Cycle 1
Health 2025-07-02 · Fire 2025-07-02
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fort Wayne, IN
Waters Of Fort Wayne Skilled Nursing Facility, The
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
5544 E State Blvd, Fort Wayne, IN
(260) 749-9506
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
77
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Infinity Healthcare Consulting
Operator or chain grouping
Approved since
1988-07-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
70 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 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
0.69
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.98
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
3.59
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.39
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
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.43
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,572
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.31
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.09
Baseline 18.89% · Performance 19.54% · Measure score 4.09 · Achievement 4.09 · Improvement 0
Healthcare-associated infections
3.82
Baseline 5.55% · Performance 6.69% · Measure score 3.82 · Achievement 3.82 · Improvement 0
Total nurse turnover
1.66
Baseline 52.54% · Performance 56.90% · Measure score 1.66 · Achievement 1.66 · Improvement 0
Adjusted total nurse staffing
0.95
Baseline 3.60 hours · Performance 3.35 hours · Measure score 0.95 · Achievement 0.95 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.66% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 10.53% · Lower 95% interval 7.41% |
| Discharge to community | 53.92% |
50.57%
3.4 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 51.61% · Lower 95% interval 39.29% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 94.74% |
95.27%
0.5 pts worse
|
Numerator 36 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 41.38% |
53.69%
12.3 pts worse
|
Numerator 12 · Denominator 29 |
| Discharge mobility score | 31.03% |
50.94%
19.9 pts worse
|
Numerator 9 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 38 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.69% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 4% · Lower 95% interval 3.3% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 81 |
| Staff flu vaccination coverage | 8.64% |
42%
33.4 pts worse
|
Numerator 7 · Denominator 81 |
| Discharge function score | 58.62% |
56.45%
2.2 pts better
|
Numerator 17 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · 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 | 91.4% |
93.6%
2.2 pts worse
|
93.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 87.2% · Q3 91.2% · Q4 93.3% · 4Q avg 91.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.2% |
95.4%
5.2 pts worse
|
95.5%
5.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.8%
1.2 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 7.7% · Q3 2.9% · Q4 3.3% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 49.6% |
24.6%
25 pts worse
|
11.4%
38.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.5% · Q2 60.0% · Q3 47.1% · Q4 55.6% · 4Q avg 49.6% |
| Percentage of long-stay residents who lose too much weight | 10.8% |
5.6%
5.2 pts worse
|
5.4%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 16.1% · Q3 10.7% · Q4 9.1% · 4Q avg 10.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
23.5%
6.4 pts better
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 19.4% · Q3 21.4% · Q4 13.6% · 4Q avg 17.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.8% |
14.8%
4 pts worse
|
16.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q3 20.8% · 4Q avg 18.8% · 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 | 15.9% |
13.3%
2.6 pts worse
|
16.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 14.4% · Q3 13.2% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.3% |
11.7%
5.6 pts worse
|
14.9%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 20.0% · Q3 25.0% · Q4 4.5% · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.6% |
0.4%
3.2 pts worse
|
1.0%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.2% · Q3 0.0% · Q4 0.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.2%
0.5 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.5% |
24.2%
3.3 pts worse
|
19.8%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 26.2% · Q3 24.2% · Q4 31.4% · 4Q avg 27.5% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
4.1%
2.7 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 9.9% · Q3 8.3% · Q4 2.6% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.2% |
81.6%
17.4 pts worse
|
81.7%
17.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 67.2% · Q2 55.1% · Q3 65.8% · Q4 69.1% · 4Q avg 64.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.3% |
10.5%
3.8 pts worse
|
12.0%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 14.8% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.3%
0.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.0% |
79.0%
10 pts worse
|
79.7%
10.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 42.5% |
22.4%
20.1 pts worse
|
23.9%
18.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 42.5% · Observed 33.3% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-04 · Fire 2024-09-04
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2023-08-16 · Fire 2023-08-16
5 health deficiencies
Top issue: Administration (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-22
F · Potential for more than minimal harm
2025-07-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-22
F · Potential for more than minimal harm
2025-07-02
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-09-22
E · Potential for more than minimal harm
2025-07-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-22
E · Potential for more than minimal harm
2025-07-02
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-09-22
E · Potential for more than minimal harm
2025-07-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-22
F · Potential for more than minimal harm
2024-09-04
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-28
F · Potential for more than minimal harm
2024-09-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-13
F · Potential for more than minimal harm
2024-09-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-28
F · Potential for more than minimal harm
2024-09-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-28
E · Potential for more than minimal harm
2024-09-04
K251 · Egress Deficiencies
Fire Safety
Conform to length requirements for dead end corridors.
Corrected 2024-10-28
E · Potential for more than minimal harm
2024-09-04
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-28
E · Potential for more than minimal harm
2024-09-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-28
E · Potential for more than minimal harm
2024-09-04
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-10-28
E · Potential for more than minimal harm
2024-09-04
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-28
E · Potential for more than minimal harm
2024-09-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-28
E · Potential for more than minimal harm
2024-09-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-28
E · Potential for more than minimal harm
2024-09-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-28
C · Minimal harm
2024-09-04
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-10-28
C · Minimal harm
2024-09-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-28
C · Minimal harm
2024-09-04
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-10-28
F · Potential for more than minimal harm
2023-08-16
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-08-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-08-16
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-08-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-29
D · Potential for more than minimal harm
2025-11-12
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 2025-11-29
D · Potential for more than minimal harm
2025-11-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-11-29
E · Potential for more than minimal harm
2025-07-02
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 2025-07-17
E · Potential for more than minimal harm
2025-07-02
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 2025-07-17
D · Potential for more than minimal harm
2025-07-02
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 2025-07-17
D · Potential for more than minimal harm
2025-07-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-17
D · Potential for more than minimal harm
2024-09-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-09-04
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-04-19
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 2024-05-10
D · Potential for more than minimal harm
2024-04-19
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-05-10
D · Potential for more than minimal harm
2024-02-06
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 2024-02-07
D · Potential for more than minimal harm
2023-09-27
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 2023-10-20
E · Potential for more than minimal harm
2023-08-16
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 2023-09-01
E · Potential for more than minimal harm
2023-08-16
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-16
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-09-01
Penalties and ownership
What sits behind the stars
Ownership
Johnson Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Berkhouse, Steven
Corporate Director · Individual
Berkhouse, Steven
Corporate Officer · Individual
Decola, Robert
W-2 Managing Employee · Individual
Duggan, Amanda
Contracted Managing Employee · Individual
Dunkle, David
Operational/Managerial Control · Individual
Dunkle, David
Corporate Director · Individual
Dunkle, David
Corporate Officer · Individual
The Waters Of Fort Wayne Skilled Nursing Facility LLC
Operational/Managerial Control · Organization
Nearby options
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#2
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Fort Wayne, IN
2-star overall rating with 3-star inspections with $7,342 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
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5-star overall rating with 5-star inspections with 2 recent health deficiencies
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