Fort Wayne, IN

Lutheran Life Villages

5-star overall rating with 4-star inspections with 3 recent health deficiencies

9802 Coldwater Road, Fort Wayne, IN

(260) 469-0600

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

84

Certified beds

Average residents

78

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2012-09-10

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

0.46

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

1.09

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.48

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

4.03

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.55

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

3.61

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.34

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.45

CMS adjusted RN staffing hours

Adjusted total hours

3.95

CMS adjusted total nurse staffing hours

Case-mix index

1.40

Higher values indicate more complex resident acuity

RN turnover

44%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

43%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,054

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

52.04

Composite VBP score used to determine payment impact.

Payment multiplier

1.0065

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

7.29

Baseline 21.81% · Performance 18.08% · Measure score 7.29 · Achievement 7.22 · Improvement 7.29

Healthcare-associated infections

7.35

Baseline 6.27% · Performance 5.64% · Measure score 7.35 · Achievement 7.35 · Improvement 4.46

Total nurse turnover

3.90

Baseline 42.86% · Performance 47.73% · Measure score 3.90 · Achievement 3.90 · Improvement 0

Adjusted total nurse staffing

2.27

Baseline 3.61 hours · Performance 3.72 hours · Measure score 2.27 · Achievement 2.27 · Improvement 0.02

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.12%	10.72% 0.4 pts worse	No Different than the National Rate · Eligible stays 103 · Observed rate 9.71% · Lower 95% interval 7.78%
Discharge to community	54.75%	50.57% 4.2 pts better	No Different than the National Rate · Eligible stays 90 · Observed rate 54.44% · Lower 95% interval 44.01%
Medicare spending per beneficiary	0.89	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 55 · Denominator 55
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 55
Discharge self-care score	61.22%	53.69% 7.5 pts better	Numerator 30 · Denominator 49
Discharge mobility score	30.61%	50.94% 20.3 pts worse	Numerator 15 · Denominator 49
Pressure ulcers or injuries, new or worsened	7.27%	2.29% 5 pts worse	Numerator 4 · Denominator 55 · Adjusted rate 8.29%
Healthcare-associated infections requiring hospitalization	5.64%	7.12% 1.5 pts better	No Different than the National Rate · Eligible stays 58 · Observed rate 0% · Lower 95% interval 2.86%
Staff COVID-19 vaccination coverage	3.39%	8.2% 4.8 pts worse	Numerator 4 · Denominator 118
Staff flu vaccination coverage	43.07%	42% 1.1 pts better	Numerator 59 · Denominator 137
Discharge function score	69.39%	56.45% 12.9 pts better	Numerator 34 · Denominator 49
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 22 · Denominator 22
Resident COVID-19 vaccinations up to date	31.82%	25.2% 6.6 pts better	Numerator 7 · Denominator 22

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.4	1.6 0.2 pts better	1.9 0.5 pts better	Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.5 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.5	1.5 1 pts better	1.8 1.3 pts better	Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.8%	93.6% 2.2 pts better	93.4% 2.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 98.5% · Q3 95.2% · Q4 95.1% · 4Q avg 95.8%
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	2.3%	3.8% 1.5 pts better	3.3% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.0% · Q3 1.6% · Q4 1.6% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.8%	24.6% 23.8 pts better	11.4% 10.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.8%
Percentage of long-stay residents who lose too much weight	4.7%	5.6% 0.9 pts better	5.4% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.3% · Q3 6.0% · Q4 6.2% · 4Q avg 4.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	14.5%	23.5% 9 pts better	19.6% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 16.4% · Q3 15.7% · Q4 14.0% · 4Q avg 14.5%
Percentage of long-stay residents who received an antipsychotic medication	6.1%	14.8% 8.7 pts better	16.7% 10.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.7% · Q3 4.3% · Q4 4.5% · 4Q avg 6.1% · 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	13.8%	13.3% 0.5 pts worse	16.3% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 13.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	12.0%	11.7% 0.3 pts worse	14.9% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 7.5% · Q3 10.4% · Q4 22.2% · 4Q avg 12.0% · 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	0.4%	1.2% 0.8 pts better	1.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	33.4%	24.2% 9.2 pts worse	19.8% 13.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 29.4% · Q3 43.3% · Q4 36.9% · 4Q avg 33.4%
Percentage of long-stay residents with pressure ulcers	4.6%	4.1% 0.5 pts worse	5.1% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 5.3% · Q3 4.1% · Q4 5.4% · 4Q avg 4.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.9%	81.6% 16.3 pts better	81.7% 16.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 98.4% · Q3 98.1% · Q4 97.6% · 4Q avg 97.9%
Percentage of short-stay residents who had an outpatient emergency department visit	16.3%	10.5% 5.8 pts worse	12.0% 4.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 13.6% · Expected 9.3% · 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	94.7%	79.0% 15.7 pts better	79.7% 15 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 94.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	14.8%	22.4% 7.6 pts better	23.9% 9.1 pts better	Short Stay · 20240701-20250630 · Adjusted 14.8% · Observed 11.4% · Expected 18.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-19 · Fire 2025-03-19

3 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-02-19 · Fire 2024-02-19

3 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 2023-04-13 · Fire 2023-04-13

1 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-03-19

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-04-01

D · Potential for more than minimal harm 2025-03-19

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-04-01

D · Potential for more than minimal harm 2025-03-19

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-04-01

D · Potential for more than minimal harm 2024-02-19

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-03-03

D · Potential for more than minimal harm 2024-02-19

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-03-03

D · Potential for more than minimal harm 2024-02-19

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-03-03

D · Potential for more than minimal harm 2023-04-13

F742 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Corrected 2023-04-29

Penalties and ownership

What sits behind the stars

Ownership

Adams County Memorial Hospital

5% Or Greater Direct Ownership Interest · Organization

100% 52 facilities 2015-07-01

Adair, Heidi