Inspection Reports for Life Care Center of Fort Wayne
1649 SPY RUN AVENUE, IN, 46805
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Moderate
Low
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Deficiencies: 0
May 20, 2025
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Life Care Center of Fort Wayne was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 84
Capacity: 115
Deficiencies: 8
May 13, 2025
Visit Reason
The survey was conducted as an Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but had multiple deficiencies related to life safety code including failure to conduct annual emergency preparedness training, incomplete documentation of smoke alarm maintenance, missing grease drip trays in kitchen hood systems, obstructed sprinkler heads, malfunctioning fire alarm system components, untested GFCI receptacles, unprotected electrical splices, incomplete fire door inspections, and lack of documentation for testing of patient-care related electrical equipment.
Severity Breakdown
SS=C: 2
SS=E: 3
SS=F: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to conduct annual training for the Emergency Preparedness Program (EPP). | SS=C |
| Failed to ensure documentation for preventative maintenance of 63 battery operated smoke alarms in resident rooms was complete. | SS=C |
| Failed to provide an approved method for returning kitchen cooking appliances to designed positions and missing grease drip trays in kitchen hood system. | SS=E |
| Failed to maintain fire alarm system in accordance with LSC; 20 smoke detectors failed sensitivity testing and needed replacement. | SS=F |
| Sprinkler heads obstructed by storage within 6 inches in storage closets. | SS=E |
| Failed to ensure 2 GFCI receptacles were properly maintained for protection against electric shock; also failed to ensure electrical splice was made in a junction box. | SS=F |
| Failed to ensure annual inspection and testing of 9 fire door assemblies and 1 oxygen room fire door was completed with required itemized documentation. | SS=F |
| Failed to maintain complete documentation of inspections for Patient-Care Related Electrical Equipment (PCREE). | SS=F |
Report Facts
Facility capacity: 115
Census: 84
Number of battery operated smoke alarms: 63
Number of fire door assemblies inspected: 9
Number of GFCI receptacles tested: 120
Number of smoke detectors failed sensitivity testing: 20
Number of obstructed sprinkler heads: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Genry | Executive Director | Signed the report and participated in exit conferences |
| Maintenance Director | Interviewed and provided information related to deficiencies and corrective actions | |
| Administrator | Interviewed and provided information related to deficiencies and corrective actions |
Inspection Report
Renewal
Census: 77
Capacity: 77
Deficiencies: 1
Apr 21, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from April 21 to April 24, 2025.
Findings
The facility failed to follow physician orders for oxygen administration for one resident (Resident 11), where oxygen was set at 3 liters per nasal cannula instead of the ordered 2 liters. The facility updated orders and care plans, conducted a facility-wide audit of oxygen orders, and provided staff education to ensure compliance.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to follow physician orders for oxygen administration for Resident 11. | SS=D |
Report Facts
Census: 77
Total Capacity: 77
Medicare Census: 7
Medicaid Census: 64
Other Payor Census: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Claudia McKinney | RN | Facility representative who signed the report |
| Registered Nurse 2 | RN | Interviewed regarding oxygen order adjustments for Resident 11 |
| Director of Nursing | DON | Interviewed regarding clarification of oxygen orders and staff in-service |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Apr 3, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00454270 and IN00454497 at Life Care Center of Fort Wayne.
Findings
No deficiencies related to the allegations in complaints IN00454270 and IN00454497 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00454270 - No deficiencies related to the allegations are cited. Complaint IN00454497 - No deficiencies related to the allegations are cited.
Report Facts
Census SNF/NF beds: 79
Census total residents: 79
Census Medicare residents: 9
Census Medicaid residents: 62
Census other payor residents: 8
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Dec 19, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00448343 at Life Care Center of Fort Wayne.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Complaint IN00448343 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Census: 78
Total Capacity: 78
Medicare Census: 6
Medicaid Census: 67
Other Payor Census: 5
Inspection Report
Complaint Investigation
Census: 82
Capacity: 82
Deficiencies: 0
Sep 30, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443942 at Life Care Center of Fort Wayne.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00443942 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Census: 82
Total Capacity: 82
Medicare Census: 5
Medicaid Census: 72
Other Payor Census: 5
Inspection Report
Re-Inspection
Census: 79
Capacity: 125
Deficiencies: 0
Aug 2, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 06/06/2024.
Findings
At this Post Survey Revisit, Life Care Center of Fort Wayne was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered except for a maintenance office/workshop/storage building.
Report Facts
Facility capacity: 125
Census: 79
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 0
Jul 9, 2024
Visit Reason
This visit was conducted for the investigation of two complaints, IN00436340 and IN00436869.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaint IN00436340 and IN00436869 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Census Bed Type: 81
Total Capacity: 81
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 67
Census Payor Type - Other: 12
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 17, 2024
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey was completed on May 17, 2024.
Findings
Life Care Center of Fort Wayne was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review for the Recertification and State Licensure survey.
Inspection Report
Routine
Census: 79
Capacity: 125
Deficiencies: 12
Jun 6, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR regulations.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but had multiple deficiencies related to life safety code including emergency power system maintenance, exit signage, fire alarm system installation and maintenance, fire extinguisher inspections, corridor door latching, electrical junction box safety, combustible decorations, power strip usage, oxygen storage room exhaust, and fire door inspections.
Severity Breakdown
SS=E: 6
SS=F: 3
SS=D: 2
SS=B: 1
SS=C: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Generator lacked required diesel fuel testing. | SS=C |
| One exterior door in memory care unit lacked 'NO EXIT' signage. | SS=E |
| Manual fire alarm pull station in kitchen mounted too high (62 inches). | SS=E |
| Fire alarm system lacked semi-annual visual inspection documentation. | SS=F |
| Two fire extinguishers were not inspected monthly as required. | SS=B |
| Beecher dining room double doors did not latch properly. | SS=E |
| Electrical junction box above drop ceiling missing cover plate with exposed wiring. | SS=E |
| Resident room door had combustible decorations covering more than 30% of door surface. | SS=D |
| Annual inspection and testing of 5 fire door assemblies not completed or documented. | SS=F |
| Annual fuel quality test for diesel generator was not documented; test completed after survey. | SS=F |
| Power strip in resident room did not meet required UL rating for patient care vicinity. | SS=D |
| Oxygen storage/transfilling room exhaust fan was not functioning to maintain negative pressure. | SS=E |
Report Facts
Facility capacity: 125
Census: 79
Fire door assemblies: 5
Fire extinguishers: 20
Power strip audit: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Gentry | Executive Director | Named as facility representative and responsible for ensuring compliance. |
Inspection Report
Renewal
Census: 80
Capacity: 80
Deficiencies: 1
May 17, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from May 13 to May 17, 2024.
Findings
The facility failed to ensure vision concerns were addressed for one resident (Resident 23), who was blind but had no documented vision diagnosis or care plan. The resident's vision care plan was updated and a follow-up ophthalmology appointment was rescheduled. Systemic corrective actions including audits and staff re-education were planned to prevent recurrence.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure vision concerns were addressed for Resident 23, who was blind but had no documented vision diagnosis or care plan. | SS=D |
Report Facts
Census: 80
Total Capacity: 80
Medicare Residents: 4
Medicaid Residents: 55
Other Payor Residents: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Gentry | Executive Director | Signed the report and provided interview statements regarding Resident 23's care |
| Director of Nursing | Director of Nursing | Interviewed regarding Resident 23's vision care and facility practices |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 83
Deficiencies: 0
Apr 16, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00431187.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00431187 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Census SNF/NF: 83
Total Capacity: 83
Census Payor Type Medicare: 9
Census Payor Type Medicaid: 53
Census Payor Type Other: 21
Inspection Report
Complaint Investigation
Census: 89
Capacity: 89
Deficiencies: 0
Jan 31, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00424905 at Life Care Center of Fort Wayne.
Findings
Life Care Center of Fort Wayne was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the investigation of Complaint IN00424905.
Complaint Details
Investigation of Complaint IN00424905; facility found in compliance with no deficiencies cited.
Report Facts
Census SNF/NF: 89
Medicare census: 7
Medicaid census: 74
Other census: 8
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Nov 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420222 at Life Care Center of Fort Wayne.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00420222 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 61
Census Payor Type - Other: 8
Inspection Report
Re-Inspection
Census: 74
Capacity: 125
Deficiencies: 0
Jul 5, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 05/18/23 was performed by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this PSR survey, Life Care Center of Fort Wayne was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered except for a maintenance office/workshop/storage building.
Report Facts
Facility capacity: 125
Census: 74
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Jun 21, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410518.
Findings
No deficiencies related to the allegations in Complaint IN00410518 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00410518 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 6
Medicaid census: 68
Other payor census: 2
Inspection Report
Annual Inspection
Deficiencies: 0
May 24, 2023
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 69
Capacity: 125
Deficiencies: 4
May 18, 2023
Visit Reason
The Indiana Department of Health conducted a Life Safety Code Recertification and State Licensure Survey on 05/18/2023 to assess compliance with Medicare/Medicaid and Life Safety Code requirements.
Findings
The facility was found not in compliance with several Life Safety Code requirements including failure to conduct weekly testing of battery-operated smoke alarms, incomplete coverage of kitchen hood fire suppression system, failure to conduct required dry sprinkler system air leakage testing, and unsealed penetrations in smoke barrier walls.
Severity Breakdown
SS=C: 1
SS=E: 2
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure preventative maintenance for 60 of 60 battery operated smoke alarms in resident rooms was conducted according to manufacturer's published instructions requiring weekly testing. | SS=C |
| Failed to ensure 1 of 1 kitchen hood extinguishing system provided complete coverage for equipment producing grease-laden vapors; deep fat fryer not covered by suppression system. | SS=E |
| Failed to conduct required air leakage testing for 1 of 1 dry sprinkler systems as required every 3 years and after system alterations. | SS=F |
| Failed to ensure penetrations caused by passage of wire/conduit through 4 of 10 smoke barrier walls were protected to maintain smoke resistance. | SS=E |
Report Facts
Battery operated smoke alarms: 60
Facility capacity: 125
Facility census: 69
Smoke barrier penetrations: 4
Residents affected by kitchen hood deficiency: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Gentry | Executive Director | Signed report as facility representative |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions; name not fully provided | |
| Administrator | Interviewed regarding deficiencies and corrective actions; name not fully provided | |
| Dietary Manager | Educated on fire extinguishing requirements for cooking equipment |
Inspection Report
Renewal
Census: 73
Capacity: 73
Deficiencies: 1
May 3, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over multiple days from April 26 to May 3, 2023.
Findings
The facility failed to ensure unit pantry refrigerator cleanliness and maintenance of proper temperatures, with uncovered and undated food items, lack of temperature logs, and frost accumulation in freezers. Housekeeping staff were responsible for maintenance, but deficiencies were noted in cleaning, labeling, and temperature monitoring.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure unit pantry refrigerator cleanliness and maintenance of proper temperatures, including uncovered and undated food items and lack of temperature logs. | SS=E |
Report Facts
Residents eating food from pantry refrigerators: 71
Residents on Beecher unit: 18
Residents on Preston unit: 38
Residents on Denton unit: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Holly Gentry | Executive Director | Signed the report as Executive Director. |
| Licensed Practical Nurse 2 | Interviewed regarding refrigerator cleanliness and temperature logs. | |
| Qualified Medication Aide 3 | Interviewed regarding temperature log and freezer conditions. | |
| Administrator | Interviewed regarding housekeeping responsibilities and food labeling. |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Mar 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00402507.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00402507 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Census: 80
Total Capacity: 80
Medicare Census: 6
Medicaid Census: 69
Other Payor Census: 5
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Dec 22, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00396571.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN001000396571 was substantiated, but no deficiencies related to the allegations were cited.
Report Facts
Census: 80
Total Capacity: 80
Medicare Census: 17
Medicaid Census: 58
Private Pay Census: 3
Other Payor Census: 2
Inspection Report
Re-Inspection
Census: 84
Capacity: 125
Deficiencies: 0
Oct 5, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/09/22 by the Indiana Department of Health.
Findings
Life Care Center of Fort Wayne was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered except for a maintenance office/workshop/storage building.
Report Facts
Facility capacity: 125
Census: 84
Inspection Report
Complaint Investigation
Census: 84
Capacity: 84
Deficiencies: 0
Aug 22, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00387899.
Findings
The complaint IN00387899 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00387899 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF: 84
Total Capacity: 84
Medicare Census: 4
Medicaid Census: 77
Other Payor Census: 3
Inspection Report
Life Safety
Census: 82
Capacity: 125
Deficiencies: 12
Aug 9, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with Medicare/Medicaid and Life Safety Code requirements.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included issues with corridor exit door latching mechanisms, cooler/freezer door release, corridor width obstructions, smoke barrier door latching, hazardous mechanical room door integrity, sprinkler system maintenance, fire extinguisher inspections, unsecured electrical panel, incomplete fire drills, combustible gases in smoking area, and oxygen transfilling room door integrity and staff training.
Severity Breakdown
SS=E: 10
SS=F: 3
Deficiencies (12)
| Description | Severity |
|---|---|
| 6 of 12 corridor exit doors had two latching mechanisms instead of one, violating LSC 7.2.1.5.10. | SS=E |
| 1 of 2 cooler/freezer doors in the kitchen could not be opened from the inside if locked. | SS=E |
| 5 of 5 corridors failed to meet clear width requirements due to unsecured furniture obstructing corridors. | SS=F |
| 1 of 7 smoke barrier doors had broken latching hardware and failed to latch properly. | SS=E |
| 1 of 3 hazardous mechanical rooms had holes in the boiler room door compromising smoke resistance. | SS=E |
| 1 of 2 sprinkler systems lacked a spare sprinkler cabinet large enough to fit all spare sprinkler heads and a sprinkler wrench. | SS=E |
| 4 of 4 sprinkler heads in the laundry were loaded with lint and debris. | SS=E |
| 1 of 30 portable fire extinguishers missed annual maintenance inspection. | SS=E |
| 1 of 1 electrical panel in the Memory Care Hall was unsecured and accessible to non-authorized personnel. | SS=E |
| Facility failed to conduct quarterly fire drills at unexpected times on all shifts and failed to verify transmission of fire alarm signal in one drill. | SS=F |
| Combustible gases (propane tank) were stored in the staff smoking area. | SS=E |
| Staff were not properly trained on oxygen transfilling procedures and the oxygen transfilling room door had holes compromising fire resistance. | SS=F |
Report Facts
Deficiencies cited: 13
Residents affected: 20
Residents affected: 22
Inspection Report
Complaint Investigation
Census: 82
Capacity: 82
Deficiencies: 0
Aug 9, 2022
Visit Reason
This visit was for the investigation of Complaint IN00384746.
Findings
Complaint IN00384746 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00384746 - Substantiated. No deficiencies related to the allegations were cited.
Report Facts
Medicare census: 5
Medicaid census: 75
Other census: 2
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 1, 2022
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey conducted on June 27, 2022.
Findings
Life Care Center of Fort Wayne was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review for the Recertification and State Licensure survey.
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