
C · Minimal harm
2023-10-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-17
E · Potential for more than minimal harm
2025-08-29
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 2025-09-15
D · Potential for more than minimal harm
2025-08-29
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-29
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 2025-09-15
D · Potential for more than minimal harm
2025-08-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-29
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-08-29
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-09-15
D · Potential for more than minimal harm
2025-06-23
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 2025-07-09
D · Potential for more than minimal harm
2025-05-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-03-10
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-04-04
D · Potential for more than minimal harm
2023-10-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-03
Penalties and ownership
What sits behind the stars
Ownership
Adams County Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Adair, Heidi
Operational/Managerial Control · Individual
Adams County Memorial Hospital
Operational/Managerial Control · Organization
Bleke, Ron
Operational/Managerial Control · Individual
Bohnke, Bryan
Operational/Managerial Control · Individual
Borne-Bauman, Candice
Operational/Managerial Control · Individual
Fink, Jane
Operational/Managerial Control · Individual
Flueckiger, Russell
Operational/Managerial Control · Individual
Flueckiger, Russell
Corporate Director · Individual
Flueckiger, Russell
Corporate Officer · Individual
Forvis Mazars Llp
Operational/Managerial Control · Organization
Gotsch, Debbie
Operational/Managerial Control · Individual
Grote, Randy
Operational/Managerial Control · Individual
Hanke, Chris
Operational/Managerial Control · Individual
Healthcare Therapy Services Inc
Operational/Managerial Control · Organization
Kiefer, Alexander
Operational/Managerial Control · Individual
Kintanar, Thomas
Operational/Managerial Control · Individual
Lehman, Scott
Operational/Managerial Control · Individual
Linnemeier, Craig
Operational/Managerial Control · Individual
Lutheran Homes, Inc.
Operational/Managerial Control · Organization
Macklin, Larry
Operational/Managerial Control · Individual
Macklin, Larry
Corporate Director · Individual
Macklin, Larry
Corporate Officer · Individual
Mcintire, David
Operational/Managerial Control · Individual
Messmann, Greg
Operational/Managerial Control · Individual
Neary, Tricia
Operational/Managerial Control · Individual
Nehring, Emily
Operational/Managerial Control · Individual
Park, Alison
Operational/Managerial Control · Individual
Price, Mark
Operational/Managerial Control · Individual
Rush, Kevin
Operational/Managerial Control · Individual
Smith, Scott
Operational/Managerial Control · Individual
Smith, Scott
Corporate Officer · Individual
Sprunger, Kyle
Operational/Managerial Control · Individual
Sprunger, Kyle
Corporate Officer · Individual
Teska, Lowell
Operational/Managerial Control · Individual
Trent, Tom
Operational/Managerial Control · Individual
Walda, Chris
Operational/Managerial Control · Individual
Wheeler, Dane
Operational/Managerial Control · Individual
Wheeler, Dane
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Majestic Care Of Fort Wayne
Fort Wayne, IN
4-star overall rating with 4-star inspections
#2
Englewood Health & Rehabilitation Center
Fort Wayne, IN
5-star overall rating with 4-star inspections with 1 recent health deficiencies
#3
Life Care Center Of Fort Wayne
Fort Wayne, IN
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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